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Background: A primary challenge in the treatment of capitellar osteochondritis dissecans (OCD) is accurate imaging assessment. Radiographic classification consensus is not available in the current literature, and correlation of radiographs with lesion stability and resultant best treatment is lacking. Purpose: To determine the inter- and intrarater reliability of the presence or absence and common radiographic characteristics of capitellar OCD lesions. Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: Anteroposterior, lateral, and oblique radiographs for 29 cases were reviewed by 7 orthopaedic surgeons. Images were assessed for elbow anthropometry and morphology, OCD presence, lesion characteristics, the presence of progeny bone and progeny features, and radial head abnormalities. Intra- and interrater reliability was assessed using Fleiss and Cohen kappa for nominal variables and intraclass correlation coefficients (ICCs) for continuous variables. Results: Surgeons demonstrated substantial to excellent inter- and intrarater reliability when assessing elbow characteristics: anthropometric (interrater ICC, 0.94-0.99; intrarater ICC, 0.82-0.96) and morphologic (Fleiss, 0.61-0.76; Cohen, 0.68). When the OCD lesion was assessed, fair to moderate interrater agreement was found for classifying the absence or presence of a lesion (Fleiss, 0.28-0.46) and the location of the OCD (Fleiss, 0.24-0.52), poor agreement for assessing the contour of the lesion (Fleiss, 0.00-0.09), and excellent agreement for measuring the size of the lesion (ICC, 0.82-0.94). Poor to fair interrater agreement was found for radial head abnormalities (Fleiss, 0.00-0.27). Progeny bone visualization and fragmentation demonstrated moderate interrater agreement (Fleiss, 0.43-0.47) where displacement of the bone demonstrated poor interrater agreement (Fleiss, 0.11-0.16). Intrarater agreement for OCD lesion characteristics, progeny bone visualization, and progeny bone features was moderate to excellent. Conclusion: Given only the fair to moderate agreement among raters for identifying OCD on radiographs, this imaging modality may not serve as a dependable screening tool in isolation. Additional imaging should be obtained if the clinical presentation suggests capitellar OCD and a definitive diagnosis is not possible with radiographs. However, clinicians can reliability measure the size of radiographically apparent OCD, suggesting that radiographs may serve as an appropriate imaging modality for follow-up care. [ABSTRACT FROM AUTHOR]

Syndactyly surgical release is one of the most common congenital hand surgeries performed by pediatric hand surgeons. The purpose of our study was to evaluate the complications associated with syndactyly release and determine factors that correlate with higher complication rates within the 2-year postoperative period. A retrospective chart review was completed for patients who underwent syndactyly release at a single pediatric center between 2005 and 2018. Patients were included if they had a diagnosis of syndactyly and underwent surgical release, and excluded for a diagnosis of cleft hand, incomplete surgical documentation, surgery performed at an outside institution, or follow-up care that did not extend beyond the first postoperative visit. Complications were classified using the Clavien-Dindo (CD) system. Fifty-nine patients met the inclusion criteria, which included 143 webs released in 85 surgeries. A total of 27 complications occurred for the 85 surgeries performed. The severity of complications was CD grade I or II in 23% of surgeries, most commonly unplanned cast changes, and CD grade III in 8% of surgeries. No CD grade IV or V complications occurred. The CD grade III complications included 6 reoperations. The complication rate was higher when performing >1 syndactyly release per surgery. It also was higher for patients undergoing >1 surgical event. Rates of complication per surgery were similar between patients with multiple surgeries compared with those with a single surgery. Concomitant diagnoses and complexity of syndactyly was not associated with a higher complication rate. Syndactyly release was associated with a complication rate of 31% per surgical event with 44% of these complications related to unplanned cast changes and 8% of complications that required admission or reoperation. Risk factors for complications following syndactyly release include >1web operated on per surgery and undergoing >1 surgical event. Prognosis IV. [ABSTRACT FROM AUTHOR]

Three commonly used classifications for thumb polydactyly are the Wassel-Flatt, Rotterdam, and Chung. The ideal classification system would have high validity and reliability and be descriptive of the thumb anomaly. The purposes of this investigation were to (1) compare the inter- and intrarater reliability of these 3 classifications when applied to a large sample of patients enrolled in the Congenital Upper Limb Differences (CoULD) Registry and (2) determine the prevalence of radial polydactyly types when using the various classifications in a North American population. Inter- and intrarater reliability were determined using 150 cases of radial polydactyly presented in a Web-based format to 7 raters in 3 rounds, a preliminary training round and 2 observation rounds. Raters classified each case according to the Wassel-Flatt, Rotterdam, and Chung classifications. Inter- and intrarater reliability were evaluated with the intraclass correlation coefficient (ICC) calculated using 2-way random measures with perfect agreement. For Wassel-Flatt, both the interrater (ICC, 0.93) and the intrarater reliability (ICC, 0.91) were excellent. The Rotterdam classification had excellent reliability for both interrater reliability (ICC, 0.98) and intrarater reliability (ICC, 0.94), when considering type alone. Interrater analysis of the additional subtypes demonstrated a wide range of reliabilities. The Chung classification had good interrater (ICC, 0.88) and intrarater reliability (ICC, 0.77). Within the Wassel-Flatt classification, the most frequent unclassifiable thumb was a type IV hypoplastic thumb as classified by the Rotterdam classification. The Wassel-Flatt and Rotterdam classifications for radial polydactyly have excellent inter- and intrarater reliability. Despite its simplicity, the Chung classification was less reliable in comparison. The Chung and Rotterdam classification systems capture the hypoplastic subtypes that are unclassifiable in the Wassel-Flatt system. Addition of the hypoplastic subtype to the Wassel-Flatt classification (eg, Wassel-Flatt type IVh) would maintain the highest reliability and classify over 90% of thumbs deemed unclassifiable in the Wassel-Flatt system. The Wassel-Flatt and Rotterdam classifications have excellent inter-and intrarater reliability for the hand surgeon treating thumb polydactyly. Addition of a hypoplastic subtype to the Wassel-Flatt (Type 4h) allows classification of most previously unclassifiable thumbs. [ABSTRACT FROM AUTHOR]

Background: Deficiency of the radial aspect of the forearm and hand is the most common congenital longitudinal deficiency of the upper limb. Radial longitudinal deficiency is associated with several named syndromes. The purpose of the present study was to explore patterns of radial longitudinal deficiency and thumb hypoplasia in syndromes and to examine the severity of these differences across various syndromes.Methods: Data were collected from the Congenital Upper Limb Differences (CoULD) registry. Congenital differences are classified in the registry with use of the Oberg-Manske-Tonkin (OMT) classification system. Diagnosis of a syndrome by a physician as noted in the CoULD registry was recorded. Thumb deficiency and radial deficiency were classified according to the modified versions of the Blauth criteria and the Bayne and Klug criteria, respectively.Results: We identified 259 patients with 383 affected limbs with radial deficiency. Eighty-three of these patients had a diagnosed syndrome. The severity of radial deficiency was correlated with the severity of thumb deficiency. The Kendall tau coefficient indicated significant correlation between radial severity and thumb severity (tau = 0.49 [95% confidence interval = 0.40 to 0.57]; p < 0.05). Subjects with a syndrome were twice as likely to have bilateral deficiency and 2.5 times more likely to have both radial and thumb deficiency compared with subjects without a syndrome. Subjects with VACTERL syndrome (vertebral defects, anal atresia, cardiac anomalies, tracheoesophageal fistula, renal anomalies, and limb defects) had patterns of thumb and radial deficiency similar to the general cohort, whereas subjects with Holt-Oram syndrome, TAR (thrombocytopenia absent radius) syndrome, and Fanconi anemia demonstrated varied presentations of thumb and radial deficiency.Conclusions: The present study investigated the characteristics of patients with radial longitudinal deficiency and thumb hypoplasia. Our results support the findings of previous research correlating the severity of radial deficiency with the severity of thumb deficiency. Furthermore, we identified characteristic features of patients with radial longitudinal deficiency and associated syndromes. [ABSTRACT FROM AUTHOR]

Background: Parental leave during graduate medical education is a component of wellness in the workplace. Although every graduate medical education program is required by the Accreditation Council for Graduate Medical Education (ACGME) to have a leave policy, individual programs can create their own policies. The ACGME stipulates that "the sponsoring institution must provide a written policy on resident vacation and other leaves of absence (with or without pay) to include parental and sick leave to all applicants." To our knowledge, a review of parental leave policies of all orthopaedic surgery residency programs has not been performed. QUESTION/PURPOSES: (1) What proportion of orthopaedic surgery residency programs have accessible parental (maternity, paternity, and adoption) leave policies? (2) If a policy exists, what financial support is provided and what allotment of time is allowed?Methods: All ACGME-accredited orthopaedic surgery residency programs in 2017 and 2018 were identified. One hundred sixty-six ACGME-accredited allopathic orthopaedic surgery residency programs were identified and reviewed by two observers. Reviewers determined if a program had written parental leave policy, including maternity, paternity, or adoption leave. Ten percent of programs were contacted to verify reviewer findings. The search was sequentially conducted starting with the orthopaedic surgery residency program's website. If the information was not found, the graduate medical education (GME) website was searched. If the information was not found on either website, the program was contacted directly via email and phone. Parental leave policies were classified as to whether they provided dedicated parental leave pay, provided sick leave pay, or deferred to unpaid Family Medical Leave Act (FMLA) policies. The number of weeks of maternity, paternity, and adoption leave allowed was collected.Results: Our results showed that 3% (5 of 166) of orthopaedic surgery residency programs had a clearly stated policy on their program website. Overall, 81% (134 of 166) had policy information on the institution's GME website; 7% (12 of 166) of programs required direct communication with program coordinators to obtain policy information. Further, 9% (15 of 166) of programs were deemed to not have an available written policy as mandated by the ACGME. A total of 21% of programs (35 of 166) offered designated parental leave pay, 29% (48 of 166) compensated through sick leave pay, and 50% (83 of166) deferred to federal law (FMLA) requiring up to 12 weeks of unpaid leave.Conclusions: Although 91% of programs meet the ACGME requirement of written parental leave policies, current parental leave policies in orthopaedic surgery are not easily accessible for prospective residents, and they do not provide clear compensation and length of leave information. Only 3% (5 of 166) of orthopaedic surgery residency programs had a clearly stated leave policy accessible on the program's website. Substantial improvements would be gained if every orthopaedic residency program clearly outlined the parental leave policy on their residency program website, including compensation and length of leave, particularly in light of the 2019 American Board of Orthopaedic Surgery changes allowing time away to be averaged over the 5 years of training.Clinical Relevance: Parental leave policies are increasingly relevant to today's trainees []. Applicants to orthopaedic surgery today value work/life balance including protected parental leave []. [ABSTRACT FROM AUTHOR]

Background: The opioid epidemic in the United States continues to be problematic as morbidity and mortality rates increase yearly. Orthopaedic surgeons are the third highest prescribing group among physicians. Studies show that orthopaedic surgeons tend to overprescribe opioids, but published data on patient opioid utilization, pain management satisfaction, and national clinical practice guidelines on opioid prescribing are scarce or lacking. Furthermore, little information is available on influences on physician prescribing behavior and whether changes in prescribing habits are lasting.Methods: Using recently published opioid utilization and prescribing guidelines for hand surgery, we created an opioid prescribing quality improvement program with the aim of reducing postoperative opioid prescribing without negatively impacting patient pain satisfaction. The main aspect of the program was the implementation and modification of an opioid prescribing order set, but the program also included surgeon education-executed in 2 intervention steps-about how their prescribing behavior compared with that of their peers. Three phases of data representing 3 months each were collected prior to, between, and after the interventions.Results: Two thousand and sixty-seven hand surgery cases were reviewed (629 in Phase 1, 655 in Phase 2, and 783 in Phase 3). The average number of morphine milligram equivalents (MMEs) was reduced from 142.0 in Phase 1 to 69.9 in Phase 2 (51% reduction) to 61.3 in Phase 3 (57% reduction compared with Phase 1). Significant reductions in MMEs occurred across the procedural categories as well as the hand surgeons. Patient pain satisfaction was similar before and after implementation of the first intervention (p = 0.96).Conclusions: Quality improvement methods were effective in altering prescribing behavior by physicians in the long term, and our approach may be effective if applied more widely. Similar studies on quality improvement methods and prescribing behavior, patient opioid utilization, and patient satisfaction with pain management are needed in other orthopaedic subspecialties.Clinical Relevance: Evidence-based guidelines, a quality improvement process, and unblinded information on prescribing behavior compared with that of peers may result in long-lasting reductions in surgeons' opioid prescribing practices. [ABSTRACT FROM AUTHOR]

A deeper investigation of medical and musculoskeletal conditions in patients with ulnar longitudinal deficiency (ULD) is needed. The association between the severity of the manifestations of ULD in the hands and forearms has not been firmly established. The purpose of this study was to describe the medical and musculoskeletal conditions associated with ULD and examine the relationship between hand and forearm anomalies. The Congenital Upper Limb Differences registry was queried for all patients with a diagnosis of ULD, as defined by the Oberg-Manske-Tonkin classification system, between 2014 and 2020. The patients' demographic information, medical and musculoskeletal comorbidities, radiographs, and clinical images were reviewed. The participants were classified using the Bayne, Cole and Manske, and Ogino classification systems. Of 2,821 patients from the Congenital Upper Limb Differences registry, 75 patients (2.7%) with ULD (14 bilateral), with 89 affected extremities, were included. Hand anomalies were present in 93% of the patients. Approximately 19% of the patients had an associated medical comorbidity, and 20% of the patients had an associated musculoskeletal condition. Cardiac anomalies were present in 8.0% of the patients, and 12% of the patients had a lower extremity abnormality. Radial head dislocation was observed in 13 of 18 patients with Bayne type II or III ULD compared with 8 of 43 patients with other types of unilateral ULD. There was a significant positive association among the Bayne and Ogino, Bayne and Cole/Manske, and Ogino and Cole/Manske classification systems in patients with unilateral ULD. Associated medical and musculoskeletal conditions are common in patients with ULD, of which cardiac and lower extremity abnormalities are most frequently observed. There is a significant positive association between the severity of forearm anomalies and that of hand anomalies in patients with unilateral ULD. All patients with ULD should undergo a thorough cardiac evaluation by their pediatrician or a pediatric cardiologist. Symptom prevalence study III. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective case series. Introduction: Open carpal tunnel release (OCTR) is a common treatment for carpal tunnel syndrome, but there is no consensus on the number of hand therapy visits needed to achieve optimal patient outcomes. Purpose of the Study: The purpose is to examine changes in patient-reported symptoms and function over a 12-week period after OCTR with 1 postoperative hand therapy visit. Methods: Eligible subjects were consecutive patients treated with a standard OCTR protocol by a fellowship trained hand surgeon that included 1 hand therapy visit at 10-14 days postoperatively. Patients were excluded from participation if they had additional surgery at the time of OCTR, had another upper extremity diagnosis that required therapeutic intervention, or received more or less than 1 visit of hand therapy. Responses on the Boston Carpal Tunnel Questionnaire (BCTQ) were collected at preoperative and 3 postoperative time points: at the hand therapy visit, 6 weeks, and 12 weeks. Change over time in the BCTQ Symptom Severity Scale and Functional Status Scale was assessed. Results: A total of 134 patients who were treated with the standard protocol had a complete BCTQ data set. Both BCTQ scales showed significant improvement over time. The Symptom Severity Scale showed significant improvement by the hand therapy visit at 10-14 days postoperatively, whereas significant improvement on the Functional Status Scale did not occur until 6 weeks postoperatively. The magnitude of change from preoperative to 12 weeks postoperative was 1.51 points on the Symptom Severity Scale and 0.91 points on the Functional Status Scale. Complication rates were low with an incidence of 13% for pillar pain and palm pain combined. Conclusions: Patient-reported symptoms and function improved significantly up to 12 weeks after OCTR. Moreover, there was a low incidence of pillar and palm pain. In a retrospective review of patients with a favorable prognosis based on having no need for extra surgical procedures or additional therapy visits, one therapy visit associated with improvements in symptoms and function, a low incidence of pillar/ palm pain and favorable 12-weeks outcomes. There appears to be a subset of less complicated patients for whom one visit can allow for favorable outcomes. Level of Evidence: 2B. [ABSTRACT FROM AUTHOR]

This study reviewed the clinical history and management of acquired growth arrest in the upper extremity in pediatric patients. The records of all patients presenting from 1996 to 2012 with radiographically proven acquired growth arrest were reviewed. Records were examined to determine the etiology and site of growth arrest, management, and complications. Patients with tumors or hereditary etiology were excluded. A total of 44 patients (24 boys and 20 girls) with 51 physeal arrests who presented at a mean age of 10.6 years (range, 0.8-18.2 years) were included in the study. The distal radius was the most common site (n=24), followed by the distal humerus (n=8), metacarpal (n=6), distal ulna (n=5), proximal humerus (n=4), radial head (n=3), and olecranon (n=1). Growth arrest was secondary to trauma (n=22), infection (n=11), idiopathy (n=6), inflammation (n=2), compartment syndrome (n=2), and avascular necrosis (n=1). Twenty-six patients (59%) underwent surgical intervention to address deformity caused by the physeal arrest. Operative procedures included ipsilateral unaffected bone epiphysiodesis (n=21), shortening osteotomy (n=10), lengthening osteotomy (n=8), excision of physeal bar or bone fragment (n=2), angular correction osteotomy (n=1), and creation of single bone forearm (n=1). Four complications occurred; 3 of these required additional procedures. Acquired upper extremity growth arrest usually is caused by trauma or infection, and the most frequent site is the distal radius. Growth disturbances due to premature arrest can be treated effectively with epiphysiodesis or osteotomy. In this series, the specific site of anatomic growth arrest was the primary factor in determining treatment. [Orthopedics. 2017; 40(1):e95-e103.]. [ABSTRACT FROM AUTHOR]

Purpose This study seeks to evaluate the need for preoperative antibiotics for wrist arthroscopy. Methods A retrospective review of 576 consecutive wrist arthroscopies was performed over a 10-year period at a single ambulatory surgery center. The chart of each included patient was reviewed for postoperative infections following the National Nosocomial Infections Surveillance criteria for diagnosis. Results Of the 576 wrist arthroscopies reviewed, 324 met the inclusion criteria. Preoperative antibiotics were administered in 209 cases (65%) and not administered in 115 cases (35%). There were 116 cases (36%) with concomitant open soft tissue procedures. We identified 2 infections (0.6% overall infection rate), both of which were in patients who had received preoperative antibiotics. Both of these patients underwent concomitant percutaneous pinning of carpal bones with Kirschner wires, which were buried beneath the skin. Conclusions Administering preoperative antibiotics for routine wrist arthroscopy does not appear to lower the surgical site infection rate. The rate of surgical site infection is so low in both cohorts that a meaningful difference cannot be determined between the 2 groups. This study adds to the current body of literature suggesting that it is acceptable practice to withhold preoperative antibiotics for surgeries that have a very low rate of infection. Type of study/level of evidence Therapeutic IV. [ABSTRACT FROM AUTHOR]

Purpose To measure and compare hand function for children with normal hand development, congenital hand differences (CHD), and neuromuscular disease (NMD) using a function test with touch screen technology designed as an iPhone application. Methods We measured touch screen hand function in 201 children including 113 with normal hand formation, 43 with CHD, and 45 with NMD. The touch screen test was developed on the iOS platform using an Apple iPhone 4. We measured 4 tasks: touching dots on a 3 × 4 grid, dragging shapes, use of the touch screen camera, and typing a line of text. The test takes 60 to 120 seconds and includes a pretest to familiarize the subject with the format. Each task is timed independently and the overall time is recorded. Results Children with normal hand development took less time to complete all 4 subtests with increasing age. When comparing children with normal hand development with those with CHD or NMD, in children aged less than 5 years we saw minimal differences; those aged 5 to 6 years with CHD took significantly longer total time; those aged 7 to 8 years with NMD took significantly longer total time; those aged 9 to 11 years with CHD took significantly longer total time; and those aged 12 years and older with NMD took significantly longer total time. Conclusions Touch screen technology has becoming increasingly relevant to hand function in modern society. This study provides standardized age norms and shows that our test discriminates between normal hand development and that in children with CHD or NMD. Type of study/level of evidence Diagnostic III. [ABSTRACT FROM AUTHOR]

Purpose To examine the relative presentation frequency of children with upper limb congenital anomalies at 3 Midwestern referral centers using the Oberg, Manske, and Tonkin (OMT) classification and to assess the utility of this new classification system. Methods 641 individuals with 653 congenital upper extremity anomalies were identified at 3 hospitals in 2 large metropolitan areas during a 1-year interval. Patients were identified prospectively and the specific upper extremity anomaly and any associated syndromes were confirmed using medical records and radiographs. We applied the OMT classification that categorizes anomalies using a dysmorphology outline as malformations, dysplasias, deformations, and syndromes, and assessed its utility and ease of use. Results There were 480 extremities (74%) with a limb malformation including 184 involving the entire limb. Arthrogryposis was the most common of these (53 extremities). Anomalies affecting only the hand plate accounted for 62% (296) of the malformations. Of these, radial polydactyly (15%) was the most common specific anomaly, followed by symbrachydactyly (13%) and cleft hand (11%). Dysplasias were noted in 86 extremities; 55 of these were multiple hereditary exostoses. There were 87 extremities with deformations and 58 of these were trigger digits. A total of 109 children had a syndrome or association. Constriction ring sequence was most common. The OMT was straightforward to use and most anomalies could be easily assigned. There were a few conditions, such as Madelung deformity and symbrachydactyly, that would benefit from clarification on how to best classify them. Conclusions Malformations were the most common congenital anomalies in the 653 upper extremities evaluated over a 1-year period at 3 institutions. We were able to classify all individuals using the OMT classification system. Type of study/level of evidence Diagnostic III. [ABSTRACT FROM AUTHOR]

Purpose: The spontaneous recovery rate for locked pediatric trigger thumb (PTT) has recently been reported at between 24% and 66%; these studies concluded that a conservative approach for this condition could be adopted. The aims of this study were to review our results of surgical release of the PTT and to survey pediatric hand surgeons regarding their practice patterns for treatment of the PTT. Methods: After institutional review board approval, we retrospectively reviewed 173 consecutive patients with 217 thumbs treated surgically at our institution. An e-mail survey of 27 pediatric hand surgeons questioned treatment of a 2-year-old child with a 6-month history of a locked trigger thumb and of an intermittently triggering thumb. Results: The retrospective review demonstrated that preoperative range of motion averaged 36° loss of extension (range, 0° to 90°; SD, 22°); postoperative range of motion averaged 1° loss of extension (range, 0° to 30°; SD, 7°) at 27-day follow-up. Using a parent questionnaire at an average follow-up of 4.2 years, there were no major complications or recurrences identified. Five thumbs developed minor skin complications that healed with conservative management. There were no secondary surgeries. The practice pattern survey demonstrated that 85% of pediatric hand surgeons would treat a locked PTT in a 2-year-old with surgical release and 52% would treat an intermittently triggering thumb in a 2-year-old with continued observation if the triggering thumb was not painful. Conclusions: The surgical results reported in this study, along with the practice pattern survey, confirm that surgical release is a short, safe, and effective procedure when performed by specialty trained hand surgeons, and it is the treatment of choice for a locked PTT. Type of study/level of evidence: Therapeutic IV. [ABSTRACT FROM AUTHOR]