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Radiographic evidence of scapho-lunate diastasis associated with a displaced distal radius fracture has been well recognized yet the clinical significance remains in question. If left untreated, will this progress to both radiographic and clinical changes consistent with intercarpal arthritis? Using the accumulated data of over 400 surgically treated distal radius fractures in the ICUC database, 16 cases of untreated scapho-lunate diastasis were followed on an average of 8 years without evidence of progressive functional or radiographic deterioration. In 50% of these cases, incidental findings of similar scapho-lunate diastasis was noted in the opposite uninjured wrist.

Background: The seesaw test consists of flexion and extension of the thumb metacarpal on the trapezium, with continuous axial pressure to keep the metacarpal base reduced in the carpometacarpal (CMC) joint. We aim to evaluate this maneuver compared with the grind test. Methods: We prospectively enrolled 80 participants from March 2017 to March 2018 at a single institution, excluding those who had previous thumb surgery or pathology. Each participant underwent both seesaw and grind tests by 2 independent examiners. We included 24 patients with a mean age of 73 years in the CMC osteoarthritis group (Eaton stages 2-4) and 44 patients with a mean age of 66 years in the control group (Eaton stages 0 and 1). We calculated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and multirater κ measure. Results: The seesaw test had a higher sensitivity than the grind test (42%-71% vs 13%-17%), but a lower specificity (82%-86% vs 91%-98%). The PPV was more consistent between examiners for the seesaw test (63%-68% vs 42%-80%), and the NPV was higher (73%-84% vs 66%-68%). There was a slight agreement between the attending surgeon and the fellow performing the grind test (κ = 0.08) and a moderate agreement between the attending surgeon and the fellow performing the seesaw test (κ = 0.59). Conclusions: The seesaw test is superior to the grind test, with a much higher sensitivity, slightly lower specificity, more consistent PPV, and slightly higher NPV. Therefore, the seesaw test could be a valuable addition or even replacement for the grind test, and we recommend considering it in daily practice.

Background Fixation and arthroplasty remain the mainstays of surgical treatment of degenerative and traumatic shoulder pathology. They also constitute an appreciable sum of Medicare expenditure. With continued concern for declines in Medicare reimbursement across orthopedic surgery, it is important to understand how trends in reimbursement correlate with relative procedure volumes. Our aims were to describe temporal changes in procedure volumes, physician payment, and patient charges for proximal humerus open reduction internal fixation (ORIF) and shoulder arthroplasty. Methods Using Medicare's Physician Fee Schedules from 2012 to 2017, we examined procedure volumes, number of unique surgeons performing, actual submitted patient charges, and surgeon payments from 2012 to 2017 for six shoulder procedures: proximal humerus ORIF (CPT-23615), traumatic hemiarthroplasty (HEMI) (CPT-23616), degenerative HEMI (CPT-23470), primary total shoulder arthroplasty (TSA) (CPT-23472), partial TSA revision (humeral or glenoid component, CPT-23473), and total TSA revision (CPT-23474). The reimbursement ratio was calculated by dividing surgeon payment by patient charges. Growth rates of charges and payment were adjusted for inflation using annual consumer price index inflation rates over the same time period. Results The total number of traumatic and degenerative HEMI cases fell over −60%. Similarly, the number of unique surgeons performing traumatic and degenerative HEMI fell over −53%. In contrast, the number of TSA procedures rose by +70%, whereas partial and total revision TSA rose by +62% and +88%, respectively. The number of unique surgeons rose +28% and over +73% for primary and revision TSA, respectively. There was a large gap (between 3.4 and 4.4 times) between submitted charges and surgeon payment for all years analyzed. After adjusting for inflation, Medicare payment to surgeons decreased for all types of surgery (−6% to −9%) other than ORIF, which increased +10%. Submitted patient charges during this period increased +14% and +9.7% for ORIF and revision TSA (total), respectively, but decreased by −6% for traumatic HEMI. The reimbursement ratio was ≤29% for all procedures analyzed across all years and fell the most for revision TSA (partial and total). Conclusion From 2012 to 2017, there was a sharp decline in the use of shoulder HEMI with a correspondingly high increase in TSA. After accounting for inflation, HEMI and TSA showed appreciable declines in surgeon payment over time, whereas ORIF was the only surgery with increased surgeon payment. Revision TSA saw the largest declines in the reimbursement rate. Physicians and health care policy makers must be aware of these trends to ensure both a sustainable payment infrastructure for surgeons as well as to maintain access to care for these procedures. Level of evidence Level III; Economic Study

OBJECTIVE To assess the direct costs of distal radius fracture volar plate (VP) fixation and to create a model to examine the effect of these cost drivers. MATERIALS AND METHODS Retrospectively, 744 distal radius fractures treated with open reduction and internal fixation (ORIF) were identified. The outcomes assessed included (1) the direct costs related to distal radius ORIF and (2) if a VP alone was amenable. Costs were represented as a cost ratio relative to the average cost of distal radius ORIF, where the average value is set as 1.0. Simulation models were run with all cost drivers (sex, age, open fracture, intra-articular fracture, and ancillary fixation) and with only ancillary fixation as a cost driver. RESULTS The cost ratio ranged from 0.61 to 1.81 and ancillary fixation was associated with increased implant costs in multivariable analysis. In the simulations, the cost ratio ranged from 0.96 to 1.23 when all cost drivers were included and from 0.99 to 1.20 if only ancillary fixation was included as a cost driver, a reduction of the range by 22.2%. Older patients, females, closed fractures, and extra-articular fractures were more amenable to VP fixation alone. CONCLUSIONS Eighty-three percent of the surgically treated distal radius fractures were treated with VP fixation alone. A disposable kit could help limit cost variance per case by roughly 22%, as only ancillary fixation varies these costs. Closed fractures and extra-articular fractures in older patients or female patients are more amenable to VP fixation alone. LEVEL OF EVIDENCE Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Identifying patients at risk for prolonged opioid use following surgery for symptomatic neuroma would be beneficial for perioperative management. The aim of this study is to identify the factors associated with postoperative opioid use of >4 weeks in patients undergoing neuroma surgery. Methods After retrospective identification, 77 patients who underwent surgery for symptomatic neuroma of the upper or lower extremity were enrolled. Patients completed the Patient-Reported Outcomes Measurement Information System (PROMIS) depression, Numeric Rating Scale (NRS) pain score, and a custom medication questionnaire at a median of 9.7 years (range: 2.5–16.8 years) following surgery. Neuroma excision followed by nerve implantation (n = 39, 51%), nerve reconstruction/repair (n = 18, 23%), and excision alone (n = 16, 21%) were the most common surgical treatments. Results Overall, 27% (n = 21) of patients reported opioid use of more than 4 weeks postoperatively. Twenty-three patients (30%) reported preoperative opioid use of which 11 (48%) did not report opioid use for >4 weeks, postoperatively. In multivariable logistic regression, preoperative opioid use was independently associated with opioid use of >4 weeks, postoperatively (odds ratio [OR] = 4.4, 95% confidence interval [CI]: 1.36–14.3, p = 0.013). Conclusion Neuroma surgery reduces opioid use in many patients but patients who are taking opioids preoperatively are at risk for longer opioid use. Almost one-third of patients reported opioid use longer than 4 weeks, postoperatively.

Background: Demographic information related to phalangeal fractures that undergo simultaneous vascular repair, as well as their complication and reoperation profiles, remain incompletely understood. This study aimed to examine the patient and fracture characteristics influencing the outcomes after these injuries in a large Unites States adult patient cohort and to identify risk factors associated with unplanned reoperation of these fractures. Methods: A retrospective study was performed, identifying 54 phalangeal fractures in 48 patients; all fractures were also associated with vascular injuries requiring repair. Patients with digital amputations were excluded. A manual chart review was performed to collect epidemiologic, radiographic, and surgical outcome information. Results: The incidence of phalangeal fractures undergoing vascular repair was higher in the non-dominant hand, middle finger, proximal phalanx, and phalangeal shaft. Most (52.9%) fractures were due to occupational injury, with the most common mechanism being sharp injuries. More than half of the fractures had a nerve injury, and 13% required a vein graft for vascular repair. More than half of the fractures required at least one reoperation, most commonly due to “stiffness/tendon adhesion” (50%) and “nonunion or delayed union” (21.4%). In multivariable analysis, thumb (odds ratio [OR]: 35.1, P = .043) and index (OR: 14.0, P = .048) fingers’ fractures were found to be independently associated with unplanned reoperation. Conclusions: Phalangeal fractures requiring vascular repair occurred most often in the occupational setting and more than 50% required at least one unplanned reoperation. Injuries sustained in the thumb and index finger were more likely to undergo unplanned reoperation, which may guide initial treatment decision-making and postoperative follow-up.

Background Distal radius fractures (DRF) are the second most common fragility fracture experienced by the elderly, and surgical management constitutes an appreciable sum of Medicare expenditure for upper extremity surgery. Using Medicare data from 2012 to 2017, our primary aim was to describe temporal changes in surgical treatment, physician payment, and patient charges for DRF fixation. Methods We examined surgical volumes and retrospective patient charge (services billed by surgeon) and surgeon payment (professional fee) data from 2012 to 2017 for four DRF surgeries: closed reduction percutaneous pinning (CRPP), open reduction internal fixation (ORIF) of extra-articular fractures, ORIF of intra-articular (IA) (2-fragment) fractures, and ORIF of IA (> 3 fragments) fractures. The reimbursement ratio was defined and calculated as the ratio of charges to payment. Rates were adjusted for inflation using the annual consumer-price index. Results For these four surgeries from 2012 to 2017, total patient charges grew by 64% from $117 to 193 million, while surgeon payment grew by 42% from $30 to 42 million. CRPP cases fell by 47%, while ORIF increased by 17, 14, and 45% for extra-articular, IA (2-fragment), and IA (> 3 fragments) surgeries, respectively. After adjusting for inflation, payment to physicians increased by more than or equal to 16% for all procedures except for CRPP, which fell by 2%. Charges during this same period increased from 13 to 38%. Reimbursement ratios declined from −9.2% to −13% for each procedure. Conclusion From 2012 to 2017, while charges have outpaced surgeon payment, payment has outpaced inflation for all forms of distal radius ORIF, aside from CRPP. There has been a continued sharp decline of CRPP. Level of Evidence is III, economic.

Hypothesis and background Some investigators speculate that excision may lead to elbow arthritis and associated problems; however, evidence supporting this theory is limited. It is hypothesized that radial head excision causes bone density changes as a result of asymmetrical stress distributions, consequently leading to osteophyte formation. In this study, we sought to quantitatively compare the 3-dimensional (3D) bone density and stress distributions between operative and nonoperative elbows in patients who underwent radial head excision. Furthermore, we aimed to quantify the bone morphologic changes using 3D models in the same cohort. Methods After retrospective identification, this study enrolled 6 patients who had undergone radial head excision for radial head fractures. We created 3D bone models using computed tomography data obtained from the injured and uninjured elbows. Humerus and ulna models were divided into anatomic regions, and the bone density of each region was assessed and described by its percentage of high-density volume (%HDV). We also constructed finite element models and measured the stress values in each region. Furthermore, we compared the bone morphology by superimposing the operative elbow onto the mirror image of the nonoperative elbow. Results The mean interval from radial head excision to examination was 8.4 ± 3.3 years. The %HDV on the operative side was higher than that of the nonoperative side at the anterolateral trochlea (77.5% ± 6.5% vs. 64.6% ± 4.0%, P = .028) and posterolateral trochlea (70.7% ± 7.8% vs. 63.1% ± 3.8%, P = .034) regions of the distal humerus. Reciprocal changes were observed in the proximal ulna, as %HDV was higher in the lateral coronoid (52.6% ± 9.6% vs. 34.2% ± 6.6%, P = .007). The stress distributions paralleled the bone density measurements. The operative elbows demonstrated an enlarged capitellum and a widened and deepened trochlea with osteophyte formation compared with the nonoperative side. Discussion and conclusion In elbows treated with radial head excision, we identified asymmetrical bone density and stress alterations on the lateral side of the ulnohumeral joint and bone morphologic changes across the joint. These data support the theory that radial head excision contributes to ulnohumeral arthritis over the long term.

Background The primary aim of our study was to identify the factors associated with revision surgery after bursal excision in patients with olecranon bursitis. The secondary aims were to describe the revision rate after bursectomy and to assess which factors are associated with flap surgery after bursectomy and describe the most common complications after bursectomy of the olecranon bursa. Methods We included 191 adult patients with olecranon bursitis who underwent olecranon bursa excision between January 2002 and October 2018. Patients who were pregnant, patients with incomplete records of the primary surgical procedure, and patients who underwent bursectomy during elbow arthroplasty were excluded. After manual chart review, we found that 22 patients had undergone revision surgery. Bivariate analysis was performed to assess the association between revision surgery and patient characteristics, comorbidities, and clinical characteristics. Additionally, we collected data regarding postoperative complications and intraoperative variables such as the use of drains, vacuum assisted closure therapy, and flap surgery. Results The overall revision rate in our cohort was 11.5% (22 of 191 patients). Bivariate analysis showed that patients who underwent revision surgery were more frequently women (P = .004), more often had a history of ipsilateral (P = .020) or contralateral (P = .012) olecranon bursitis, and more often received a diagnosis of rheumatoid arthritis (P = .001) or diabetes mellitus (P = .019). The most common complications were delayed wound healing (n = 8, 4.2%) and osteomyelitis (n = 8, 4.2%). Flap surgery was performed in 5 patients (2.6%). Bivariate analysis showed that patients with rheumatoid arthritis underwent flap surgery more frequently (P = .011). Conclusion The revision rate after bursectomy for olecranon bursitis was 11.5% (22 of 191 patients). Patients with rheumatoid arthritis, diabetes mellitus, or a history of ipsilateral and contralateral olecranon bursitis and female patients underwent revision surgery after bursectomy for olecranon bursitis more frequently. In addition, patients with rheumatoid arthritis underwent flap surgery after bursectomy more frequently.

Introduction The aim of this study was to describe patient characteristics, treatment, and oncologic outcomes of soft-tissue sarcomas (STSs) of the hand. Methods Sixty-nine STSs of the hand in adult patients treated at a tertiary referral center were retrospectively included. We describe patient and tumor characteristics along with oncologic outcomes. Results Epithelioid sarcoma (23%) was the most common histologic subtype, followed by synovial sarcoma (15%). Of all tumors, 17 (25%) were grade I, 22 (32%) were grade II, and 30 (44%) were grade III. The 5-year disease-free survival for epithelioid sarcomas was 75% with a disease survival of 100%, along with a metastatic rate of 15%. Of the patients with a synovial sarcoma, 40% developed metastases, and the 5-year disease-free survival was 68% and the 5-year disease survival was 73%. Conclusion Hand STSs are aggressive tumors with a high metastatic potential. Even with adequate oncologic treatment, long-term clinical follow-up (10 years) in these tumors is advised. The treating surgical oncologist should not be deceived by their smaller size.

Item does not contain fulltext BACKGROUND AND OBJECTIVES: This study compares long-term patient-reported outcomes between patients that underwent limb-salvage surgery with complex reconstruction by free or pedicled flap (LS) or amputation. Additionally, the need for revision surgery is compared. METHODS: A total of 43 patients were studied at a median follow-up of 9.54 years. Sixteen patients completed questionnaires regarding functional outcome and mental wellbeing. Functional outcomes were measured by using the Toronto Extremity Salvage Score (TESS), QuickDASH, and PROMIS Upper Extremity instruments. Mental wellbeing was assessed using the PROMIS Anxiety and Depression instruments. Revision surgery was assessed for the entire follow-up. RESULTS: The median TESS scores were 96.0 versus 71.7 (p = 0.034) and the PROMIS Upper Extremity scores were 50.1 versus 40.3 (p = 0.039) for the LS and amputation cohorts, respectively. No significant difference was found regarding symptoms of anxiety (52.7 vs. 53.8; p = 0.587) or depression (52.0 vs. 50.5; p = 0.745). Of the patients in the LS cohort 51.6% required at least one reoperation compared to 8.33% in the amputation cohort. CONCLUSIONS: LS surgery maintains functional benefits over amputation after almost a decade of follow-up. Still, mental wellbeing seems to be comparable between these patients, whereas LS procedures are associated with a sixfold increased need for reoperations.

Background The aims of this study are to evaluate the rate of wrist joint preservation, allograft retention, factors associated with reoperation and to report the patient reported outcomes after osteoarticular allograft reconstruction of the distal radius. Methods Retrospective chart review identified 33 patients who underwent distal radius resection followed by osteoarticular allograft reconstruction, including 27 giant cell tumors and 6 primary malignancies. Ten patients with a preserved wrist joint completed the QuickDASH, PROMIS-CA physical function, and Toronto extremity salvage score (TESS) at a median of 13 years postoperatively. Results The allograft retention rate was 89%, and an allograft fracture predisposed to conversion to wrist arthrodesis. The reoperation rate was 55% and 36% underwent wrist arthrodesis at a median of 4.2 years following index surgery. The use of locking plate fixation was associated with lower reoperation and allograft fracture rates. Patients reported a median QuickDASH of 10.2 (range: 0-52.3), a mean PROMIS physical function of 57.8 (range: 38.9-64.5) and the median TESS was 95.5 (range: 67.0-98.4). Conclusion Osteoarticular allograft reconstruction results in acceptable long-term patient reported outcomes, despite a high revision rate. Allograft fixation with locking plates seems to reduce the number of reoperations and allograft fractures, along with reduction in wrist arthrodesis rates.

Background: Predicting which patients will do well with arthroscopic triangular fibrocartilage complex (TFCC) debridement alone or which patients may benefit from arthroscopic debridement and ulnar shortening at the same time can be challenging. In this retrospective cohort study, we aimed to assess the rate and type of complications and reoperations after arthroscopic TFCC debridement. Furthermore, we aimed to identify factors associated with reoperation and specifically ulnar shortening osteotomy (USO) after this procedure. Methods: We included 163 patients who underwent arthroscopic TFCC debridement as a first surgery for treatment of their ulnar-sided wrist pain. Patient charts were manually reviewed, and ulnar variance was measured on preoperative posteroanterior radiographs of the wrist. Bivariate analysis and multivariable logistic regression analysis were performed to identify factors associated with reoperation. Additional subgroup analyses looking at USO after TFCC debridement were performed with Kaplan-Meier analysis and Cox regression survival analysis. Results: We found a complication rate of 14% and a reoperation rate of 19% (most common USO with 10%). Chondromalacia was independently associated with reoperation. Forty percent of patients with a positive ulnar variance later proceeded to USO. A hazard ratio of 1.8 per millimeter of ulnar variance was found. Conclusions: Our data suggest that patients with a positive ulnar variance with frank chondral loss at the time of arthroscopic TFCC debridement may benefit from simultaneous USO.

Background Bone grafting during primary reverse shoulder arthroplasty (RSA) is a technique used to restore poor glenoid bone, increase lateralization, and restore abnormal inclination or version. The purpose of this article is to analyze early outcomes of bone grafting during RSA, assessing the influence of technical and patient considerations. Methods In a 4.5-year time period, 137 RSAs with glenoid bone grafting were performed with a minimum 3 months' follow-up. The mean follow-up was 17 months (range, 3-38). The mean age was 71 years (range, 45-89), and body mass index was 28 (range, 19-44). The source of the autografts were humeral head (n = 113) and iliac crest autograft (ICBG; n = 24). The humeral components included 84 onlay and 53 inlay designs. Results Overall, there were 16 complications (12%), of which 6 were major (5%) (3 graft nonunions and 3 infections) and 10 minor (8%) (1 carpal tunnel syndrome and 9 transient axillary neuropraxias). Of the 9 axillary neuropraxias, 8 resolved by the most recent follow-up, whereas 1 patient was lost to follow-up. There were 4 reoperations (3%): 2 for glenoid baseplate loosening, 1 for severe notching associated with severe glenoid bone loss, and 1 for deep periprosthetic infection. One additional patient had a baseplate failure and is undergoing further treatment. There was no difference in the occurrence of graft nonunions, revision surgery, or glenoid component loosening when comparing type of graft or humeral component used. There was an association of revision surgery (P = .02) with ICBG and older age at the time of surgery (P = .02) and an association of transient neuroapraxia with onlay humeral components (P = .01) and workers' compensation cases (P = .04). Conclusions There is a high union rate and low complication rate after bone grafting of the glenoid performed with RSA. Transient neuropraxias are the most frequent complication, but the majority resolve within the first postoperative year. These early findings can serve as the basis for future long-term, comprehensive analysis of complications and outcomes after bone grafting during RSA.

The current understanding of the factors associated with a second surgery or loss of alignment after operative treatment of a proximal humerus fracture has relied on small sample studies with stepwise regression analysis. In this study, we used a powerful regression analysis over a large sample and with many variables to test the null hypothesis that there are no factors associated with a revision surgery or loss of alignment after operative treatment of proximal humerus fractures. A retrospective review of all surgically treated proximal humerus fractures from January 1, 2000, to December 31, 2015, was performed at a tertiary level hospital. We extracted longitudinal medical records for all patients, and the data were organized into two categories of predictors: fracture/operative characteristics and patient characteristics. During the study period, 423 patients met the inclusion criteria. Three hundred and fourteen of the fractures underwent Open Reduction Internal Fixation (ORIF) and 109 underwent Hemiarthroplasty. Thirty-three patients underwent revision surgery (8%). Seventy-nine patients treated with ORIF had loss of alignment (25%). Across the entire cohort, the least absolute shrinkage selection operator (LASSO) analysis found that patients between 40 and 60 years of age had a higher odds of revision surgery (OR = 1.6). In patients treated with ORIF, the LASSO regression found an unreduced calcar to be the strongest predictor of loss of alignment (OR = 5.5), followed by osteoporosis (OR = 1.3), prior radiation treatment (OR = 1.3), unreduced greater tuberosity (OR = 1.2) and age over 80 years (OR = 1.2). Reoperation after proximal humerus surgery is infrequent even though loss of alignment is common. In our cohort, not all patients who had a loss of alignment underwent revision surgery; consequently, obtaining the best possible reduction at the index surgery is paramount.

Background: The goals of this study are to describe the reoperation rates in patients who underwent Wilson osteotomy compared with patients who underwent carpometacarpal (CMC) arthroplasty for early-stage arthritis and to evaluate the factors influencing the patient-reported outcomes. Methods: Retrospectively, 52 patients who underwent surgery for stage I/II osteoarthritis of the thumb carpometacarpal were identified, consisting of 17 (33%) patients who underwent Wilson osteotomy and 35 (67%) who underwent carpometacarpal arthroplasty. A total of 28 (55%) patients completed the outcome questionnaires, consisting of 11 (39%) patients who underwent Wilson osteotomy and 17 (61%) patients who underwent carpometacarpal arthroplasty. We performed a multivariable linear regression model to identify factors associated with the Numeric Rating Scale (NRS) pain intensity at final follow-up. Results: Among the patients who underwent CMC arthroplasty, 2 had a reoperation. Among the patients who underwent Wilson osteotomy, 3 had a reoperation. Among the patients who completed the outcome questionnaires, the median quick Disabilities of the Arm, Shoulder and Hand score was 10 and the median NRS Pain Intensity score was 0. In multivariable analysis, the postoperative Patient-Reported Outcomes Measurement Information System Pain Interference (PROMIS PI) was independently associated with higher postoperative NRS pain scores. Conclusion: In younger patients with stage I/II CMC osteoarthritis, Wilson osteotomy may be a reasonable alternative to CMC arthroplasty. Outcomes were similar between both groups at mid-term follow-up, with only a slightly higher pain score in the osteotomy group. In patients with stage I/II carpometacarpal osteoarthritis, the PROMIS PI is the main factor indicating successful outcomes.

Background Our primary aim was to develop a prediction model for return to the operating room (OR) after open finger fractures by studying the reoperation rate of open finger fractures based on patient demographics, injury mechanism, injury severity, and type of initial surgical fixation. The secondary aim was to study the predictors for secondary surgery due to nonunion, postoperative infection, and secondary amputation. Methods In the retrospective chart review, 1321 open finger fractures of 907 patients were included. Demographic-, injury-, and treatment-related factors were gathered from medical records. Results We found that open fractures involving the thumb had lower odds of undergoing secondary surgery. Crush injury, proximal phalangeal fracture, arterial injury, other injured fingers, and other injuries to the ipsilateral hand were associated with higher odds of undergoing secondary surgery. However, the associated factors we identified were not powerful enough to create a predictive model. Other injury to the ipsilateral hand, vein repair, and external fixator as initial treatment were associated with postoperative nonunion. Crush injury and proximal phalangeal fracture were associated with postoperative infection. No factors were associated with secondary amputation. Conclusions A quarter of open finger fractures will likely need more than one surgical procedure, especially in more severely injured fingers, due to crush or with vascular impairment. Furthermore, fractures involving the thumb have less reoperation, while fractures involving the proximal phalanx have poorest outcomes.

Background: To evaluate the impact of coronavirus disease 2019 (COVID-19) on the clinical practice, health, and quality of life of Brazilian hand surgeons when only essential services and emergency procedures were being provided. Method: A questionnaire of 50 questions was sent to members of the Brazilian Society of Hand Surgery addressing work and life routines before the pandemic and during the initial quarantine period from April to August 2020. Results: Two hundred ten hand surgeons answered the questionnaire; 55.2% lived in the southeast region and worked in the capital and metropolitan regions, in both the private and public systems. Thirty-eight percent of the sample had other sources of income besides medicine, and due to a drop of 50% or more in the volume of consultations and surgeries, one-third had to apply for financial loans or access personal savings, and 69% made financial cuts in their domestic and life routines. More than 40% gained weight and stopped doing physical activities, while 20% lost weight and started physical activities. Approximately 30% were diagnosed with COVID-19, 92% of whom had mild symptoms and quarantined at home, and 89% had psychological symptoms such as anxiety, fear, insecurity, and insomnia. Conclusions: Coronavirus disease 2019 had a significant impact on the lives of Brazilian hand surgeons by drastically reducing the number of consultations and surgical procedures, generating not only financial difficulties but also changes in the exercise routine, changes in body weight, associated psychological symptoms, and changes in the family/life routine.

Background The addition of 3D CT scans for observers evaluating tibial plateau fractures decreases agreement and diagnostic accuracy, possibly due to obstruction of the view by unfractured bones (i.e., patella, fibula, and femur) in 3D reconstructions. Questions/purposes This study compared 1) the interobserver agreement between (subgroups of) observers classifying 3DCT reconstructions of tibial plateau fractures according to Schatzker, Luo, and AO/OTA, 2) recognition of different fracture characteristics, and 3) the level of confidence on a scale from 0 to 10 with and without subtraction of the unfractured bones. Methods We selected twenty consecutive 3DCT reconstructions of tibial plateau fractures treated in a level I trauma center between 2013-2014. Members of the [blinded] were randomized (1:1) to evaluate reconstructions with or without subtraction of the unfractured bone. Forty-nine surgeons completed the survey. The interobserver agreement was determined using Fleiss’ kappa, and bootstrapping (resamples = 1000) was used to calculate the standard error, z statistic, and confidence intervals. Results Overall, subtraction of unfractured bones did not affect interobserver agreement in Schatzker, Luo, and AO/OTA classification systems, agreement on the presence of fracture characteristics, and level of confidence. In subgroup analysis, non-trauma surgeons had significantly higher agreement in the three classification systems with subtraction. For fracture characteristics, some subgroups had higher agreement while others had lower agreement with subtraction. Discussion The finding that agreement on classification of tibial plateau fractures is limited on 3DCT scan and is not improved by subtraction of unfractured bones suggests that disagreement may be based on variations in understanding and bias. Reliability of these classification systems might benefit from a focus on accounting for these pre-existing conceptualizations rather than further emphasis on imaging detail. Level of Evidence Diagnostic, level 1

Aims We quantitatively compared the 3D bone density distributions on CT scans performed on scaphoid waist fractures subacutely that went on to union or nonunion, and assessed whether 2D CT evaluations correlate with 3D bone density evaluations. Methods We constructed 3D models from 17 scaphoid waist fracture CTs performed between four to 18 weeks after fracture that did not unite (nonunion group), 17 age-matched scaphoid waist fracture CTs that healed (union group), and 17 age-matched control CTs without injury (control group). We measured the 3D bone density for the distal and proximal fragments relative to the triquetrum bone density and compared findings among the three groups. We then performed bone density measurements using 2D CT and evaluated the correlation with 3D bone densities. We identified the optimal cutoff with diagnostic values of the 2D method to predict nonunion with receiver operating characteristic (ROC) curves. Results In the nonunion group, both the distal (100.2%) and proximal (126.6%) fragments had a significantly higher bone density compared to the union (distal: 85.7%; proximal: 108.3%) or control groups (distal: 91.6%; proximal: 109.1%) using the 3D bone density measurement, which were statistically significant for all comparisons. 2D measurements were highly correlated to 3D bone density measurements (Spearman’s correlation coefficient (R) = 0.85 to 0.95). Using 2D measurements, ROC curve analysis revealed the optimal cutoffs of 90.8% and 116.3% for distal and proximal fragments. This led to a sensitivity of 1.00 if either cutoff is met and a specificity of 0.82 when both cutoffs are met. Conclusion Using 3D modelling software, nonunions were found to exhibit bone density increases in both the distal and proximal fragments in CTs performed between four to 18 weeks after fracture during the course of treatment. 2D bone density measurements using standard CT scans correlate well with 3D models. In patients with scaphoid fractures, CT bone density measurements may be useful in predicting the likelihood of nonunion. Cite this article: Bone Joint J 2020;102-B(9):1200–1209.

Purpose Giant cell tumors (GCT) of the distal radius are thought to be more aggressive than in other locations. Therefore, the aim of this study was to investigate factors associated with recurrence of GCTs in the upper extremity. Methods We retrospectively identified 82 patients who underwent primary surgical treatment for an upper extremity GCT. Tumors were located in the radius (n = 47), humerus (n = 17), ulna (n = 9), and hand (n = 9). Treatment consisted of either wide resection or amputation or intralesional resection with or without adjuvants. A multivariable logistic regression was performed including tumor grade, type of surgery, and tumor location, from which the percentage of contribution to the model of each variable was calculated. Results The recurrence rate after intralesional resection was 48%; after wide resection or amputation, it was 12%. Two patients developed a pulmonary metastasis (2.4%). In multivariable analysis, intralesional resection was independently associated with recurrence. Intralesional resection had a 77% contribution to predict recurrence and the distal radius location had a 16% contribution in the predictive model. Conclusions As expected, intralesional resection was the strongest independent predictor of recurrence after surgical treatment for GCT. The distal radius location contributed to the prediction of giant cell tumor recurrence to a lesser extent. Type of study/level of evidence Prognostic IV.

Background Local health care facilities are often unequipped to treat complex upper extremity injuries, and patients are therefore transferred to designated trauma centers. This study describes the characteristics of patients transferred to a Level I trauma center for hand and upper extremity injuries and to investigate the accuracy of the provided diagnosis at the time of referral. Methods Adult patients transferred from outside facilities to the authors' Level I trauma center by means of direct contract with the on-call fellow for the care of hand and upper extremity injuries were identified. Patient- and injury-related information was prospectively collected at the time of referral before patient transfer, and again following diagnostic evaluation by a hand surgeon at the authors' institution. Results Sixty-three patients were transferred to the authors' hand surgery service from outside facilities after direct contact with the on-call fellow. Most patients were referred by emergency medicine physicians [n = 47 (76 percent)], followed by midlevel emergency department providers (physician assistant or nurse practitioner) [n = 12 (19 percent)] or hand surgeons [n = 3 (5 percent)]. Six patients were transferred directly from a Level I trauma center. Twenty-one transferred patients (33 percent) had an inaccurate diagnosis at the time of referral. Factors associated with an inaccurate diagnosis included trauma level of the referring hospital and diagnoses of infection or dysvascularity. Conclusions The diagnostic accuracy for hand injuries transferred from outside facilities by means of provider-to-provider communication is imperfect, and some injuries are misdiagnosed. Hand surgeons should continue to improve the triage and transfer process for patients with acute hand surgery injuries. Clinical question/level of evidence Diagnostic, IV.

Background: Benign soft-tissue tumors of the hand are more common than both their benign bone and malignant soft-tissue counterparts. This study evaluates the characteristics and treatment of benign soft tissue tumors in light of 1 institution’s experience. Methods: Histologically confirmed benign soft-tissue tumors of the hand were retrospectively identified using International Classification of Disease codes from 1992 to 2015. A medical chart review was conducted to collect patient demographics, tumor epidemiology, and treatment. Results: A total of 199 soft-tissue tumors were identified. The median patient age at time of treatment was 47.4 ± 14.7 years in age. The majority of tumors were located in the digits (n = 168, 84%) and treated by excision (n = 191, 96%). Localized type tenosynovial giant cell tumors (n = 71, 36%) were the most common and had the highest rates of recurrence (8.5%) in this series. Other frequent histologies included hemangioma, schwannoma, and glomus tumors. Conclusion: Awareness and understanding of tumor characteristics may help physicians with diagnosis and treatment. There is an extensive variety of tumors, but the principles of clinical and imaging diagnosis are common to all of them. Marginal excision for the treatment pain, improvement of function, and cosmetic correction applies to all these tumors independent of the histology.

Background: The aim of flexor pollicis longus (FPL) repair is to create a construct that is strong enough to withstand forces encountered during rehabilitation and to achieve an optimal active range of motion. The aim of this study was to: (1) assess factors influencing active thumb interphalangeal (IP) joint flexion; and (2) assess the factors associated with reoperation. Methods: Retrospectively, 104 patients with primary repair of a Zone II FPL laceration from 2000 to 2016 were identified. A medical chart review was performed to collect patient-, injury-, and surgery characteristics as well as the degree of postoperative active IP-flexion and occurrence of reoperation. Bivariate analyses were performed to identify factors influencing active IP-flexion and factors associated with reoperation. Results: The reoperation rate was 17% (n = 18) at a median of 3.4 months (range: 2.3-4.4). Indications for reoperation mainly included adhesion formation (n = 10, 56%) and re-rupture (n = 5, 28%). The median range of active IP-flexion was 30° (interquartile range [IQR]: 20-45) at a median of 12.4 weeks (IQR: 8.1-16.7). Solitary injury to the thumb (β = 17.9, P = .022) and the use of epitendinous suture (β = 10.0, P = .031) were associated with increased active IP-joint flexion. No factors were statistically associated with reoperation. Conclusions: About 1 in 5 patients undergo reoperation following primary repair of a Zone II FPL laceration, mostly within 6 months of initial surgery. The use of epitendinous suture is associated with greater active IP-flexion. Patients with multiple digits injured accompanying a Zone II FPL laceration have inferior IP-joint motion.

BACKGROUND: The regulatory focus theory posits that, in general, people tend to be predominantly “promotion focused” or “prevention focused”, and each individual’s values and motivations influence which approach he or she may use when pursuing personal goals. People who are primarily promotion focused mostly see goals as opportunities to gain or advance (that is, play to win); people who are prevention focused mostly see goals as opportunities to stay safe (that is, play not to lose). Understanding the role of regulatory focus in the recovery of patients with orthopaedic conditions could provide novel insight into how surgeons can best communicate with patients to improve how they recover from illness or injury. QUESTION/PURPOSE: Are improvements in pain intensity and disability over 6 months associated with a patient’s levels of promotion focus or prevention focus? METHODS: In this longitudinal observational study, we enrolled 144 patients with an upper extremity orthopaedic illness at a tertiary teaching hospital and followed them for 6 months. At baseline, patients completed validated self-reported measures of regulatory focus (Regulatory Focus Questionnaire), pain (Numerical Rating Scale), disability (the QuickDASH), and demographics. Assessments were repeated 6 months later, with 76% (110 of 144) of patients completing follow-up assessments. We examined whether regulatory focus was associated with recovery outcomes (level of pain and disability at 6 months). The patient’s regulatory focus was graded as two numerical scores on separate promotion-focus and prevention-focus continuums. Each individual received a score on promotion focus and one on prevention focus.. RESULTS: An individual’s level of promotion (ΔR(2) = 0.021; p = 0.03; small effect size), but not his or her level of prevention (ΔR(2) = 0.003; p = 0.35; negligible effect size), was associated with improvement in disability over a 6-month period (R(2) = 0.61; p < 0.001). Patients with high promotion (n = 20, b = 0.284; p = 0.001) had the greatest improvements in disability after 6 months compared with patients with moderate (n = 73, b = 0.422; p < 0.001) or low (n = 17, b = 0.561; p < 0.001) promotion. The levels of promotion (b = -0.22; p = 0.09) and prevention (b = -0.04; p = 0.65) were not associated with pain over time. CONCLUSIONS: To support improvements in disability for patients with upper extremity orthopaedic conditions, surgeons’ communication strategies, including explanations of diagnoses and recovery trajectories, should focus on increasing patients’ level of promotion (for example, by emphasizing gains and promoting positive thinking), rather than prevention (for example, by providing reassurance and problem-solving what might go wrong). LEVEL OF EVIDENCE: Level II, prognostic study.

Objectives Our understanding of distal radius fractures with concomitant scapholunate (SL) diastasis primarily comes from plain radiographs and arthroscopy. The clinical implications of SL diastasis are not clear. The aim of this study is to describe fracture characteristics of distal radius fractures on computed tomography (CT) scans in patients with distal radius fractures and static SL diastasis. Methods We queried our institutional databases to identify patients who were treated for a distal radius fracture, had a CT scan with a wrist-protocol, and static SL diastasis on their CT scan. Our final cohort consisted of 26 patients. We then collected data on their demographics, injury, treatment, evaluated injury patterns, and measured radiographic SL characteristics. Our study cohort consisted of 11 men (42%) and almost half of our cohort (n = 12; 46%) had a high-energy mechanism of injury. The majority of the patients (n = 20; 77%) had operative treatment for their distal radius fracture and two patients (7.7%) had operative treatment of their SL injury. Results The mean SL distance was 3.5 ± 1.1 mm. Twenty patients (77%) had an intra-articular fracture. In these patients, we observed three patterns: (1) scaphoid facet impaction; (2) lunate facet impaction; and (3) no relative impaction. We observed other injury elements including rotation of the radial styloid relative to the lunate facet and partial carpal subluxations. Conclusion Static SL dissociation in the setting of distal radius fractures may be an indication of a complex injury of the distal radius, which may not be directly apparent on plain radiography. If these radiographs do not demonstrate impaction of the lunate or scaphoid facet, a CT scan may be warranted to have a more detailed view of the articular surface. Level of Evidence This is a Level III, diagnostic study.

Background: Benign tumors of the hand present in a wide array of histological subtypes and compose most of the bony tissue tumors in the hand. This study evaluates the characteristics and treatment of benign bone tumors in light of one institution’s experience. Methods: Histologically confirmed benign tumors of the hand were retrospectively identified using International Classification of Diseases codes from 1992 to 2015. A medical chart review was conducted to collect patient characteristics and tumor epidemiology and treatment. Results: A total of 155 benign bone tumors were identified. The median age of patients at the time of surgery was 39.9 ± 12.8 years. All bone tumors were located in the digits, and most were treated by intralesional curettage (n = 118, 76%). Pathologic fractures occurred in 79 bone tumors (51%). Conclusion: Enchondromas (n = 118, 76%) were the most common bone tumor in this series, whereas giant cell tumors were the most destructive and also had the highest recurrence rate (40%). Awareness of tumor features may help physicians with diagnosis, and awareness of recurrence rates is important when counseling patients.

BACKGROUND Long-term follow-up studies are an important tool in the evaluation of orthopaedic illness and its treatment options. However, a patient's participation in a follow-up study may be affected by several factors, leading to variability in response rates and the risk of selection bias. QUESTIONS/PURPOSES (1) What is the average response rate in hand surgery questionnaire studies? (2) What factors are associated with higher and lower response rates to research questionnaires? (3) What factors are associated with higher and lower contact, initial participation, and completion rates? METHODS We included 798 adult patients who were enrolled in one of 12 questionnaire follow-up studies in the hand and upper extremity service of our institution. All included studies evaluated patient-reported outcomes for the surgical treatment of upper extremity conditions using questionnaires and all used the same enrollment design. Patients were invited by letter to ask if they would be willing to participate, and we informed them that they would be contacted by telephone at least three times if they did not respond to the letter. Patients were contacted at a median of 6.6 years (interquartile range [IQR] 3.7 to 11) after surgery. The successful response rate was 49% (390 of 798 patients). We manually reviewed records to collect data on patient characteristics, and we performed bivariate analysis and multivariable logistic regression analysis to identify factors associated with the contact rate (percentage of patients reached by either mail, phone, or email), initial response rate (percentage of reached patients who initiated participation), completion rate (percentage of patients who initiated participation and completed the entire follow-up questionnaire), and our primary outcome successful response rate (percentage of patients who were contacted and who completed the entire questionnaire). RESULTS The average response rate in hand surgery questionnaire studies was 49% (390 of 798 patients). In the multivariable analysis, enrollment of women (odds ratio 1.43 [95% confidence interval 1.03 to 1.97]; p = 0.031) was independently associated with higher response rates. On the contrary, a longer follow-up time from surgery (OR 0.95; 95% CI 0.92 to 0.99]; p = 0.015) and multiple researchers contacting patients (OR 0.51 [95% CI 0.37 to 0.71]; p < 0.001) were independently associated with lower response rates. The contact rate was higher for women (OR 1.46 [95% CI 1.03 to 2.06]; p = 0.034) and patients with higher income (OR 1.000007 [95% CI 1.000001 to 1.000013]; p = 0.019). The contact rate was lower in patients with a longer follow-up time from surgery (OR 0.93 [95% CI 0.90 to 0.97]; p = 0.001). The initial participation rate was lower when patients were contacted by multiple researchers (OR: 0.34 [95% CI 0.23 to 0.52]; p < 0.001). Studies with a lower number of questions (36; IQR 22 to 46) were completed more frequently than studies with a higher number of questions (51; IQR 39 to 67; p = 0.044). CONCLUSIONS Studies assessing long-term outcomes that have a large proportion of men and longer follow-up time tend to have lower response rates. When performing a follow-up study, it seems beneficial to have one researcher contact the patients and use a shorter questionnaire. Results of this study can help clarify the response rates in hand surgery follow-up questionnaire studies and help with the planning of future follow-up studies. LEVEL OF EVIDENCE Level II, prognostic study.

Introduction The main aim of the study was to investigate the survival and health-related quality of life (HRQoL) after hospitalization for necrotizing soft tissue infections (NSTIs) of the upper extremity. Materials and Methods A retrospective study with long-term follow-up of patients surviving NSTIs of the upper extremity was performed. Survival and HRQoL after hospital discharge were the primary outcomes. The HRQoL was measured using the 36-item Short Form (SF-36), EuroQoL-5D-5L (EQ-5D), Quick Disability of Shoulder, Arm and Hand (QuickDASH), and numeric rating scales (NRS) for satisfaction with appearance and pain. Results A median of 6.5 years after hospitalization, 81% of the 108 patients survived. The response rate was 45% (n = 38). The SF-36 score was 80 (interquartile range [IQR]: 58–91), the EQ-5D score 1.4 (IQR: 1.2–2.2), the EuroQoL-Visual Analog Scale score 77 (IQR: 67-90), the QuickDASH score 13.6 (IQR: 2.3-30.7), the NRS for satisfaction with appearance 8 (IQR: 7–9), and NRS for pain 1 (IQR: 0-5). Conclusion Six-and-a-half years after the NSTI, 81% of the patients were still alive. General health prior to the NSTI mainly influenced the risk at secondary mortality. In surviving patients, the HRQoL varied widely, but was adversely affected by female sex, intravenous drug use, NSTI type I or III, and longer length of hospital stay.

National registries provide useful information in understanding outcomes of surgeries that have late sequelae, especially for rare operations such as total elbow arthroplasty (TEA). A systematic search was performed and data were compiled from the registries to compare total elbow arthroplasty outcomes and evaluate trends. We included six registries from Australia, the Netherlands, New Zealand, Norway, the United Kingdom and Sweden. Inflammatory arthritis was the most common indication for total elbow arthroplasty, followed by acute fracture and osteoarthritis. When comparing 2000–2009 to 2010–2017 data, total elbow arthroplasty for inflammatory arthritis decreased and total elbow arthroplasty for fracture and osteoarthritis increased. There was an increase in the number of revision TEAs over this time period. The range of indications for total elbow arthroplasty is broadening; total elbow arthroplasty for acute trauma and osteoarthritis is becoming increasingly more common. However, inflammatory arthritis remains the most common indication in recent years. This change is accompanied by an increase in the incidence of revision surgery. Cite this article: EFORT Open Rev 2020;5:215-220. DOI: 10.1302/2058-5241.5.190036

Background Many surgical techniques are used to treat symptomatic neuroma, but options are limited for digital neuromas because of a paucity of soft-tissue coverage and/or the absence of the terminal nerve end. The authors assessed factors that influence patient-reported outcomes after surgery for symptomatic digital neuroma. Methods The authors retrospectively identified 29 patients with 33 symptomatic digital neuromas that were treated surgically. Patients completed the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity and Pain Interference scales, a numeric rating scale for pain, and the PROMIS Depression scale at a median follow-up of 7.6 years postoperatively (range, 3.2 to 16.8 years). Surgical treatment for neuroma included excision with nerve repair/reconstruction (n =13; 39 percent), neuroma excision alone (n =10; 30 percent), and excision and implantation (n =10; 30 percent). Multivariable linear regression was performed to identify the factors that independently influenced patient-reported outcomes. Results The mean postoperative PROMIS Upper Extremity score was 45.2 ± 11.2, the mean Pain Interference score was 54.3 ± 10.7, and the mean numeric rating scale pain score was 3 (interquartile range, 1 to 5). Compared with other treatment techniques, neuroma excision with nerve repair/reconstruction was associated with lower numeric rating scale pain scores; lower Pain Interference scores, corresponding to less daily impact of pain; and higher Upper Extremity scores, reflecting better upper extremity function. Older age and higher Depression scores were associated with lower Upper Extremity scores and higher Pain Interference scores. Smoking was associated with higher Pain Interference and numeric rating scale pain scores. Conclusions Neuroma excision followed by nerve repair/reconstruction resulted in better outcomes compared with neuroma excision alone with or without implantation. Patient age and psychosocial factors influenced patient-reported outcomes. Clinical question/level of evidence Risk, III.

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

Introduction: The primary objective of this study is to determine whether time from injury to fasciotomy is associated with increased risk for death or limb amputation in patients with acute leg compartment syndrome. The secondary objective of this study is to identify other risk factors for death or limb amputation in patients with acute leg compartment syndrome. Methods: In an institutional review board approved retrospective study, we identified 546 patients with acute compartment syndrome of 558 legs treated with fasciotomies from January 2000 to June 2015 at two Level I trauma centers. Our primary outcome measures were death and limb amputation during inpatient hospital admission. Electronic medical records were analyzed for patient-related factors and treatment-related factors. Bivariate analyses were used to screen for variables associated with our primary outcome measures, and explanatory variables with a p value below 0.05 were included in our multivariable logistic regression analyses. Results: In-hospital death occurred in 6.6% and in-hospital limb amputation occurred in 9.5% of acute leg compartment syndrome patients. Neither death nor limb amputation was found to be associated with time from injury to fasciotomy. Multivariable logistic regression analyses showed that older age (p = 0.03), higher modified Charlson Comorbidity Index (p = 0.009), higher potassium (p = 0.02), lower hemoglobin (p = 0.002), and higher lactate (p < 0.001) were associated with death, and diabetes mellitus (p = 0.05), no compartment pressure measurement (p = 0.009), higher PTT (p = 0.03), and lower albumin (p = 0.01) were associated with limb amputation. Conclusions: Time to fasciotomy is not found to be associated with death or limb amputation in acute leg compartment syndrome. Death and limb amputation are associated with patient-related factors and injury severity. Level of evidence: Level III Prognostic.

In this cohort study, we report on short-term outcomes of 203 patients (203 wrists) who underwent scapholunate ligament reconstruction using a three-ligament tenodesis technique between December 2013 and December 2017. Patients completed the Patient Rated Wrist Evaluation questionnaire and a visual analogue scale for pain online before surgery and at 3 months and 1 year after surgery. We also measured the range of movement before surgery, in 150 patients 3 months after surgery, and in 90 patients 1 year after surgery. The patients reported clinically significant improvements in both pain and function postoperatively, with continuing improvement at both 3 and 12 months. We conclude that the short-term outcomes of this procedure are generally good in term of patients’ function, satisfaction, and pain relief, but about 20% of the operated wrists did not improve. Our data may help patients and surgeons in joint decision-making regarding treatment for chronic scapholunate injuries. Level of evidence: III

Objective Since 1958, more than 50 postresidency fellowship programs in hand surgery have been introduced within the United States. Ongoing changes in health care and medical education necessitate the evaluation of these fellowships. The purpose of this study is to identify trends in operative experience over time regarding procedure volume, surgery type, and anatomic region. Materials and Methods National Accreditation Council for Graduate Medical Education (ACGME) case logs of graduating orthopaedic hand surgery fellows were evaluated for years 2011 to 2019. Procedures were grouped according to ACGME-defined categories for hand surgery. The mean number of procedures per fellow in each category was trended over time using a Mann–Kendall test. Results All 1,257 fellows were included. The mean number of procedures completed annually by each fellow increased from 797.6 in 2011 to 945.6 in 2019 (p Conclusion There has been an increase in the number of procedures performed by orthopaedic hand surgery fellows over the past decade. This appears to be due to the increase in nerve, fracture, and soft tissue categories, and there has been a decrease in the number of congenital cases completed. These data confirm that the operative experiences for most hand surgery fellows are robust and growing over time.

Ongoing concern for declining Medicare payment to surgeons may incentivize surgeons to perform more cases to maintain productivity goals. The authors evaluated trends in physician payment, patient charges, and reimbursement ratios for the most common hand and upper extremity surgical procedures.The authors examined Medicare surgeon payment, patient charges, and surgical volume from 2012 to 2017 for 83 common surgical procedures, incorporating the year-to-year Consumer Price Index to adjust for inflation. The reimbursement ratio was calculated by dividing payment by charge. Weighted (by surgery type and volume) averages were calculated.Total Medicare surgeon payment increased 5.6 percent to $272 million for the studied procedures. Patient charges were seven times greater than payment, growing 24 percent to $1.9 billion. Despite growth of total payment, the average overall weighted payment for a single surgery decreased 3.5 percent. The average weighted patient charge increased 8 percent, whereas the reimbursement ratio decreased 13 percent. A hand surgeon would need to perform three more cases per 100 in 2017 to maintain the same reimbursement received in 2012. After categorizing these 83 surgical procedures, distal radius fixation (3 parts, 21 percent increase;2-part intra-articular, extra-articular, and percutaneous pinning, 17 percent increase), bony trauma proximal to the distal radius (10 percent increase), and upper extremity flap (5 percent increase) were subject to the greatest increases in payment. Payment for forearm fasciotomy (39 percent decrease), endoscopic carpal tunnel release (30 percent decrease), and mass excisions proximal to the wrist (18 percent decrease) decreased the most.From 2012 to 2017, despite a disproportionate increase in procedure charges, Medicare surgeon payment has not decreased substantially; however, total reimbursement is multifactorial and involves multiple sources of revenue and cost.