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Single center studies are limited by bias, lack of generalizability and variability, and inability to study rare conditions. Multicenter observational research could address many of those concerns, especially in hand surgery where multicenter research is currently quite limited; however, there are numerous barriers including regulatory issues, lack of common terminology, and variable data set structures. The Observational Health Data Sciences and Informatics (OHDSI) program aims to surmount these limitations by enabling large-scale, collaborative research across multiple institutions. The OHDSI uses the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM) to standardize health care data into a common language, enabling consistent and reliable analysis. The OMOP CDM has been transformative in converting multiple databases into a standardized code with a single vocabulary, allowing for coherent analysis across multiple data sets. Building upon the OMOP CDM, OHDSI provides an extensive suite of open-source tools for all research stages, from data extraction to statistical modeling. By keeping sensitive data local and only sharing summary statistics, OHDSI ensures compliance with privacy regulations while allowing for large-scale analyses. For hand surgery, OHDSI can enhance research depth, understanding of outcomes, risk factors, complications, and device performance, ultimately leading to better patient care., Competing Interests: Conflicts of Interest No benefits in any form have been received or will be received related directly to this article., (Copyright © 2025 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Diagnosing acute tissue ischemia is challenging, particularly in patients with higher skin melanin content. We investigated whether near-infrared spectroscopy (NIRS) is effective and consistent in detecting upper extremity ischemia across various skin phenotypes., Methods: Volunteers underwent tourniquet-induced upper extremity ischemia. Skin color was evaluated by the Fitzpatrick scale (FP, range: I-VI) and the Von Luschan scale (vL, range: 1-36). A NIRS probe was placed on one finger. The tourniquet was inflated to 250 mmHg and perfusion was restricted for 7 minutes, followed by a 10-minute monitored reperfusion period. The percent tissue oxygenation (StO 2 ) was recorded., Results: A total of 55 volunteers were enrolled (22 self-identified as Caucasian, 21 African American, 7 Asian, 2 Latinx, and 2 Biracial). Average starting and ending StO 2 for the cohort was 72.2% and 45.9%, respectively. However, there was variability based on skin melanin content. Increasing vL correlated with lower starting StO 2 , smaller StO 2 decrease, and shorter time to reach ischemic steady state. High skin melanin (FP scale IV-VI) was associated with significantly lower starting StO 2 (-7.1%) and shorter time to reach ischemic steady state (-0.3 mins). African Americans had lower starting StO 2 (-8.6%) and 7.8% lesser total StO 2 decrease than other groups., Conclusions: NIRS can rapidly detect acute onset tissue ischemia in the upper extremity. However, given the lower starting StO 2 and smaller total StO 2 decrease after tourniquet-induced ischemia for patients with higher skin melanin, using NIRS for clinical detection of acute ischemia may be more challenging in these patients. These inconsistencies may limit use of NIRS clinically for spot identification of ischemia., Clinical Relevance: Although NIRS has utility in tracking tissue oxygenation, variable performance with different skin melanin content raises concerns as to whether different cutoff/threshold levels are needed for different groups, and whether NIRS is reliable for spot checks in acute events., (Copyright © 2025. Published by Elsevier Inc.)

The opioid epidemic has been a defining crisis in American health care. Many attempts to address the epidemic have focused on issues around opioid prescribing. Legislation at the state and federal levels has been passed; however, the results from these policies have been mixed. Changes to prescription workflows alongside patient and provider education have also had some success. Within hand surgery in particular, recent progress has been made toward promoting opioid-sparing regimens for postoperative pain, including nonopioid and limited-opioid protocols. These regimens offer promise particularly in the setting of ambulatory surgeries, especially soft tissue procedures, and potentially in more invasive and complicated surgical settings. However, there are downsides and failures from these protocols that must be addressed, such as limited data on bony and complex soft tissue procedures, minimal diversity on published alternatives for limited regimens, and times when multimodal approaches are not adequate. Future work should focus on developing opioid-sparing protocols for more complex procedures as well as identifying patients at risk of requiring more comprehensive pain management approaches even for relatively minor procedures., Competing Interests: Conflicts of Interest No benefits in any form have been received or will be received related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Patient-reported outcomes are essential to understanding success in plastic surgery procedures, many that aim to improve quality of life. Patient-reported outcome measures (PROMs) should be written at or below the sixth-grade reading level recommended by the American Medical Association. This study aimed to evaluate the readability of plastic surgery PROMs., Methods: We conducted a literature review to identify validated, commonly used PROMs in plastic surgery. We extracted PROMs' text and instructions and analyzed readability using different approaches that estimate the grade level required to understand. Our primary outcome was the Simple Measure of Gobbledygook (SMOG) index, which detects word complexity and expects 100% comprehension at the grade level rating assigned. We also included the Flesch-Kincaid grade level, Coleman-Liau index, and automated readability index., Results: Forty-three PROMs met the inclusion criteria. The mean SMOG index was 8.2 (SD = 1.3), indicating an eighth-grade reading level. Mean reading grade levels measured by the Flesch-Kincaid grade level, Coleman-Liau index, and automated readability index ranged from third to sixth grade, although these may underestimate readability difficulties. Only 6 (14%) PROMs had a SMOG index at or below the sixth-grade level. PROM instructions had significantly higher reading levels than the questions/responses for all readability indexes ( P < 0.01)., Conclusions: PROMs used in plastic surgery, including the instructions, exceed the reading level recommended by the American Medical Association. This may limit comprehension and accurate completion and compromise validity and reliability. PROMs should be written and designed to be accessible to patients of all literacy levels., Competing Interests: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Purpose: Eulerian video magnification (EVM)+waveform is a novel video processing software that enhances visualization of tissue perfusion and has been shown to improve hand surgeon identification of ischemia via video alone. The purpose of this study is to determine whether EVM+waveform technology will support improved accuracy in identifying hand ischemia for less experienced persons, regardless of the evaluator's health care experience or the melanin content of the hand in the video., Methods: Healthy volunteers were recruited for us to record videos of their hands both perfused and under tourniquet-induced ischemia. Videos were processed with EVM+waveform and inserted into a 26-question survey. There were two types of questions presented in each survey. One format showed a video processed with EVM+waveform, and the respondent was asked if the hand was ischemic, perfused, or if they were unsure. The second format presented two side-by-side videos, one ischemic and one perfused. Both were processed with EVM+waveform, and the respondent had to choose which was ischemic. Respondents included both medical and non-medical professionals none of whom had experience with hand surgery., Results: A total of 64 survey responses were recorded. The EVM+waveform technology significantly improved accuracy in determining ischemia regardless of the respondent's health care experience. Respondents were divided into medical doctorate (MD; n = 15) and non-MD (n = 49) groups. Both groups demonstrated significant improvement in determining ischemia when using EVM+waveform. Within the non-MD cohort, accuracy percentages significantly improved across Fitzpatrick types IV, V, and VI. Within the MD cohort, accuracy percentages significantly improved across Fitzpatrick types III, V, and VI., Conclusions: These findings further establish EVM+waveform as an effective modality for identifying ischemia via video alone, as it enhanced performance for inexperienced evaluators. EVM+waveform is effective for assessing various skin types, especially those with higher skin melanin content., Type of Study/level of Evidence: Diagnostic, IV., Competing Interests: The study was funded by 10.13039/100005367AFSH clinical research grant #2819. No benefits in any form have been received or will be received related directly to this article., (© 2024 The Authors.)

Purpose: Despite the increasing percentage of women within the American Society for Surgery of the Hand, women remain underrepresented within leadership in academic hand surgery. Although this disparity in leadership representation may be improving, we aimed to investigate the role mentorship plays in advancing women in academic hand surgery., Methods: This is a survey-based, mixed-methods study. A written survey assessing themes in personal and professional experiences with mentorship was sent to hand fellowship-trained women. Inclusion criteria were the completion of a hand fellowship and current affiliation with an academic institution. An evolved grounded theory framework was used to evaluate the responses. Themes were identified based on common responses., Results: Of 186 eligible participants, 144 (85.2%) received the survey. The response rate was 48.6%. Respondents indicated that residency was the stage at which mentorship was most impactful (n = 25, 37%), and half of the respondents identified their desire to work in academic hand surgery during residency (n = 35, 50%). Obstacles to finding a mentor included lack of availability (n = 46, 67.7%), hesitance in searching for a mentor (n = 16, 23.5%), and searching for a mentor within an environment that was not conducive to success for trainees (n = 7, 10.3%). Most (84%) cited instances were the ones having the advice of a woman mentor was more impactful than that of a mentor who is a man. The reported need for same-sex mentorship fell into three categories: (1) insight into shared experiences, (2) assistance with conflict/bias management, and (3) support during career navigation., Conclusions: The findings of this study demonstrate the need for high-quality mentorship during the residency with a specific emphasis on same-sex mentorship., Clinical Relevance: Our findings provide clear objectives related to improving access to and quality of mentorship. This foundational understanding will enrich mentor-mentee relationships, allowing for greater personal and professional success and satisfaction for both parties., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: The Evidence-Based Practice Committee of the American Society for Surgery of the Hand set out to assess the membership's practice patterns (PPs) and familiarity with evidence-based principles for scaphoid fracture and nonunion management., Methods: Using a consensus-generated 25-item online survey, all the American Society for Surgery of the Hand members were invited to participate via email in September 2023. Two question types were used including evidence-based practice (EBP) and PPs. The survey was divided into the following subtopics: minimally displaced scaphoid fracture, operative options for scaphoid fixation, and treatment of scaphoid nonunion., Results: Of 9 EBP questions, only one was answered with the preferred response by >80% of surgeons. The remaining seven EBP questions had greater frequencies of less preferred responses. These questions concerned the current evidence for initial imaging options, optimal nonsurgical immobilization, percutaneous management, and the identification and treatment of nonunion. Of the PP questions, there were substantial differences of opinion on the choice of bone graft for nonunion, revisions, and patients with avascular necrosis. Nearly unanimous agreement was found for the use of headless compression screws for scaphoid fixation; however, the choice of approach for waist fixation was split between dorsal and volar percutaneous techniques and an open dorsal approach., Conclusions: Scaphoid fracture and nonunion management continues to be an area of expanding evidence. There remain opportunities for our community to improve knowledge and familiarization with current evidence-based data. Many PPs areas demonstrated substantial agreement among the membership; however, there are areas of differences particularly graft choice, optimal approach for waist fixation, and postfixation protocols. Knowledge and familiarity with peer practices may help develop future areas of research and help to optimize patient care through a critically review and interpretation of the evidence., Type of Study/level of Evidence: Economic/decision analyses V., Competing Interests: No benefits in any form have been received or will be received related directly to this article., (© 2024 The Authors.)

Purpose: Patients with Kienbock disease can present with coronal fracture and collapse of the proximal lunate (Unified B2/Bain grade 1, 2B). Traditionally, this was considered unsalvageable. However, medial femoral trochlea (MFT) osteochondral reconstruction, used to recreate the proximal lunate surface, can be paired with reduction and repair of the coronal plane fracture, thus restoring midcarpal congruity. The purpose of this study was to report radiographic and clinical outcomes following lunate coronal fracture fixation at the time of MFT osteochondral reconstruction., Methods: This was a retrospective study performed at a single institution. We identified patients with Kienbock disease who underwent MFT osteochondral reconstruction from 2014 to 2023. Patients were included if they had a coronal fracture of the lunate distal articular surface fixed at the time of surgery. Radiographic and clinical parameters were evaluated, including carpal height ratio, union rate, presence of heterotopic ossification, need for revision surgery, and patient-reported outcome measures., Results: Thirty-three patients were included, with a mean age of 27.5 years (range: 15-41); 19 (58%) were women. Mean radiographic follow-up time was 5.8 months, and mean clinical follow-up time was 22.6 months. Union was achieved in 30/33 patients (91%). Carpal height ratio improved from 1.32 to 1.4. Two patients (6%) required reoperation, one for removal of heterotopic ossification and another for conversion to proximal row carpectomy. Patients demonstrated meaningful improvement in brief Michigan Hand Questionnaire and Patient-Reported Outcomes Measurement Information Upper Extremity scores. Range of motion before and after surgery was similar., Conclusions: Lunate coronal fracture fixation with MFT osteochondral reconstruction represents an additional management option in select patients with Kienbock disease. This technique restores the midcarpal joint during lunate reconstruction and may allow patients to avoid salvage procedures. Early radiographic and clinical outcomes are promising., Type of Study/level of Evidence: Therapeutic IV., Competing Interests: Conflicts of Interest No benefits in any form have been received or will be received related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Osteoporotic patients are at risk of peri-implant fractures after distal radius fixation. A unicortical screw in the proximal hole of the plate can theoretically decrease stress riser formation by eliminating the hole in the far bone cortex. This construct has been proposed in orthopedic literature to prevent peri-implant fractures but has not been tested in an osteoporotic distal radius model., Methods: Eleven paired cadaver radii were harvested and plated with four-hole titanium volar distal radius plates. No osteotomies were created. The fixation constructs were identical except that group A used a bicortical proximal locking screw and group B used a unicortical proximal locking screw. Bone mineral density was estimated using radiographic measurements. The samples were potted and tested for four-point bending stiffness, torsion stiffness, and load to failure., Results: Between the bicortical and unicortical screw groups, there was no significant difference in four-point bending stiffness (110.8 vs 106.2 N/mm, apex volar bending; 105.4 vs 107.1 N/mm, apex dorsal bending) or torsional stiffness (430.6 vs 427.6 N-mm/degree, internal rotation; 430.8 vs 429.7 N-mm/degree, external rotation). There was also no significant difference in load to failure with apex dorsal four-point bending (795.3 vs 770.0 N)., Conclusions: This study shows that a healed osteoporotic distal radius volar plate construct with a proximal unicortical locking screw is not statistically different from a bicortical screw in stiffness or load to failure in apex dorsal bending. Although a unicortical locking screw has been proposed as a mechanism to prevent stress risers at the proximal aspect of the distal radius plate, this study suggests no significant difference when compared with a bicortical locking screw., Clinical Relevance: There is no significant biomechanical advantage to unicortical over bicortical locking screws in the proximal hole of a distal radius plate to prevent diaphyseal peri-implant fractures in osteoporotic patients., Competing Interests: No benefits in any form have been received or will be received related directly to this article.

Purpose: Letters of recommendation (LORs) function as an indicator of competence and future potential for a trainee. Our purpose was to evaluate gender bias in hand surgery fellowship applicant LORs., Methods: This was a retrospective study of all LORs submitted to a hand surgery fellowship program between 2015 and 2020. Demographic data about applicants and letter writers were collected. Linguistic analysis was performed using a text analysis software, and results were evaluated with nonparametric tests, multiple linear regression models, and a mixed effects regression model., Results: Letters of recommendation were analyzed; 720 letters for 188 (23.4%) female applicants and 2,337 letters for 616 (76.6%) male applicants. Compared with LORs written for men, those written for women had more references to categories of anxiety (eg, worried and fearful) and affiliation (eg, ally and friend). Letters for women had more "clout." In subgroup analysis, letters for female plastic surgery applicants had more words signaling power, whereas recommendations for female applicants from orthopedic residencies had more words related to anxiety, achievement, work, and leisure., Conclusions: Letters of recommendation written for female residents applying to hand fellowship had more references to anxiety but were written with higher clout and more words of affiliation. Subgroup analysis looking at orthopedic and plastic surgery applicants separately found a mixed picture. Overall, these LORs written for applicants to hand fellowship had no notable specific patterns of gender bias in our analyses., Clinical Relevance: Because programs look to train the next generation of hand surgeons, alerting letter readers to trends in implicit bias may help in the selection of qualified applicants. Bringing topics of implicit bias forward may help writers think more critically about word choice and topics., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To characterize the periosteal and endosteal arterial perfusion of the proximal phalanx using micro-computed tomography angiography (micro-CTA)., Methods: Cadaveric upper extremities were injected with a barium sulfate/gelatin suspension. Phalanges were imaged using micro-CTA and analyzed with a focus on osseous arterial anatomy. Periosteal and endosteal perfusion was characterized by number of vessels, length, anatomic course, and caliber., Results: The base of the proximal phalanx had a significantly greater number (8.0 ± 3.5) of periosteal vessels than those of the shaft (4.1 ± 1.6) and head (1.3 ± 1.1). One-third (34.4%) of the specimens demonstrated a complete absence of periosteal vessels in the head. A nutrient endosteal vessel was noted in 100% of the specimens. Entering at the junction of the middle and distal third of the bone (25.8 ± 3.9 mm from base), the nutrient vessel entered the proximal phalanx of the index finger along its ulnar aspect (8 of 8 specimens), the middle finger along its radial aspect (6 of 8), the ring finger along its ulnar aspect (5 of 8), and the little finger along its radial aspect (7 of 8). The nutrient vessel branched into proximal and distal extensions toward the shaft and head, respectively, with an average endosteal length of 10.7 ± 5.2 mm and average diameter of 0.36 ± 0.11 mm., Conclusions: Periosteal contributions to the perfusion of the proximal phalanx appear to diminish distally. The endosteal arterial anatomy remains consistent, with a single nutrient vessel entering the intramedullary canal with reliable laterality on each digit. This is often the only vessel supplying the head of the proximal phalanx, making this area particularly susceptible to vascular compromise., Clinical Relevance: An understanding of the patterns of perfusion of the proximal phalanx provides some insight into clinically observed pathology, as well as guidance for operative management., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Introduction: Almost all patient-reported outcomes measures (PROMs) are text-based, which impedes accurate completion by low and limited literacy patients. Few PROMs are designed or validated to be self-administered, either in clinical or research settings, by patients of all literacy levels. We aimed to adapt the Patient Reported Outcomes Measurement Information System Upper Extremity Short Form (PROMIS-UE) to a multimedia version (mPROMIS-UE) that can be self-administered by hand and upper extremity patients of all literacy levels., Methods: Our study in which we applied the Multimedia Adaptation Protocol included seven phases completed in a serial, iterative fashion: planning with our community advisory board; direct observation; discovery interviews with patients, caregivers, and clinic staff; ideation; prototyping; member-checking interviews; and feedback. Direct observations were documented in memos that underwent rapid thematic analysis. Interviews were audio-recorded and documented using analytic memos; a rapid, framework-guided thematic analysis with both inductive and deductive themes was performed. Themes were distilled into design challenges to guide ideation and prototyping that involved our multidisciplinary research team. To assess completeness, credibility, and acceptability we completed additional interviews with member-checking of initial findings and consulted our community advisory board., Results: We conducted 12 hours of observations. We interviewed 17 adult English-speaking participants (12 patients, 3 caregivers, 2 staff) of mixed literacy. Our interviews revealed two distinct user personas and three distinct literacy personas; we developed the mPROMIS-UE with these personas in mind. Themes from interviews were distilled into four broad design challenges surrounding literacy, customizability, convenience, and shame. We identified features (audio, animations, icons, avatars, progress indicator, illustrated response scale) that addressed the design challenges. The last 6 interviews included member-checking; participants felt that the themes, design challenges, and corresponding features resonated with them. These features were synthesized into an mPROMIS-UE prototype that underwent rounds of iterative refinement, the last of which was guided by recommendations from our community advisory board., Discussion: We successfully adapted the PROMIS-UE to an mPROMIS-UE that addresses the challenges identified by a mixed literacy hand and upper extremity patient cohort. This demonstrates the feasibility of adapting PROMs to multimedia versions. Future research will include back adaptation, usability testing via qualitative evaluation, and psychometric validation of the mPROMIS-UE. A validated mPROMIS-UE will expand clinicians' and investigators' ability to capture patient-reported outcomes in mixed literacy populations., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Azad et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Regional anesthesia ("block") is an important component of upper extremity (UE) surgery pain control. However, little is known about patient experience related to perioperative opioid use. This study assessed patient-reported pain control and satisfaction with UE blocks and evaluated how opioid consumption impacted these outcomes before the block "wore off.", Methods: A postoperative phone survey was administered to patients who underwent outpatient UE surgery at a surgery center for more than 16 months. It assessed pain scores (scale 1-10), satisfaction with block duration (scale 1-5), duration until return of UE function, and opioid consumption. Analyses used Mann-Whitney U tests, Fisher exact tests, and bivariate and multivariable linear and ordered logistic regressions to understand relationships between opioid use and outcomes., Results: A total of 509 patients (61%) completed the survey, and 441 (88%) were satisfied with block duration. Initial and final pain scores were significantly higher in patients who took opioids prior to the block wearing off (6 and 4.5, P = .04 and 3.5 and 2, P = .002, respectively). Although satisfaction with block duration was not different in group comparisons (ie, patients who premedicated vs those who did not), in a multivariable analysis, patients who premedicated with opioids had 78% increased odds of reporting the highest level of satisfaction compared with the lower 4 levels ( P = .03)., Conclusions: Upper extremity blocks are associated with high overall patient satisfaction and postsurgical pain control. Premedicating before the block wears off may increase patient satisfaction with block duration even if pain is not notably impacted., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background:  Gender bias in graduate medical evaluations remains a challenging issue. This study evaluates implicit gender bias in video-based evaluations of microsurgical technique, which has not previously been described in the literature., Methods:  Two videos were recorded of microsurgical anastomosis; the first was performed by a hand/microsurgery fellow and the second by an expert microsurgeon. A total of 150 surgeons with microsurgical experience were recruited to evaluate the videos; they were told these videos depicted a surgical trainee 1 month into fellowship followed by the same trainee 10 months later. The only variable was the name ("Rachel" or "David") that each participant was randomly assigned to evaluate. Participants were asked to score each video for quality, technique, efficiency, as well as overall progression and development after the second video compared with the initial video. To focus on bias, these outcome measures were selected to be purposefully subjective and all ratings were based on a subjective 1to 10 scale (10 = excellent)., Results:  The analysis included 150 participants (75% male). There were no statistically significant differences in scores between the "female" and "male" trainee. The trainees received the same median initial (1-month video) and final (11th-month video) scores for all criteria except initial technique, in which the female trainee received a 7 and the male trainee received an 8. Notably, 11-month scores were consistently the same or lower than 1-month scores for both study groups ( p  < 0.001). There were also no differences within either study group based on participant sex. Microsurgery practitioners overall rated both groups lower than those who do not currently practice microsurgery., Conclusion:  Our study did not identify a gender bias in this evaluation method. Further investigation into how we assess and grade trainees as well as the presence and impact of implicit biases on varying surgical assessment methods is warranted., Competing Interests: None declared., (Thieme. All rights reserved.)

Purpose: Multiple interventions have been implemented to reduce opioid prescribing in upper extremity surgery. However, few studies have evaluated pain relief and patient satisfaction as related to failure of these protocols. We sought to evaluate the efficacy of limited and nonopioid ("opioid-sparing") regimens for upper extremity surgery as it pertains to patient satisfaction, pain experienced, and need for additional refills/rescue analgesia., Methods: We aimed to systematically review randomized controlled trials of opioid-sparing approaches in upper extremity surgery. An initial search of studies evaluating opioid-sparing regimens after upper extremity surgery from the elbow distal yielded 1,320 studies, with nine meeting inclusion criteria. Patient demographics, surgery type, postoperative pain regimen, satisfaction measurements, and number of patients inadequately treated within each study were recorded. Outcomes were assessed using descriptive statistics., Results: Nine randomized controlled trials with 1,480 patients were included. Six of nine studies (67%) reported superiority or equivalence of pain relief with nonopioid or limited opioid regimens. However, across all studies, 4.2% to 25% of patients were not adequately treated by the opioid-sparing protocols. This includes four of seven studies (57%) assessing number of medication refills or rescue analgesia reporting increased pill consumption, refills, or rescue dosing with limited/nonopioid regimens. Five of six studies (83%) reporting satisfaction outcomes found no difference in satisfaction with pain control, medication strength, and overall surgical experience using opioid-sparing regimens., Conclusions: Opioid-sparing regimens provide adequate pain relief for most upper extremity surgery patients. However, a meaningful number of patients on opioid-sparing regimens required greater medication refills and increased use of rescue analgesia. These patients also reported no difference in satisfaction compared with limited/nonopioid regimens., Type of Study/level of Evidence: Therapeutic II., Competing Interests: Conflicts of Interest No benefits in any form have been received or will be received related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Propeller perforator flaps (PPFs) have increased in popularity due to the freedom in design and ability to cover a variety of defects without sacrificing the major vessels. Present reports of PPFs for upper limb reconstruction have not provided guidance for hand reconstruction, specifically. This study aims to review the current literature and evaluate techniques for use of PPFs in hand reconstruction., Methods: A comprehensive literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for articles published from 1991 to 2021. The database search was queried for records using appropriate Medical Subject Headings (MeSH) terms. Studies reporting PPFs were limited to English language and excluded lower extremity or upper extremity reconstruction not specific to defects in the hand or digits. Study characteristics, patient demographics, indications, preoperative testing, flap characteristics, flap survival, and complication rates were collected., Results: Out of the initial 1,348 citations yielded, 71 underwent full-text review. Ultimately, 25 unique citations were included encompassing 12 retrospective reviews (48%), 3 prospective cohort studies (10%), and 10 case series (40%). In review, 525 patients underwent reconstruction with a total of 613 propeller flaps performed to repair defects of the hand, digits, or both with use of 18 unique flap types. Overall flap survival was 97.8%. Acute wounds accounted for 72.9% of performed reconstructions. The mean flap coverage was 14.7 cm 2 . Complications occurred in 19.8% of cases, with venous congestion and partial flap necrosis occurring in 5.5 and 6.5% of cases, respectively, leading to a flap failure rate of 2.1%., Conclusion: PPFs are a reliable option for hand or digital reconstruction, allowing surgeons to cover a variety of defects without sacrificing local vasculature. Despite nearly a 20% reported complication rate, nearly all flaps with venous congestion and partial flap necrosis included in these articles resolved without the need for secondary intervention, retaining an excellent overall flap survival., (© 2024 Society for Indian Hand Surgery and Micro Surgeons. Published by Elsevier B.V. All rights reserved.)

Several studies have linked calcification of the thoracic and lower extremity arterial trunks to an increased risk of developing coronary artery disease (CAD). Calcifications of the radial and/or ulnar artery are regularly identified in hand/wrist x-rays; however, the clinical relevance of these findings as related to identifying subclinical CAD is not well understood. Associations between CAD and upper extremity calcifications have been reported, but the timeline is unclear. The purpose of this study was to evaluate the association between upper extremity arterial calcifications on hand radiographs with CAD by coronary artery calcification (CAC) scoring in patients with no known history of CAD. This is a pilot single-center, prospective, matched cohort study. We included patients with no known history of CAD, related symptoms, or major risk factors. We recruited five patients with calcifications (cal+) and five patients matched by age, race, sex, and medical history but without calcifications (cal-). CAC scores were determined from computed tomography scanning, and lipid profile was evaluated. In the cal+ group, the mean CAC total score was 244.1; in the control (cal-) group, it was 85.2. The mean total cholesterol levels were 220.8 mg per dL and 167 mg per dL in the cal+ and cal- groups, respectively. Two cal+ patients with CAC scores of 937 and 669 died shortly after being enrolled in our study. Preliminary findings suggest that calcifications in the radial or ulnar artery in otherwise asymptomatic patients with no history of CAD may be an independent sign of CAD., Competing Interests: The authors have no financial interest to declare in relation to the content of this article. Disclosure statements are at the end of this article, following the correspondence information., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Engaging patients and family members in formal feedback for health care processes can be impactful, especially when cultivating new care and research protocols. However, most surgical groups lack established systems for enlisting these critical stakeholders. This is a descriptive report of how we built our Patient and Family Advisory Council (PFAC) through a multistep process with patients, providers, research staff, and administrators. We also detail how it has advanced research, care, and mutually beneficial collaboration at our hand center. For example, our PFAC has provided vital input on multiple grant submissions, assisted with the development of a web-based digital application for thumb arthritis therapy, and improved our patient care approaches. To successfully create and sustain a PFAC, there must be commitment from multiple stakeholders across clinical, research, administration, and leadership spectra. Through this alliance, all stakeholders can develop better care and investigative strategies., Competing Interests: No benefits in any form have been received or will be received related directly to this article., (© 2024 The Authors.)

Purpose: Current guidelines recommend bone mineral density (BMD) testing after fragility fractures in patients aged 50 years or older. This study aimed to assess BMD testing and subsequent fragility fractures after low-energy distal radius fractures (DRFs) among patients aged 50-59 years., Methods: We used the 2010-2020 MarketScan dataset to identify patients with initial DRFs with ages ranging between 50 and 59 years. We assessed the 1-year BMD testing rate and 3-year non-DRF fragility fracture rate. We created Kaplan-Meier plots to depict fragility fracture-free probabilities over time and used log-rank tests to compare the Kaplan-Meier curves., Results: Among 78,389 patients aged 50-59 years with DRFs, 24,589 patients met our inclusion criteria, and most patients were women (N = 17,580, 71.5%). The BMD testing rate within 1 year after the initial DRF was 12.7% (95% CI, 12.3% to 13.2%). In addition, 1-year BMD testing rates for the age groups of 50-54 and 55-59 years were 10.4% (95% CI, 9.9% to 11.0%) and 14.9% (95% CI, 14.2% to 15.6%), respectively. Only 1.8% (95% CI, 1.5% to 2.1%) of men, compared with 17.1% (95% CI, 16.5% to 17.7%) of women, underwent BMD testing within 1 year after the initial fracture. The overall 3-year fragility fracture rate was 6.0% (95% CI, 5.6% to 6.3%). The subsequent fragility fracture rate was lower for those with any BMD testing (4.4%; 95% CI, 3.7% to 5.2%), compared with those without BMD testing (6.2%; 95% CI, 5.9% to 6.6%; P < .05)., Conclusions: We report a low BMD testing rate for patients aged between 50 and 59 years after initial isolated DRFs, especially for men and patients aged between 50 and 54 years. Patients who received BMD testing had a lower rate of subsequent fracture within 3 years. We recommend that providers follow published guidelines and initiate an osteoporosis work-up for patients with low-energy DRFs to ensure early diagnosis. This provides an opportunity to initiate treatment that may prevent subsequent fractures., Type of Study/level of Evidence: Prognosis II., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Importance: The No Surprises Act implemented in 2022 aims to protect patients from surprise out-of-network (OON) bills, but it does not include ground ambulance services. Understanding ground ambulance OON and balance billing patterns from previous years could guide legislation aimed to protect patients following ground ambulance use., Objective: To characterize OON billing from ground ambulance services by evaluating whether OON billing risk differs by the site of ambulance origination (home, hospital, nonhospital medical facility, or scene of incident)., Design, Setting, and Participants: Cross-sectional study of the Merative MarketScan dataset between January 1, 2015, and December 31, 2020, using claims-based data from employer-based private health insurance plans in the US. Participants included patients who utilized ground ambulances during the study period. Data were analyzed from June to December 2023., Exposure: Medical encounter requiring ground ambulance transportation., Main Outcomes and Measures: Ground ambulance OON billing prevalence was calcuated. Linear probability models adjusted for state-level mixed effects were fit to evaluate OON billing probability across ambulance origins. Secondary outcomes included the allowed payment, patient cost-sharing amounts, and potential balance bills for OON ambulances., Results: Among 2 031 937 ground ambulance services (1 375 977 unique patients) meeting the inclusion and exclusion criteria, 1 072 791 (52.8%) rides transported men, and the mean (SD) patient age was 41 (18) years. Of all services, 1 113 676 (54.8%) were billed OON. OON billing probabilities for ambulances originating from home or scene were higher by 12.0 percentage points (PP) (95% CI, 11.8-12.2 PP; P < .001 for home; 95% CI, 11.7-12.2 PP; P < .001 for scene) vs those originating from hospitals. Mean (SD) total financial burden, including cost-sharing and potential balance bills per ambulance service, was $434.70 ($415.99) per service billed OON vs $132.21 ($244.92) per service billed in-network., Conclusions and Relevance: In this cross-sectional study of over 2 million ground ambulance services, ambulances originating from home, the scene of an incident, and nonhospital medical facilities were more likely to result in OON bills. Legislation is needed to protect patients from surprise billing following use of ground ambulances, more than half of which resulted in OON billing. Future legislation should at minimum offer protections for these subsets of patients often calling for an ambulance in urgent or emergent situations.

Purpose: Timely and accurate triage of upper extremity injuries is critical, but current perfusion monitoring technologies have shortcomings. These limitations are especially pronounced in patients with darker skin tones. This pilot study evaluates a Eulerian Video Magnification (EVM) algorithm combined with color channel waveform extraction to enable video-based measurement of hand and finger perfusion., Methods: Videos of 10 volunteer study participants with Fitzpatrick skin types III-VI were taken in a controlled environment during normal perfusion and tourniquet-induced ischemia. Videos were EVM processed, and red/green/blue color channel characteristics were extracted to produce waveforms. These videos were assessed by surgeons with a range of expertise in hand injuries. The videos were randomized and presented in 1 of 3 ways: unprocessed, EVM processed, and EVM with waveform output (EVM+waveform). Survey respondents indicated whether the video showed an ischemic or perfused hand or if they were unable to tell. We used group comparisons to evaluate response accuracy across video types, skin tones, and respondent groups., Results: Of the 51 providers to whom the surveys were sent, 25 (49%) completed them. Using the Pearson χ 2 test, the frequencies of correct responses were significantly higher in the EVM+waveform category than in the unprocessed or EVM videos. Additionally, the agreement was higher among responses to the EVM+waveform questions than among responses to the unprocessed or EVM processed. The accuracy and agreement from the EVM+waveform group were consistent across all skin pigmentations evaluated., Conclusions: Video-based EVM processing combined with waveform extraction from color channels improved the surgeon's ability to identify tourniquet-induced finger ischemia via video across all skin types tested., Clinical Relevance: Eulerian Video Magnification with waveform extraction improved the assessment of perfusion in the distal upper extremity and has potential future applications, including triage, postsurgery vascular assessment, and telemedicine., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: A patient-reported outcomes measure (PROM) is responsive if it is sensitive to clinical status changes. The minimal clinically important difference (MCID) is used to indicate meaningful change, helpful in designing studies and adding context to some study results, and is related to instrument responsiveness. Our purpose was to provide MCID estimates for the brief Michigan Hand Outcomes Questionnaire (bMHQ) and Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) in a hand and upper extremity surgery cohort within the context of varying patient-reported mental health., Methods: Data were analyzed from 1,262 adult patients who received surgical care at a single center between January 1, 2018, and December 31, 2019. Patients completed PROMIS PI, PROMIS Global Health (including global mental health [GMH] component), bMHQ, and a pain-focused anchor question before each clinic visit. Data were collected 8 ± 2 weeks before and after surgery. A distribution-based MCID then was calculated for the general patient population, lowest 10th percentile of GMH scores, and top 10th percentile of GMH scores., Results: Minimal clinically important difference estimates were 10.4 for the bMHQ and 4.3 for PROMIS PI. Analysis of MCID across different GMH score groups showed a mean score of 11.5 for bMHQ for the lowest 10th percentile of GMH, 9.6 for bMHQ for the top 10th percentile, 4.5 for PI for the lowest 10th percentile, and 4.9 for PI for the top 10th percentile., Conclusions: Analysis of subgroups stratified by preoperative patient-reported mental health condition found that preoperative mental health status, as indicated by GMH score, does not have a meaningful impact on responsiveness of bMHQ or PROMIS PI., Clinical Relevance: A patient's reported mental health condition does not meaningfully change how these common PRO instruments reflect the patient condition after hand and upper extremity surgery., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Cognitive behavioral therapy (CBT) is an established option to improve pain and function for many orthopedic conditions. Our purpose was to obtain patient perspectives regarding CBT for thumb, hand, or wrist pain and function., Methods: Between March and April 2022, we distributed an electronic survey via email to patients in our institution's health system with a diagnosis of arthritic or non-specific thumb, hand, or wrist pain. The survey included the opening statement "Cognitive Behavioral Therapy (CBT) is a non-medication option to help manage pain and improve function" and up to 13 questions pertaining to patients' experiences and perceptions regarding CBT. The survey was anonymous and did not collect protected health information. We used descriptive statistics for the findings., Results: We distributed the survey to 327 patients, yielding a 30% response rate (98/327). Of the respondents, 17 reported already using CBT to specifically help with pain/function. Of these, 15 felt it was helpful and agreed it could help others. Of the subset that used CBT for arthritis, all felt it was helpful. Of the 75 respondents with no CBT experience, 42 indicated "I've never heard of it," 28 responded "I never had it recommended as an option," and 16 marked "I don't know enough about it." Small subsets noted potential personal barriers to CBT implementation, such as cost, time involved, or perceived lack of potential efficacy for themselves., Conclusions: A small proportion of patients from our institution with thumb, hand, or wrist pain are utilizing CBT, and the majority finds it helpful., Clinical Relevance: While some patients are already substantially benefiting from CBT to improve their thumb, hand, or wrist pain or function, there is a notable opportunity for providers to increase awareness and recommendations for this option., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Coronavirus Disease 2019 (COVID) induces a hypercoagulable state causing an increased risk of venous and arterial thromboses. Distal limb and microvascular circulation are critical to the success of many hand surgeries, and patients who are actively or recently infected with COVID may be at a higher risk for perioperative thrombotic events. Little information is available regarding how to handle actively or recently infected COVID patients, including preoperative risk assessment, intraoperative decision making, and postoperative considerations regarding thrombotic risk. Our aim was to review the literature to determine how the hand surgeon can best prepare for and manage the actively or recently COVID-positive patients undergoing hand surgeries., (© 2023 The Authors.)

Purpose: We compared 2 suturing techniques for reattachment of the flexor digitorum profundus (FDP) via all-suture anchor., Methods: We used fresh, matched-pair, cadaveric hands. We disarticulated the fingers at the proximal interphalangeal joints, preserving the proximal FDP. We released the FDPs at their distal insertion and placed an all-suture, 1.0-mm anchor at the center of each FDP footprint. Each anchor's sutures were used to reattach each FDP using 1 of 2 techniques: group H (n = 14) via horizontal mattress; group H + K (n = 12) via horizontal mattress with knots thrown and, with each suture tail, 3 proximal, running-locking, Krackow-type passes on the radial and ulnar FDP sides with the suture ends tied together. We excluded 2 specimens from the H + K group because of improper anchor placement. All other fingers in both groups were individually mounted in an MTS machine for FDP loading in the following sequence for 500 cycles each: (1) to 15 N to simulate passive motion forces; (2) to 19 N for short-arc active motion forces; and (3) to 28 N for full active motion forces. Specimens that had not failed during cyclic testing were then loaded to failure. We measured FDP-to-bone gapping via a digital transducer. We defined failure as >3-mm gapping., Results: The H + K group had significantly less gapping during cyclic loading up to 19 N and significantly higher load to failure. The H + K group failed exclusively at the anchor-bone level; the H group failed mostly by suture-tendon pullout., Conclusions: The H + K group performed significantly better regarding cyclic and load-to-failure testing after FDP reattachment., Clinical Relevance: The H + K technique combines the benefits of horizontal-mattress tendon-to-bone apposition and Krackow-tendon locking. It converts the point of failure to the bone level rather than the suture-tendon level., (Copyright © 2023 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Hospitals and providers may increase hand surgery charges to compensate for decreasing reimbursement. Higher charges, combined with increasing utilization of ambulatory surgical centers (ASCs), may threaten the accessibility of affordable hand surgery care for uninsured and underinsured patients., Methods: We queried the Physician/Supplier Procedure Summary to collect the number of procedures, charges, and reimbursements of hand procedures from 2010 to 2019. We adjusted procedural volume by Medicare enrollment and monetary values to the 2019 US dollar. We calculated weighted means of charges and reimbursement that were then used to calculate reimbursement-to-charge ratios (RCRs). We calculated overall change and r 2 from 2010 to 2019 for all procedures and stratified by procedural type, service setting, and state where service was rendered., Results: Weighted mean charges, reimbursement, and RCRs changed by + 21.0% (from $1,227 to $1,485; r 2 = 0.93), +10.8% (from $321 to $356; r 2 = 0.69), and -8.4% (from 0.26 to 0.24; r 2 = 0.76), respectively. The Medicare enrollment-adjusted number of procedures performed in ASCs increased by 63.8% ( r 2 = 0.95). Trends in utilization and billing varied widely across different procedural types, service settings, and states., Conclusions: Charges for hand surgery procedures steadily increased, possibly reflecting an attempt to make up for reimbursements perceived to be inadequate. This trend places uninsured and underinsured patients at greater risk for financial catastrophe, as they are often responsible for full or partial charges. In addition, procedures shifted from inpatient to ASC setting. This may further limit access to affordable hand care for uninsured and underinsured patients., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Free fibula flap (FFF) and medial femoral condyle (MFC) flap are commonly used for upper extremity osseous reconstruction, yet donor-site morbidity has never been systematically compared., Methods: Patients who underwent an FFF or MFC for upper extremity extra-carpal osseous reconstruction at 3 academic hand centers were retrospectively identified. Only patients who underwent reconstruction for a defect in which either flap type is routinely used or has been described in the literature were deemed eligible. Patients who agreed to participate were asked to complete the Lower Extremity Functional Scale (LEFS) and Lower Limb Core Scale (LLCS). The reported population norm median score of LEFS is 77 points. The LLCS population norm mean score is 90.52 points., Results: Twenty-one patients (10 MFC, 11 FFF) were enrolled. The median LEFS score for patients after MFC was 76 (interquartile range [IQR], 49-80) points and 75 (IQR, 56-79) points after FFF. The median LLCS score for patients after MFC was 96.4 (IQR, 87.9-100) points and 100 (IQR, 91-100) points after FFF. Median LEFS scores were slightly below the population norm, whereas median LLCS scores were above the norm for both FFF and MFC. All patients stated they would have the surgery again and that any dysfunction or pain in the leg was justified by the benefit in the arm., Conclusions: When considering whether to use an MFC or FFF for upper extremity reconstruction, both flap types appear to result in modest and comparable donor-site morbidity.

Purpose: We sought to investigate the role of prophylactic antibiotics for distal fingertip crush injury or transphalangeal amputation treated outside of an operating room and better understand the factors that contribute to antibiotic-prescribing decisions. We hypothesized that prophylactic antibiotics do not meaningfully reduce the incidence of infection and that antibiotics are prescribed in a predictable way., Methods: This is a retrospective review of all patients treated in a MedStar-affiliated emergency department or urgent care for nonsurgical distal fingertip trauma in 2019. Patient demographics, comorbidities, injury characteristics, interventions, and follow-up details were recorded. Exclusion criteria included signs of infection at the time of presentation, minor injuries not requiring intervention, bite wounds, one-time intravenous antibiotic administration without oral course, and surgical intervention. Outcomes included infection and interventions at follow-up. Chi-square analysis was performed, comparing antibiotic and no-antibiotic groups. A stepwise binomial regression was used to evaluate for variables predictive of antibiotic prescription., Results: We identified eight infections in 323 patients included in the study (2.5% incidence of infection). There was no statistically significant difference in the incidence of infection between patients treated with antibiotics (2.7%) and those who did not receive antibiotics (2.2%). However, due to the low incidence of infections, we were likely underpowered for this analysis. We also created a model to predict antibiotic prescribing, which achieved an area under the receiver operating characteristic curve of 0.86 ( P < .0001) based on age, bleeding disorders, depressive disorders, open wound status, amputation, fractures, and encounter type., Conclusions: The low incidence of infection (2.5%) and lack of a meaningful difference between the groups call into question prophylactic antibiotic prescribing after these distal fingertip injuries. Our model does predict provider prescribing habits, identifying areas for potential practice pattern change., Type of Study/level of Evidence: Therapeutic III., (© 2023 The Authors.)

Background: Which treatments patients continue to use more than 1 year after primary thumb carpometacarpal arthritis surgery, and how such use relates to patient-reported outcomes, is largely unknown., Methods: The authors identified patients who had isolated primary trapeziectomy alone or with ligament reconstruction ± tendon interposition and were 1 to 4 years postoperative. Participants completed a surgical site-focused electronic questionnaire about what treatments they still used. Patient-reported outcome measures were the Quick Disability of the Arm, Shoulder, and Hand questionnaire and visual analog/numerical rating scales for current pain, pain with activities, and typical worst pain., Results: A total of 112 patients met inclusion and exclusion criteria and participated. At a median of 3 years after surgery, over 40% reported current use of at least one treatment for their thumb carpometacarpal surgical site, with 22% using more than one treatment. Of those who still used treatments, 48% used over-the-counter medications, 34% used home or office-based hand therapy, 29% used splinting, 25% used prescription medications, and 4% used corticosteroid injections. A total of 108 participants completed all patient-reported outcome measures. With bivariate analyses, the authors found that use of any treatment after recovering from surgery was associated with statistically and clinically significantly worse scores for all measures., Conclusions: Clinically relevant proportions of patients continue to use various treatments a median of 3 years after primary thumb carpometacarpal arthritis surgery. Continued use of any treatment is associated with significantly worse patient-reported outcomes for function and pain., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Opioids play a role in pain management after surgery, but prolonged use contributes to developing opioid use disorder. Identifying patients at risk of prolonged use is critical for deploying interventions that reduce or avoid opioids; however, available predictive models do not incorporate patient-reported data (PRD), and it remains unclear whether PRD can predict postoperative use behavior. The authors used a machine learning approach leveraging preoperative PRD and electronic health record data to predict persistent opioid use after upper extremity surgery., Methods: Included patients underwent upper extremity surgery, completed preoperative PRD questionnaires, and were prescribed opioids after surgery. The authors trained models using a 2018 cohort and tested in a 2019 cohort. Opioid use was determined by patient report and filled prescriptions up to 6 months after surgery. The authors assessed model performance using area under the receiver operating characteristic, sensitivity, specificity, and Brier score., Results: Among 1656 patients, 19% still used opioids at 6 weeks, 11% at 3 months, and 9% at 6 months. The XGBoost model trained on PRD plus electronic health record data achieved area under the receiver operating characteristic 0.73 at 6 months. Factors predictive of prolonged opioid use included income; education; tobacco, drug, or alcohol abuse; cancer; depression; and race. Protective factors included preoperative Patient-Reported Outcomes Measurement Information System Global Physical Health and Upper Extremity scores., Conclusions: This opioid use prediction model using preintervention data had good discriminative performance. PRD variables augmented electronic health record-based machine learning algorithms in predicting postsurgical use behaviors and were some of the strongest predictors. PRD should be used in future efforts to guide proper opioid stewardship., Clinical Question/level of Evidence: Risk, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Purpose: We investigated closed passive manipulation as an alternative to surgery for certain proximal interphalangeal (PIP) joint extension contractures., Methods: We retrospectively reviewed all patients with PIP joint extension contractures treated with passive manipulation at our institution between 2015 and 2019. The included patients were a minimum of 12 weeks from their initial injury/surgery (median 179 days; interquartile range: 130-228 days), had plateaued with therapy, and underwent a 1-time passive manipulation. All included fingers had congruent PIP joints and no indwelling hardware that could have had direct adhesions. Most (80%) patients had a direct injury to the finger ray(s) that led to the contractures. Most (75%) patients had the manipulation performed under local anesthesia in the office. Available measures of passive range of motion (PROM) and active range of motion (AROM) immediately, within 6 weeks, between 6 and 12 weeks, and at >12 weeks after the manipulation were recorded., Results: Twenty-eight patients and 46 digits met the criteria. The median PIP joint PROM improved from 50° to 90° immediately following the manipulation. The median PROM values within 6 weeks, between 6 and 12 weeks, and at >12 weeks following manipulation were 80°, 85°, and 85°, respectively. The median AROM immediately after the manipulation improved from 40° to 90°, and the median AROM values within 6 weeks, between 6 and 12 weeks, and at >12 weeks were 70°, 50°, and 60°, respectively. None of the patients experienced worsening of PIP joint range of motion. One patient who had 4 fingers manipulated had a 45° distal interphalangeal joint extension lag for one of the fingers after the manipulation. Eight fingers underwent later flexor tenolysis or reconstruction to improve AROM after the gains in PROM via manipulation were maintained., Conclusions: Passive manipulation is an alternative to surgical release for select PIP joint extension contractures., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2023 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Amount of opioid use correlates poorly with procedure-related pain; however, prescription limits raise concerns about inadequate pain control and impacts on patient-reported quality indicators. There remain no consistent guidelines for postoperative pain management after carpal tunnel release (CTR). We sought to understand how postoperative opioid use impacts patient-reported outcomes after CTR., Methods: This is a pragmatic cohort study using prospectively collected data from all adult patients undergoing uncomplicated primary CTR over 17 months at our center. Patients were categorized as having received or not received a postoperative opioid prescription, and then as remaining on a prescription opioid at 2-week follow-up or not. Questionnaires were completed before surgery and at 2-week follow-up. We collected brief Michigan Hand questionnaire (bMHQ) score, Patient-Reported Outcomes Measurement Information System Global Health score, satisfaction, and pain score., Results: Of 505 included patients, 405 received a postoperative prescription and 67 continued use at 2-weeks. These 67 patients reported lower bMHQ, lower satisfaction, and higher postoperative pain compared to those that discontinued. Multivariable regressions showed that receiving postoperative prescriptions did not significantly influence outcomes or satisfaction. However, remaining on the prescription at 2 weeks was associated with significantly lower bMHQ scores, particularly in patients reporting less pain., Conclusions: Patients remaining on a prescription after CTR reported worse outcomes compared to those who discontinued. Unexpectedly, the widest bMHQ score gap was seen across patients reporting lowest pain scores. Further research into this high-risk subgroup is needed to guide policy around using pain and patient-reported outcomes as quality measures. Level of Evidence: Level III.

The Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS-UE) is frequently used in research/clinical care, but how it is understood by patients is unknown. We conducted a qualitative study including 12 cognitive interviews with patients with hand/upper extremity conditions and those purposively sampled for mixed literacy. Using framework analysis, we identified six themes total: difficulty answering questions due to insufficient information; uncertainty about whether to respond with the ability to perform the task with the injured extremity alone, either the injured or healthy extremity, or both; lack of experience doing certain tasks; uncertainty about whether to answer questions based on ability to perform the task with or without adaptive techniques; answering questions based on limitations not related to upper extremity function; and uncertainty regarding whether to answer questions on the basis of ability or pain. This study demonstrates the challenges in completing questionnaires and that variability may limit the reliability, validity and responsiveness of the PROMIS-UE.

Purpose: Several improvised dynamic external fixation devices are used for treating unstable dorsal proximal interphalangeal (PIP) joint fracture-dislocations. We compared the effectiveness of 3 constructs for simulated dorsal PIP joint fracture-dislocations in a cadaver model., Methods: We tested 30 digits from 10 fresh-frozen, thawed cadaver hands. We aimed to remove the palmar 50% of the base of each digit's middle phalanx (P2), simulating an unstable dorsal PIP joint fracture-dislocation. Each PIP joint was then stabilized via external fixation with either a pins-and-rubber-bands construct, pins-only construct, or tuberculin syringe-pins construct. We allocated 10 digits per fixation group. The finger tendons were secured to a computer-controlled stepper motor-driven linear actuator. Via this mechanism, all PIP joints were taken through 1,400 cycles of flexion-extension. With the PIP joint in neutral extension, we measured the P2 dorsal translation at baseline, after fixator stabilization, and after the motion protocol., Results: The actual mean P2 palmar defect created was 48% of the base. All PIP joints were unstable after creating the defect, with a mean initial P2 dorsal displacement of 3.7 mm. After application of the fixators, all PIP joint dislocations were reduced. The median residual P2 dorsal displacements were 0.0 mm for the pins-rubber bands group, 0.1 mm for the pins-only group, and 0.5 mm for the syringe-pins group. There were no cases of PIP joint redislocation after flexion-extension cycling, and the median dorsal P2 displacements were 0.0 mm for the pins-rubber bands group; 0.0 mm for the pins-only group; and 0.5 mm for the syringe-pins group., Conclusions: All 3 external fixators restored PIP joint stability following simulated dorsal fracture-dislocation, with all reductions maintained after motion testing. The syringe-pins construct had significantly greater median residual P2 dorsal displacement after the initial reduction and motion testing, which is of unclear clinical importance., Clinical Relevance: This study informs surgeon decision-making when considering dynamic external fixator options for dorsal PIP joint fracture-dislocations., (Copyright © 2023 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Ultrasound offers a fast and inexpensive way to evaluate the median nerve. However, there is a paucity of data assessing ultrasound in acute trauma. Our study aimed to characterize median nerve changes indicative of acute carpal tunnel syndrome (ACTS) in a cadaveric distal radius fracture (DRF) model., Methods: We used 10 upper-extremity specimens. We induced ACTS (carpal tunnel pressure >40 mm Hg) in a distraction-only model and then used a DRF model as a neutral position, under traction, or wrist extension. We measured the median nerve cross-sectional area (CSA), height, and width with ultrasound in each model. We used a novel calculation, height-width ratio (HWR), to describe nerve shape. A low HWR indicates an elliptical shape; as the HWR increases toward one, the shape becomes more circular. The CSA measurements and HWR at pressures >40 mm Hg were used to calculate a 95% confidence interval, which defined the threshold for ACTS., Results: Wrist distraction created carpal tunnel pressures >40 mm Hg in all specimens. Distraction increased CSA compared with baseline (9.1 ± 0.9 mm 2 vs 6.3 ± 1.2 mm 2 , P < .001). Under ACTS-level pressures, the thresholds for CSA and HWR were 8.5 mm 2 and 0.41, respectively. HWR significantly increased with distraction compared with baseline (0.47 ± 0.10 vs 0.28 ± 0.09, P  = .006). Most neutral DRF models (n = 8, 80%) met the CSA threshold for ACTS, whereas all specimens with a DRF extended or under traction had CSAs above the ACTS threshold. Compared to the baseline, the shape of the median nerve was more circular in all DRFs, including neutral (0.28 ± 0.09 vs 0.39 ± 0.13), under traction (0.43 ± 0.09), and extended (0.45 ± 0.09)., Conclusions: ACTS should be suspected in patients with median nerves demonstrating increased CSA and adopting a more circular shape. Fracture positioning impacts median nerve CSA with wrist extension, causing the greatest change. Median nerve HWR may offer an easier ultrasonographic alternative to CSA., Type of Study/level of Evidence: Diagnostic III., (© 2023 The Authors.)

Background: The medial femoral trochlea (MFT) osteochondral flap is employed for reconstruction of unsalvageable scaphoid proximal pole nonunions. The convex surface of the cartilage-bearing proximal trochlea is used to replace the similarly contoured proximal scaphoid and articulate with the concave scaphoid fossa of the radius. A magnetic resonance imaging (MRI) comparison of the shape of the MFT as it relates to the native proximal scaphoid has not been previously performed. Our study aimed to quantifiably compare the shape of the MFT, proximal scaphoid, and scaphoid fossa., Methods: Using imaging processing software, we measured radius of curvature of the articular segments in MRI scans of 10 healthy subjects' wrists and knees., Results: Compared with the scaphoid fossa, average ratio of the radius of circumference of the proximal scaphoid was 0.79 and 0.78 in the coronal and sagittal planes, respectively. Compared with the scaphoid fossa, average ratio of the radius of circumference of the MFT was 0.98 and 1.31 in the coronal and sagittal planes, respectively. The radius of curvature of the MFT was larger than the proximal scaphoid, in the coronal and sagittal planes. In the coronal plane, the MFT radius of curvature is nearly identical to the scaphoid fossa, a closer match than the scaphoid itself. In the sagittal plane, the radius of curvature of the MFT was larger than the radius of curvature of the scaphoid fossa., Conclusions: Our data suggest that the radius of curvature, in the sagittal and coronal planes, of the MFT and proximal scaphoid is disparate.

Background: Symptomatic postresection interdigital neuroma is a frustrating problem that causes debilitating foot pain. Implementing the concepts of targeted muscle innervation, this study offers a novel nerve transfer involving the resected third common plantar digital nerve (CPDN) to the motor nerve branch of the third dorsal interosseous muscle (DIMB) to improve postresection pain., Methods: Ten fresh feet from seven cadaveric donors were used for this study. CPDN and DIMB lengths and diameters were measured, along with nerve overlap after the transfer with ankle in neutral position and in maximal dorsiflexion. Motor entry point to the calcaneal tuberosity and to the fifth metatarsal tuberosity were measured and used to evaluate the ratio relative to foot length. Means, standard deviations, and P values were calculated for each measure and between sexes and feet (right and left)., Results: In all specimens, the nerve transfer was technically feasible, without notable size mismatch between the donor and recipient nerves. CPDN, DIMB, and important anatomical reference points were identifiable in all specimens. Average CPDN length was 30.1 ± 8.2 mm. The average DIMB length was 14.4 ± 3.9 mm. The overlap between the donor and recipient in neutral ankle position at the transfer site was 6.4 ± 1.8 mm., Conclusions: Given their anatomical locations, a nerve transfer between the third CPDN and third DIMB is surgically feasible. This novel technique is a viable option that can be used instead of the conventional technique of muscle implantation or more proximal re-resection for symptomatic postresection interdigital neuroma., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Purpose: Patients may receive surprise out-of-network bills even when they present to in-network facilities. Surprise bills are common following emergency care. We sought to characterize and determine risk factors for surprise billing in hand and upper extremity trauma patients in the emergency department (ED)., Methods: We used IBM MarketScan data to evaluate hand and upper extremity trauma patients who received care in the ED from 2010 to 2017. Our primary outcome was the surprise billing incidence, defined as encounters in in-network EDs with out-of-network claims. We used descriptive and bivariate analyses to characterize surprise billing and used multivariable logistic regression to evaluate independent factors associated with surprise billing., Results: Of 710,974 ED encounters, 97,667 (14%) involved surprise billing. The incidence decreased from 26% in 2010 to 11% in 2017. Mean coinsurance payments were higher for surprise billing encounters and had double the growth from 2010 to 2017 compared to those without surprise billing. Receiving care from different provider types-especially therapists, radiologists, and pathologists, as well as hand surgeons-was associated with significantly higher odds of surprise billing. Transfer to another facility was not significantly associated with surprise billing., Conclusions: Although the incidence of surprise billing decreased, more than 10% of patients treated in an ED for hand trauma remain at risk. Coinsurance for surprise billing encounters increased by twice as much as encounters without surprise billing. Patients requiring services from therapists, radiologists, pathologists, and hand surgeons were at greater risk for surprise bills. The federal No Surprises Act, passed in 2020, targets surprise billing and may help address some of these issues., Clinical Relevance: Many hand and upper extremity patients requiring ED care receive surprise bills from various sources that result in higher out-of-pocket costs., (Copyright © 2022 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: The mismanagement of missing data in large clinical databases may lead to inaccurate findings. The purpose of this study was to demonstrate the effects of missing data on hand surgery research findings using an analysis of postoperative morbidity in patients undergoing hospital-based hand surgery., Methods: The National Surgical Quality Improvement Program database was queried for patients undergoing common hand and upper extremity surgery between 2011 and 2016. Major and minor postoperative complications were identified. Demographics, comorbidity, and preoperative laboratory values were identified, and the percentage missing of each was tabulated. To demonstrate how missing data can alter analysis results, these variables were evaluated for an association with major complications using multivariable regression on 3 separate cohorts: (1) all patients; (2) all patients after exclusion of any patient entry with &gt;10% of missing data; and (3) after removal of any patient entry with any missing data., Results: Groups 1, 2, and 3 had 48 370, 23 118, and 6280 patients, respectively. There were 14 variables associated with increased odds of major complications in group 1, yet only 10 and 9 variables for groups 2 and 3, respectively. Six variables were associated with increased major complications across all 3 groups, whereas only 1 was associated with decreased odds of major complications across all groups., Conclusions: Filtering patient cohorts according to the amount of missing patient information affected analyses of predictors for major complications associated with hospital-based hand surgery. These findings highlight the importance of considering and addressing missing data in large database studies.

Purpose: Opioids play an important role in pain management after surgery but also increase the risk of prolonged opioid use in patients. The identification of patients who are more likely to use opioids after intended short-term treatment is critical for employing alternative management approaches or targeted interventions for the prevention of opioid-related problems. We used patient-reported data (PRD) and electronic health record information to identify factors predictive of prolonged opioid use after surgery., Methods: We used our institutional registry containing data on all patients who underwent elective upper extremity surgeries. We evaluated factors associated with prolonged opioid use in the cohort from the year 2018 to 2019. We then validated our results using the 2020 cohort. The predictive variables included preoperative PRD and electronic health record data. Opioid use was determined based on patient reports and/or filled opioid prescriptions 3 months after surgery. We conducted bivariate regression, followed by multivariable regression analyses, and model validation using area under the receiver operating curve., Results: We included 2,114 patients. In our final model on the 2018-2019 electronic health records and PRD data (n = 1,589), including numerous patient-reported outcome questionnaire scores, patients who were underweight and had undergone trauma-related surgery had higher odds of being on opioids at 3 months. Additionally, each 5-unit decrease in the preoperative Patient-Reported Outcomes Measurement Information System Global Physical Health score was associated with a 30% increased odds of being on opioids at 3 months. The area under the receiver operating curve of our model was 70.4%. On validation using data from the 2020 cohort, the area under the receiver operating curve was 60.3%. The Hosmer-Lemeshow test indicated a good fit., Conclusions: We found that preoperative questionnaire scores were associated with prolonged postoperative opioid use, independent of other variables. Furthermore, PRD may provide unique patient-level insights, alongside other factors, to improve our understanding of postsurgical pain management., Type of Study/level of Evidence: Prognostic II., (Copyright © 2022. Published by Elsevier Inc.)

Purpose: Comminuted intra-articular fractures and fracture dislocations of the metacarpophalangeal (MCP) and interphalangeal joints are challenging. Dynamic external fixation, permitting early joint motion while still minimizing forces across the healing joint, can result in acceptable postoperative active range of motion (AROM). However, some fractures are not initially stable enough for early dynamic motion; further, many available dynamic external fixation systems are costly and cumbersome. We reviewed our experience using an external fixator made from a 1-mL syringe and K-wires and report outcomes using it as a static fixator, dynamic fixator, or configured as a static fixator and then converted to a dynamic fixator in the clinic., Methods: Patients with intra-articular fractures and fracture dislocations of the MCP and proximal interphalangeal (PIP) joints treated between 2014 and 2020 using syringe external fixators were retrospectively reviewed. We reviewed demographics, mechanisms, treatment types and durations, and postoperative AROM, as well as complications including infection, pin loosening, nonunion, hardware failure, and need for further surgery. Patients were analyzed by the level of joint injury (MCP versus PIP) and by treatment pattern., Results: After excluding 23 patients with 25 joint injuries who were lost to follow-up or had inadequate outcome data, 27 patients with 29 joint injuries were reviewed. The average follow-up was 171 days after surgery. The postoperative AROM at the MCP level averaged 55° for static fixation and 30° for static-to-dynamic fixation. The postoperative AROM at the PIP level averaged 64° for static fixation, 66° for static-to-dynamic fixation, and 80° for dynamic fixation. Three pin site infections and 2 loose pins were reported., Conclusions: The syringe external fixator is an inexpensive, effective, and customizable treatment for intra-articular MCP and interphalangeal fractures and fracture dislocations, and results in acceptable postoperative AROM outcomes and complication rates., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2022 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the degree of disuse osteopenia (DO) and factors associated with its development during treatment of distal radius fractures (DRFs)., Methods: We retrospectively reviewed charts and radiographs of patients with DRFs treated with and without surgery at 2 health care systems. We defined DO as a >10% drop from initial to 6-week second metacarpal cortical percentage and 6-week absolute second metacarpal cortical percentage <60%. Bivariate analyses were performed to evaluate associations between treatment type, patient and fracture characteristics, and radiographic measurements with odds of developing DO. Significant associations were included in multivariable analyses, adjusting for patient and fracture characteristics., Results: Approximately 18% of 517 included patients met the criteria for development of DO (n = 93). Bivariate analysis showed that surgical treatment was associated with lower odds of developing DO, whereas advancing age was associated with increased odds. In adjusted multivariable models, only advancing age was associated with increased odds of developing DO., Conclusions: A fairly important proportion of patients with DRF develop hand DO 6 weeks after surgical or nonsurgical treatment. The clinical relevance of this finding is uncertain and requires further investigation., Type of Study/level of Evidence: Prognostic IV., (© 2022 The Authors.)

Purpose: Emergency department (ED) visits for postoperative concerns that could be safely addressed in outpatient clinics have an impact on cost, quality measures, and care workflows. Patient-reported data (PRD) may give unique insights into individual-level factors that predict overuse of health care resources, and guide opportunities for intervention and prevention. We investigated the relationship between preoperative PRD and preventable ED use after outpatient hand surgery to determine whether the preoperative PRD can be used to identify patients at higher odds of having preventable ED visits., Methods: All adult patients undergoing outpatient surgery at our hand center between January 1, 2018, and December 31, 2019, were included. Questionnaires, including the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) and pain interference (PI) scales, were completed before surgery. We used our regional health information exchange to identify ED visits within 90 days of surgery., Results: Our cohort included 2,819 patients. Within 90 days after surgery, 106 (3.8%) had preventable ED visits. Race, insurance status, and transportation issues increased odds of a preventable ED visit. Multivariable models found that each 1-point increase in the preoperative PROMIS UE score was associated with 4% decreased odds of ED presentation (odds ratio, 0.96; 95% confidence interval, 0.94-0.99), and each 1-point increase in the preoperative PROMIS PI score was associated with 4% increased odds of ED presentation (odds ratio, 1.04; 95% confidence interval, 1.0-1.1). Any PROMIS UE or PI scores ≥1SDs worse than population norms increased the probability of a preventable ED visit, independent of other factors., Conclusions: Worse preoperative PROMIS UE and PI scores were associated with increased odds of preventable ED visits. Preoperative PRD may allow for identification of outliers at higher risk for preventable ED use, and facilitate preventative interventions., Type of Study/level of Evidence: Prognostic IV., (Copyright © 2022. Published by Elsevier Inc.)

Current outcome measures, including strength/range of motion testing, patient-reported outcomes (PROs), and motor skill testing, may provide inadequate granularity in reflecting functional upper extremity (UE) use after distal radius fracture (DRF) repair. Accelerometry analysis also has shortcomings, namely, an inability to differentiate functional versus nonfunctional movements. The objective of this study was to evaluate the accuracy of machine learning (ML) analyses in capturing UE functional movements based on accelerometry data for patients after DRF repair. In this prospective study, six patients were enrolled 2-6 weeks after DRF open reduction and internal fixation (ORIF). They all performed standardized activities while wearing a wrist accelerometer, and the data were analyzed by an ML algorithm. These activities were also videotaped and evaluated by visual inspection. Our novel ML algorithm was able to predict from accelerometry data whether the limb was performing a movement rated as functional, with accuracy of 90.4% ± 3.6% for within-subject modeling and 79.8% ± 8.9% accuracy for between-subject modeling. The application of ML algorithms to accelerometry data allowed for capture of functional UE activity in patients after DRF open reduction and internal fixation and accurately predicts functional UE use. Such analyses could improve our understanding of recovery and enhance routine postoperative rehabilitation in DRF patients., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Purpose: Neuroma formation following upper-extremity peripheral nerve injury often results in persistent, debilitating neuropathic pain with a limited response to medical management. Vascularized, denervated muscle targets (VDMTs) offer a newly described surgical approach to address this challenging problem. Like targeted muscle reinnervation and regenerative peripheral nerve targets, VDMTs are used to redirect regenerating axons from an injured nerve into denervated muscle to prevent neuroma formation. By providing a vascularized muscle target that is reinnervated via direct neurotization, VDMTs offer some theoretical advantages in comparison with the other contemporary surgical options. In this study, we followed the short-term pain outcomes of patients who underwent VDMT surgery for neuroma prevention or treatment., Methods: We performed a retrospective chart review of 9 patients (2 pediatric and 7 adult) who underwent VDMTs either for symptomatic upper-extremity neuromas or as a prophylactic measure to prevent primary neuroma formation. In-person and/or telephone interviews were conducted to assess their postoperative clinical outcomes, including the visual analog pain scale simple pain score., Results: Of the 9 patients included in this study, 7 underwent VDMT surgery as a prophylactic measure against neuroma formation, and 2 presented with symptomatic neuromas that were treated with VDMTs. The average follow-up was 5.6 ± 4.1 months (range, 0.5-13.2 months). The average postoperative pain score of the 7 adult patients was 1.1 (range, 0-8)., Conclusions: This study demonstrated favorable short-term outcomes in a small cohort of patients treated with VDMTs in the upper extremity. Larger, prospective, and comparative studies with validated patient-reported and objective outcome measures and longer-term follow-ups are needed to further evaluate the benefits of VDMTs in upper-extremity neuroma management and prevention., Type of Study/level of Evidence: Therapeutic III., (© 2022 The Authors.)

Introduction: On January 1, 2019, in an effort to improve price transparency, the Centers for Medicare and Medicaid Services (CMS) mandated that hospitals display chargemasters and pricing for diagnosis-related groups (DRGs) online. We examined the compliance of the 50 top orthopaedic hospitals, ranked by US News, with CMS's mandate and compared pricing., Methods: The chargemaster and pricing of DRG codes related to total knee arthroplasty (TKA) and total hip arthroplasty (THA) (469, 470, 461, 462, 466, 467, and 468) were evaluated in the top 50 orthopaedic hospitals in the United States. Spearman rank correlation coefficients (ρ) were used to evaluate the association between DRG 469, 470, and 467 prices with geographic practice cost index (GPCI) work and practice expense values., Results: Thirty-six of the 50 hospitals reported DRG pricing for THA and TKA. Of these hospitals, 15 had prices for all seven DRGs of interest; only 467, 469, and 470 were reported across all the 36 hospitals. Of the 14 hospitals without DRG information, 12 had nothing and two had unsatisfactory reporting. Prices for DRGs 469, 470, and 467 were moderately or weakly correlated with both GPCI work and GPCI practice expense. All correlation analyses were statistically significant (P < 0.05)., Discussion: In summary, compliance with CMS's 2019 rule was poor overall. Fourteen of the 50 hospitals did not adequately report any DRG pricing, and only 15 of the hospitals were fully compliant with the mandate. In addition to poor compliance, the reported costs had variation not strongly accounted for by established geographic differences., (Copyright © 2022 by the American Academy of Orthopaedic Surgeons.)

Purpose: To identify patient-level barriers and facilitators to completion of patient-reported outcomes measures (PROMs) in a hand and upper extremity clinic in Baltimore, Maryland., Methods: We conducted 12 h of direct observation of PROM completion (October-November, 2020). Ethnographic observation memos were qualitatively analyzed for barriers and facilitators using rapid thematic analysis. Informed by observation findings, we conducted 17 semi-structured interviews with mixed-literacy patients, caregivers, and clinic staff to understand the patient experience when completing PROMs (November 2020-March 2021). We identified initial themes through inductive and deductive framework analysis and validated findings through subsequent interviews with member-checking., Results: We identified nine patient-level factors that influence PROM completion: platform design, print literacy, health literacy, technology literacy, language proficiency, physical functioning, vision, cognitive functioning, and time., Conclusions: There are multiple distinct patient-level factors that affect PROM completion. Failure to consider these factors in PROM design and implementation may lower completion rates or prevent accurate completion, undermining PROM validity. Because certain factors affect minority populations at disproportionate rates, this may also contribute to existing health disparities., (© 2021. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)