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Gun-related violence is becoming increasingly more common in the United States, and ballistic injuries pose a challenge to the orthopaedic surgeon on trauma call. The guiding principles of trauma care are almost exclusively based on blunt trauma, and the management principles do not always translate. Ballistic long bone fractures, particularly of the lower extremity, can often be managed with similar principles, although the injury pattern can make restoration of anatomic alignment a challenge. Some data suggest that patients with ballistic arthrotomies can be safely treated with medical management and antibiotic therapy alone; however, gross contamination can be encountered, and this decision is at the surgeon's discretion. Retained ballistic fragments may result in intra-articular changes and elevated lead levels over time, warranting consideration for surgical excision. Ballistic injuries to the hand and wrist are often present with concomitant soft-tissue injury, including nerve and tendon injuries. Providing stable bony fixation while also facilitating early motion for rehabilitation is a difficult balance to reach. In addition, the management of ballistic nerve injuries is controversial, as many injuries are not simply neurapraxic, and either early exploration or evaluation with ultrasonographic imaging may help detect injuries for which repair or grafting can be considered. Last, ballistic trauma can have mental health implications for patients and families and even contribute to the burnout epidemic demonstrated in health care professionals.

Purpose: Cubital tunnel syndrome (CuTS) is the second most common upper-extremity neuropathy and can cause debilitating symptoms. Patients presenting to care with severe CuTS can be left with permanent weakness and numbness despite treatment. The aim of this study was to examine the relationship between area-level deprivation and the severity of CuTS on presentation to a hand surgeon., Methods: We retrospectively identified 369 patients who were diagnosed with CuTS at a new patient visit between January 2017 and December 2021. We queried the electronic health record to assess the severity of CuTS using the McGowan grade. We used patient addresses to determine the national percentile of area-level deprivation for each patient. Bivariate analyses were used to determine if sociodemographic factors were associated with CuTS severity on presentation or rates of surgical intervention., Results: In bivariate analysis, patients with higher levels of area-level deprivation had more severe CuTS. Those who were older, were men, and had public insurance were also found to have more severe CuTS. Secondary analysis revealed that patients with higher levels of deprivation were more likely to receive nerve conduction testing. No sociodemographic factors were associated with whether patients received surgical intervention or in time from presentation to surgery., Conclusions: Patients from marginalized backgrounds present to hand surgeons with more severe CuTS disease., Clinical Relevance: Delayed presentation can lead to worse outcomes in CuTS. Understanding barriers to earlier presentation in more deprived locations and certain patient populations can help develop solutions to address these disparities., Competing Interests: Conflict of Interest The authors declare that they have no conflicts of interest., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Cannabinoids are a diverse group of compounds under investigation for various medical purposes, including analgesia. Given the evolving landscape of cannabinoid use, we aimed to analyze their prevalence and effect in pain management among urban orthopedic hand patients., Methods: An electronic survey was administered to 122 new patients presenting to the orthopedic hand clinic of a major urban academic hospital. Demographic data, numerical rating scale pain scores, cannabinoid usage, and other concomitant pain regimens were recorded., Results: Approximately half of the new patients were dissatisfied with current pain management for their hand pathology. Prescription (Rx) and over-the-counter (OTC) pain medications were used by 58% (71/122) of patients, while cannabinoids were used by 15% (18/122) of patients. Compared with pre-usage pain scores, both cannabinoids and Rx/OTC medications induced significant reductions in pain associated with patients' hand pathologies (Cannabinoid: Δ4.4, P = .002; Rx/OTC: Δ3.0, P < .001). Cannabinoids induced a larger analgesic effect, but this difference was not statistically or clinically significant ( P = .06). Subjectively, cannabinoid users either preferred their cannabinoid over Rx/OTC medications or liked both equally. Opioid use was higher among cannabinoid users (22.2% vs 12.5%), although this was not statistically significant ( P = .28)., Conclusion: Approximately 15% of new urban hand patients use cannabinoids for pain control, and these compounds have similar analgesic efficacy in hand pathologies as Rx/OTC medications. Cannabinoids are equally liked or preferred relative to traditional medications in this cohort, and they may play an important role in pain management for hand 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.

» Gunshot injuries to the upper extremity (UE) have high likelihood for causing peripheral nerve injury secondary to the high density of vital structures. Roughly one-fourth of patients sustaining a gunshot wound (GSW) to the UE incur a nerve injury. Of these nerve injuries, just over half are neurapraxic. In cases of surgical exploration of UE nerve injuries, nearly one-third demonstrate a transected or discontinuous nerve.» Existing literature regarding surgical management of nerve injuries secondary to GSWs comes from both military and civilian injuries. Outcomes are inconsistently reported, and indications are heterogeneous; however, reasonable results can be obtained with nerve reconstruction.» Our proposed management algorithm hinges on 4 treatment questions: if there is a nerve deficit present on examination, if there is a concomitant injury in the extremity (i.e., fracture or vascular insult), whether the injured nerve would be in the operative field of the concomitant injury, and whether there was an identified nerve lesion encountered at the time of surgery by another surgeon?» Early exploration rather than continued expectant management may offer improved recovery from GSW nerve injuries in particular situations. When an UE nerve deficit is present, establishing follow-up after the initial GSW encounter and early referral to a peripheral nerve surgeon are pivotal., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/B120)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Nerve injuries secondary to gunshot wounds (GSWs) have been traditionally thought of as neurapraxic injuries with high likelihood of complete recovery. A review of the literature, however, highlights the misconceptions surrounding ballistic nerve injuries and their treatments. Contrary to this accepted dogma, approximately 30% to 60% of GSWs to the upper extremity may result in nerve injury requiring repair or reconstruction. Surgical exploration following ballistic injury reveals that 20% to 55% of nerves were lacerated requiring repair or grafting. Despite these numbers, outcomes after nerve repair or grafting are limited, and the limited data show evidence of poor functional recovery. In our experience, delayed exploration of GSW-related nerve injuries in patients without signs of functional recovery demonstrate large neuromas in continuity often requiring meticulous dissection and excision with resulting large gaps that require reconstruction. This has led us to explore options to identify patients with nerve deficits after GSWs who may benefit from earlier exploration. Others advocate for the exploration of all ballistic nerve injuries, which would represent a logistical challenge in high volume centers and may lead to unnecessary explorations of in continuity nerves. To facilitate identification of nerve injury following GSWs, we have explored the utilization of early ultrasound to identify patients with nerve lacerations that may benefit from early exploration (1-2 weeks after injury). Earlier exploration can lead to less technically challenging surgery, shorter nerve gaps, and more time for the nerve to recover. Herein, we present a series of cases to help illustrate this approach to the patient. Although early exploration and repair versus grafting of nerves may have benefits as outlined above, there are little to no data on outcomes of nerve repair or grafting in ballistic injuries in the more acute setting, 1 to 2 weeks after injury. Further research is needed both with regards to diagnosis and utilization of ultrasound, as well as postoperative outcomes in patients with ballistic nerve injuries to help guide our ever-evolving treatment protocols., Competing Interests: No benefits in any form have been received or will be received related directly to this article., (© 2024 The Authors.)

Background: The Patient-Reported Outcomes Measurement Information System® (PROMIS®) may be used to assess an individual patient's perspective of their physical, mental, and social health through either standard or computer adaptive testing (CAT) patient questionnaires. These questionnaires are used across disciplines; however, they have seen considerable application in orthopaedic surgery. Patient characteristics associated with PROMIS CAT completion have not been examined within the context of social determinants of health, such as social deprivation or health literacy, nor has patient understanding of the content of PROMIS CAT been assessed., Questions/purposes: (1) What patient demographics, including social deprivation, are associated with completion of PROMIS CAT questionnaires? (2) Is health literacy level associated with completion of PROMIS CAT questionnaires? (3) Do patients with lower health literacy have a higher odds of completing PROMIS CAT without fully understanding the content?, Methods: Between June 2022 and August 2022, a cross-sectional study was performed via a paper survey administered to patients at a single, urban, quaternary academic medical center in orthopaedic subspecialty clinics of foot and ankle, trauma, and hand/upper extremity surgeons. We considered all English-speaking patients aged 18 or older, including those with limited reading and/or writing abilities, as eligible provided they received an iPad in clinic to complete the PROMIS CAT questionnaire as part of their routine standard clinical care or they completed the questionnaire via a patient portal before the visit. In all, 946 patients were considered eligible during the study period and a convenience sample of 36% (339 of 946) of patients was approached for inclusion due to clinic time constraints. Fifteen percent (52 of 339) declined to participate, leaving 85% (287 of 339) of patients for analysis here. Median (range) age of study participants was 49 years (35 to 64). Fifty-eight percent (167 of 287) of study participants self-identified as non-Hispanic Black or African American and 26% (75 of 287) as non-Hispanic White. Even proportions were observed across education levels (high school graduate or less, 29% [82 of 287]; some college, 25% [73 of 287]; college graduate, 25% [71 of 287]; advanced degree, 20% [58 of 287]). Eighteen percent (52 of 287) of patients reported an annual income bracket of USD 0 to 13,000, and 17% (48 of 287) reported more than USD 120,000. Forty-six percent (132 of 287) of patients worked full-time, 21% (59 of 287) were retired, and 23% (66 of 287) were unemployed or on disability. The primary outcome of interest was self-reported PROMIS CAT questionnaire completion grouped as: fully completed, partially completed, or no part completed. Overall, self-reported PROMIS CAT questionnaire completion proportions were: 80% (229 of 287) full completion, 13% (37 of 287) partial completion, and 7% (21 of 287) no part completed. We collected the National Area Deprivation Index (ADI) score and the Brief Health Literacy Screening Tool (BRIEF) as part of the study survey to associate with level of completion. Additionally, patient understanding of PROMIS CAT was assessed through Likert-scaled responses to a study survey question that directly asked whether the patient understood all of the questions on the PROMIS CAT questionnaire. Responses to this question may have been limited by social desirability bias, and hence may overestimate how many individuals genuinely understood the questionnaire content. However, the benefit of this approach was it efficiently allowed us to estimate the ceiling effect of patient comprehension of PROMIS CAT and likely had a high degree of specificity for detecting lack of comprehension., Results: ADI score adjusted for age was not associated with PROMIS CAT completion (partial completion OR 1.00 [95% CI 0.98 to 1.01]; p = 0.72, no part completed OR 1.01 [95% CI 0.99 to 1.03]; p = 0.45). Patients with lower health literacy scores, however, were more likely to not complete any part of their assigned questionnaires than patients with higher scores (no part completed OR 0.85 [95% CI 0.75 to 0.97]; p = 0.02). Additionally, 74% (26 of 35) of patients who did not fully understand all of the PROMIS CAT questionnaire questions still fully completed them-hence, 11% (26 of 229) of all patients who fully completed PROMIS CAT did not fully understand the content. Among patients self-reporting full completion of PROMIS CAT with health literacy data (99% [227 of 229]), patients with inadequate/marginal health literacy were more likely than patients with adequate health literacy to not fully understand all of the questions (21% [14 of 67] versus 8% [12 of 160], OR 3.26 [95% CI 1.42 to 7.49]; p = 0.005)., Conclusion: Within an urban, socioeconomically diverse, orthopaedic patient population, health literacy was associated with PROMIS CAT questionnaire completion. Lower health literacy levels increased the likelihood of not completing any part of the assigned PROMIS CAT questionnaires. Additionally, patients completed PROMIS CAT without fully understanding the questions. This indicates that patient completion does not guarantee comprehension of the questions nor validity of their scores, even more so among patients with low health literacy. This is a substantive concern for fidelity of data gathered from PROMIS CAT., Clinical Relevance: Clinical implementation of the PROMIS CAT in orthopaedic populations will benefit from further research into health literacy to increase questionnaire completion and to ensure that patients understand the content of the questions they are answering, which will increase the internal validity of the outcome measure., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2023 by the Association of Bone and Joint Surgeons.)

Purpose: Social determinants of health (SDOH) are linked to poor health care outcomes across the different medical specialties. We conducted a scoping review to understand the existing literature and identify further areas of research to address disparities within hand surgery., Methods: A systematic search of PubMed, Scopus, and Cochrane was conducted. Inclusion criteria were English studies examining health disparities in hand surgery. The following were assessed: the main SDOH, study design/phase/theme, and main disease/injury/procedure. A previously described health disparities research framework was used to determine study phase: detecting (identifying risk factors), understanding (analyzing risk factors), and reducing (assessing interventions). Studies were categorized according to themes outlined at the National Institute of Health and American College of Surgeons: Summit on Surgical Disparities., Results: The initial search yielded 446 articles, with 49 articles included in final analysis. The majority were detecting-type (31/49, 63%) or understanding-type (12/49, 24%) studies, with few reducing-type studies (6/49, 12%). Patient factors (31/49, 63%) and systemic/access factors (16/49, 33%) were the most frequently studied themes, with few investigating clinical care/quality factors (4/49, 8%), clinician factors (3/49, 6%), and postoperative/rehabilitation factors (1/49, 2%). The most commonly studied SDOH include insurance status (13/49, 27%), health literacy (10/49, 20%), and social deprivation (6/49, 12%). Carpal tunnel syndrome (9/49, 18%), upper extremity trauma (9/49, 18%), and amputations (5/49, 10%) were frequently assessed. Most investigations involved retrospective or database designs (29/49, 59%), while few were prospective, cross-sectional, or mixed-methods., Conclusions: Despite an encouraging upward trend in health disparities research, existing studies are in the early phases of investigation., Clinical Relevance: Most of the literature focuses on patient factors and systemic/access factors in regard to insurance status. Further work with prospective, cross-sectional, and mixed-method studies is needed to better understand health disparities in hand surgery, which will inform future interventions., (Copyright © 2023 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Milestones have been in effect for Accreditation Council for Graduate Medical Education-accredited hand surgery fellowships since 2015. In 2016, the Accreditation Council for Graduate Medical Education began an improvement process to make the milestones easier to read, understand, and assess. This article looks at the process used for hand surgery, makes comparisons between the two versions, and discusses the resulting changes. A representative group of hand surgery faculty and fellows worked together to review the milestones data and identify necessary changes. Working iteratively in large and small groups, the milestones were edited, and a supplemental guide was developed. The new hand surgery milestones have fewer patient care subcompetencies, yet include the same overarching themes. The medical knowledge subcompetencies have been reduced to four, and they now focus on key dimensions of knowledge development instead of pure anatomical knowledge. Systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills include subcompetencies harmonized with all other accredited programs. Finally, the supplemental guide was created as an aid to clinical competency committees to provide clear understanding of the intent of the milestones. The guide includes examples for individual milestones, ideas for how to assess each subcompetency, and resources for faculty and fellows alike. The new hand surgery milestones were designed to be clearer and easier for clinical competency committees to evaluate and for faculty and fellows to understand. The accompanying supplemental guide is a new addition that will help individual programs better understand how to implement these changes. The new hand surgery milestones can be found at https://www.acgme.org/globalassets/pdfs/milestones/handsurgerymilestones.pdf., (Copyright © 2023. Published by Elsevier Inc.)

Background: The authors aimed to explore patients' perioperative experience after trapeziectomy and ligament reconstruction tendon interposition through semistructured patient interviews to identify deficiencies in preoperative patient counseling., Methods: The authors conducted semistructured interviews with 14 patients who had undergone ligament reconstruction tendon interposition either 10 to 14 weeks or 9 to 12 months postoperatively at the time of their interview. The semistructured interview guide was developed by a fellowship-trained hand surgeon and a qualitative research specialist to discuss each patient's perioperative experience. Inductive and deductive qualitative coding strategies were used to develop a codebook. All transcripts were then double-coded and discussed to develop recurrent major themes from the patient interviews., Results: The authors' interviews identified three major themes discussed consistently on the patient perioperative experience. First, despite specific counseling about a 3- to 6-month postoperative rehabilitation period, patients were still surprised at the length of the recovery process in regaining function, range of motion, and strength. Second, patients repeatedly outlined that surgery on the dominant hand imparted specific limitations that made the postoperative course difficult. Third, patients discussed the importance of hand therapy both in rehabilitation and in guiding patient postoperative expectations., Conclusions: Preoperative counseling is of vital importance to set patient expectations in terms of overall expected outcomes, but also regarding early limitations, expectations, and overall recovery length. These themes have influenced how we counsel our patients about recovery after thumb carpometacarpal surgery and may help other surgeons identify areas for improvement in their discussions with patients., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Purpose: The purpose of this study was to determine whether extremities undergoing carpal tunnel release (CTR) have an increased rate of trigger finger (TF) compared with conservatively managed carpal tunnel syndrome., Methods: Data were collected from the Humana Insurance Database, and subjects were chosen on the basis of a history of CTR with propensity matching performed to develop a nonsurgical cohort. Following propensity matching, 16,768 patients were identified and equally split between surgical and nonsurgical treatments. Demographic information and medical comorbidities were recorded. Univariate and multivariate analyses were performed to identify risk factors for the development of TF within 6 months of carpal tunnel syndrome diagnosis., Results: Patients in the surgical cohort were more likely to develop TF than those in the nonsurgical cohort whether in the ipsilateral or contralateral extremity. Whether managed surgically or nonsurgically, extremities with carpal tunnel syndrome demonstrated an increased prevalence of TF than their contralateral, unaffected extremity., Conclusions: Surgeons should be aware of the association of TF and CTR both during the presurgical and postsurgical evaluations as they might impact patient management. With knowledge of these data, surgeons may be more attuned to detecting an early TF during the postsurgical period and offer more aggressive treatment of TF pathology during CTR., Type of Study/level of Evidence: Prognostic III.

Purpose: Several studies have explored opioid consumption and opioid prescriber education for upper extremity procedures; however, less literature has focused on patient-centered interventions and their impact on opioid consumption after surgery. The purpose of this study was to create a standardized perioperative patient education program regarding postoperative pain management after hand surgery and to determine if it could reduce opioid use after hand surgery., Methods: Patients scheduled to undergo elective outpatient hand surgery comprising minor soft tissue procedures at and distal to the wrist were randomized to receive pain management education or standard care. Before the surgery, all patients viewed a webinar with instructions for participation, whereas the education group received an additional 10 minutes of education on postoperative pain management and a pain management reference card for review after the surgery. All patients completed a postoperative daily log documenting the number of opioids consumed, other pain management modalities used, and pain scores. The primary outcome of the number of opioid pills consumed by the patients was compared between the groups. We constructed a linear regression model to determine the risk factors for postoperative opioid use after surgery., Results: One hundred seventy-four patients completed the study (n = 90 education group; n = 84 standard care group). Patients in the education group took significantly fewer opioid pills (median = 0, range 0-13) than those in the standard care group (median = 0.5, range 0-40). A linear regression model showed that average week-1 pain (B = 0.93; 95% confidence interval, 0.56-1.3) and the number of pills prescribed (B = 0.12; 95% confidence interval, 0.017-0.22) were predictive of greater opioid use., Conclusions: Perioperative patient education significantly reduced postoperative opioid use following a minor soft tissue hand surgery, with greater than 70% of the patients taking no opioids., Type of Study/level of Evidence: Prognostic II., (Copyright © 2022 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Competing Interests: The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Background: Patient-reported allergies (PRAs) are associated with suboptimal orthopaedic surgery outcomes and may serve as a proxy for mental health. While mental health disorders are known risk factors for increased opioid use, less is known about how PRAs impact opioid use after orthopedic surgery. The purpose of this study was to investigate the association between PRAs and postoperative opioid use, pain, and satisfaction following hand surgery. Methods: Patients who underwent ambulatory hand surgery at a single institution from May 2017 to March 2019 were retrospectively reviewed. Various scores, including the Mindfulness Attention Awareness Scale (MAAS), were collected preoperatively. Postoperatively, patients completed a 2-week pain diary, satisfaction, and visual analog scale (VAS) pain scores. Opioid consumption was converted to oral morphine equivalents (OMEs) using standard conversions. Results: A total of 137 patients were divided into 2 groups based on presence (≥1) (n = 73) or absence (0) (n = 64) of PRAs. At baseline, the ≥ 1 PRA group had significantly higher female composition ( P < .001) and pain ( P < .001) and lower PROMIS mental health scores ( P = .044). Postoperative OME consumption averaged 42.5 (range 0-416) in the entire cohort, with no differences between groups. Among patients with ≥ 1 PRA, increasing number of allergies significantly correlated with increasing OME consumption across all time points (week 1, P = .016; week 2, P = .001; total, P = .005). Conclusions: The presence of PRAs did not impact postoperative narcotic usage, pain, or satisfaction. Increasing numbers of PRAs did, however, significantly correlate with higher narcotic use. These results may have implications for postoperative pain management in this population.

Purpose: This study investigated the long-term outcomes of direct scapholunate ligament (SLL) repairs with or without dorsal capsulodesis performed within 6 weeks (acute repair) of a SLL tear versus 6 to 12 weeks following injury (subacute repair)., Methods: A review of medical records from April 1996 to April 2012 identified 24 patients who underwent SLL repair (12 acute, 12 subacute). Patients returned to the clinic for radiographic examinations of the injured wrist, standardized physical examinations, and validated questionnaires., Results: The mean follow-up times for the acute and subacute groups were 7.2 and 6.2 years, respectively. At the final examination, patients with acute surgery regained more wrist extension (acute = 55°, subacute = 47°). The total wrist flexion-extension arcs, grip strengths, pinch strengths, and patient-rated outcome scores were found to be similar between groups. The final scapholunate gap, scapholunate angle, and the prevalence of arthritis were also found to be similar between the acute and subacute groups., Conclusions: Although SLL repair is more commonly recommended for treatment of acute SLL injuries, there were no significant long-term differences between acute and subacute SLL surgeries (repair ± capsulodesis)., Type of Study/level of Evidence: Prognostic III., (© 2021 The Authors.)

Purpose: To establish the incidence of revision carpal tunnel surgery within a 1-year postoperative period using a national administrative database. This information has been unknown until this point because of the absence of laterality-specific coding with the International Classification of Diseases, Ninth Edition and earlier coding systems., Methods: Data were collected from the Humana insurance database using PearlDiver patient records from 2015 to 2017. Subjects were identified using Current Procedural Terminology and International Classification of Diseases procedure codes related to carpal tunnel diagnosis and release. Codes were used to identify patients who underwent carpal tunnel release (CTR) and had revision CTR within a 1-year follow-up period. Patient demographic characteristics, including age, sex, medical comorbidities, and smoking status, were collected. In addition, multivariable analysis of the risk of a revision procedure within 1 postoperative year was performed to determine independent risk factors, including the surgical approach, associated with revision CTR., Results: Among 4,549 patients who underwent a primary CTR during the study period, 207 patients (4.8%) underwent a revision CTR within 1 year. The average time from the primary CTR to the revision CTR was 135 days (standard deviation, 99.1 days; range, 21-365 days). Primary endoscopic CTR was associated with an increased rate of revision CTR (odds ratio, 1.3; 95% confidence interval, 1.2-1.6). Patient factors associated with a higher likelihood of requiring revision CTR included diabetes mellitus, tobacco use, psychiatric condition, cervical disease, and history of cubital tunnel release., Conclusions: This study identified a rate of revision CTR of 4.8% within the first postoperative year. Both the surgical technique and patient-specific risk factors influence the likelihood of requiring revision surgery. Notably, an endoscopic approach is associated with a higher risk of revision surgery., Type of Study/level of Evidence: Prognostic II., (Copyright © 2021 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Objective: Guidelines for opioid prescription post-operatively exist; however, the majority of these are for adults. Nevertheless, opioid risks are present for pediatric patients also. This study investigates the effect of a single institution's guidelines on post-operative opioid prescribing for pediatric orthopedic patients undergoing knee surgery. We hypothesized that a standardized set of prescribing guidelines would result in a decrease in opioids prescribed at discharge home after these surgeries., Design: Retrospective observational., Setting: Urban, tertiary care, academic orthopedic hospital., Patients: Pediatric, sports knee surgery, 23-month period., Interventions: Guidelines were implemented institutionally for post-operative opioid prescribing practices. We reviewed all post-operative opioid prescriptions for pediatric patients undergoing sports knee surgery with two pediatric sports surgeons for the 11 months prior to the guidelines and 12 months afterwards, totaling 316 surgeries., Main Outcome Measure: Oral morphine equivalents (OMEs) prescribed on discharge from the hospital before and after implementation of guidelines., Results: There was a significant reduction in OMEs from 229 OMEs to 175 OMEs before and after opioid prescribing guidelines (p < 0.001). This is a decrease in approximately seven 5 mg oxycodone tablets per patient., Conclusions: This study demonstrates that at our institution, with a pediatric patient population having sports knee surgery, prescribing guidelines reduced the number of opioids prescribed at discharge.

Background: Despite the growing hand surgery literature on postoperative opioid use, there is little research focused on patient-centered interventions. The purpose of this randomized controlled trial was to create a standardized patient education program regarding postoperative pain management after hand surgery and to determine whether that education program would decrease postoperative opioid use., Methods: Patients scheduled to undergo ambulatory hand surgery were recruited and randomized to standardized pain management education or standard of care. All patients received a webinar with instructions for study participation, whereas the education group received an additional 10 minutes of education on postoperative pain management. All patients completed a postoperative daily log documenting opioid consumption. The total number of opioid pills consumed was compared between groups. The authors constructed a linear regression model to determine risk factors for postoperative opioid use after surgery., Results: A total of 267 patients were enrolled in the study. One hundred ninety-one patients completed the study (standardized education, n = 93; control group, n = 97). Patients in the standardized education group were more likely to take no opioid medication (42 percent versus 25 percent; p = 0.01) and took significantly fewer opioid pills (median, two) than those in the control group (median, five) (p < 0.001). Standardized education predicted decreased postoperative opioid pill consumption, whereas higher number of pills prescribed and a history of psychiatric illness were risk factors for increasing opioid use., Conclusion: Perioperative patient education and limitation of postoperative opioid prescription sizes reduced postoperative opioid use following ambulatory hand surgery., Clinical Question/level of Evidence: Therapeutic, II., Competing Interests: Disclosure:Each author certifies that he or she has no commercial associations that might pose a conflict of interest in connection with the submitted article., (Copyright © 2020 by the American Society of Plastic Surgeons.)

Background: Injuries to the hand and wrist constitute up to 25% of all athletic injuries, yet not much information is available on the effects of such injuries on the careers of professional athletes. Understanding whether elite athletes can return to sport and at what level has value for athletes, coaches, managers, and others, including athletes at other levels of play., Questions/purposes: The purpose of this study was to systematically review the literature on injuries of the hand and wrist in professional athletes to determine the prevalence and types of injuries sustained in professional sports, the management and clinical outcomes of such injuries, and the statistics regarding return to play., Methods: A systematic review was conducted of PubMed/MEDLINE and the Cochrane Central Register of Controlled Trials to identify all studies reporting on hand and wrist injuries in professional athletes that were published between January 1970 and April 2019. Inclusion criteria were injuries of the upper extremity distal to the elbow that occurred in professional athletes during athletic competition, English language, and a study cohort consisting of four or more subjects. Details of injury sustained, sport, treatment, clinical outcome, and return to sport were extracted., Results: We identified 32 nonoverlapping studies involving a total of 4299 hand and wrist injuries. The most common sport studied was baseball (eight studies), followed by football (seven), boxing (six), and basketball (five). Specific injury type was included in 29 of 32 studies and totaled 792 injuries. Metacarpal fractures were the most common injuries ( n  = 273; 34.5%), followed by thumb collateral ligament injuries ( n  = 110; 13.9%), phalangeal fractures ( n  = 87; 11.0%), and scaphoid fractures ( n  = 56; 7.1%). The overall operative rate was 18.3% ( n  = 708 of 3867). One-half of the studies reported the return to play (average, 2.8 months; range, 0.5 to 9 months). Seven studies reported sport-specific objective performance measures, with six describing consistent return to preinjury levels of performance among athletes., Conclusions: Based on the available evidence, a large majority of hand and wrist injuries in professional athletes are treated conservatively. Athletes frequently return to preinjury levels of performance after surgery. Additionally, return to play after a hand injury appears to be faster than that after other bony injuries. Further research is needed into the impact of these injuries on athletic performance, as well as how surgical intervention affects validated patient-reported outcome measures in professional athletes., Competing Interests: Conflict of InterestJason D. Lehman, MD; Karthik R. Krishnan, MS; and Jeffrey G. Stepan, MD, MSc, declare that they have no conflict of interest. Benedict U. Nwachukwu, MD, MBA, declares educational support from Smith & Nephew, outside the submitted work., (© Hospital for Special Surgery 2020.)

Purpose: The primary aims of this study were to determine how level of evidence and publication rates of American Society for Surgery of the Hand (ASSH) abstracts presented at the national meeting have changed over the past 23 years., Methods: Abstracts presented at the ASSH annual meeting from 1992 to 2014 were reviewed. Level of evidence (LoE) and publication status for each abstract were recorded. We calculated annual and overall LoE, publication rates, average time to publication, and top journals of publication for abstracts presented from 1992 to 2014. The LoE was categorized into level 1 or 2 studies, levels 3 to 5 studies, or nonclinical study., Results: A total of 1,757 abstracts were presented at ASSH meetings from 1992 to 2014; 942 abstracts were published in peer-reviewed journals for an overall publication rate of 53.6%. There was a significant increase in the proportion of levels 1 to 2 LoE abstracts over time (18% in 2007-2014 vs 11% in 1999-2006 and 2% in 1992-1998). There was also a significantly higher percentage of abstracts published over time (62% in 2007-2014 vs 52% in 1999-2006 and 47% in 1992-1998). Levels 1 to 2 LoE studies were associated with higher publication rates than nonclinical or levels 3 to 5 LoE studies., Conclusions: This research provides historical trends on the LoE of abstracts presented at the ASSH annual meetings. Our study shows there are increasing numbers of levels 1 to 2 studies as well as higher publication rates of abstracts presented at more recent ASSH annual meetings. Levels 1 to 2 studies are more likely to be published than nonclinical or levels 3 to 5 studies., Clinical Relevance: Although not all questions can be feasibly answered with level 1 or level 2 studies, authors should continue to search for ways to strengthen study designs, producing more valid and comparable results with increased likelihood of publication driving forward the quality of hand surgery research. Higher recent publication rates may be partially due to the increased number of available journals for publication., (Copyright © 2020 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Study Design: Prospective observational study OBJECTIVE.: The aim of this study was to record daily opioid use and pain levels after 1-level lumbar decompression or microdiscectomy., Summary of Background Data: The standardization of opioid-prescribing practices through guidelines can decrease the risk of misuse and lower the number of pills available for diversion in this high-risk patient population. However, there is a paucity of quantitative data on the "minimum necessary amount" of opioid appropriate for post-discharge prescriptions., Methods: At two institutions between September 2017 and 2018, we prospectively enrolled 85 consecutive adult patients who underwent one-level lumbar decompression or microdiscectomy. Patients with a history of opioid dependence were excluded. Daily opioid consumption and pain scores were collected using an automated text-messaging-based platform for 6 weeks or until consumption ceased. Refills during the study period were monitored. Patients were asked for the number of pills left over and the method of disposal. Opioid use was converted to oral morphine equivalents (OMEs). Results are also reported in terms of "pills" (oxycodone 5 mg equivalents) to facilitate clinical applications. Risk factors were compared between patients in the top and bottom half of opioid consumption., Results: Total opioid consumption ranged from 0 to 118 pills, with a median consumption of 32 pills (236.3 OME). Seventy-five percent of patients consumed ≤57 pills (431.3 OME). Mean Numeric Rating Scale pain scores declined steadily over the first 2 weeks. By postoperative day 7 half of the study population had ceased taking opioids altogether. Only 22.4% of patients finished their initial prescription, and only 9.4% of patients obtained a refill., Conclusion: These data may be used to formulate evidence-based opioid prescription guidelines, establish benchmarks, and identify patients at the higher end of the opioid use spectrum., Level of Evidence: 2.

Background: Injury to and rupture of the flexor pollicis longus (FPL) tendon are known complications after volar locking plate fixation for distal radial fractures. Recent investigations have demonstrated that plate positioning contributes to the risk of tendon rupture; however, the impact of plate design has yet to be established. The purpose of this study was to compare FPL tendon-to-plate distance, FPL tendon-plate contact, and sonographic changes in the FPL tendon for 2 volar locking plate designs (ADAPTIVE compared with FPL) using ultrasound examination., Methods: We identified patients who underwent distal radial fracture fixation by 2 fellowship-trained hand surgeons with either standard (ADAPTIVE) or FPL plates. Patients were matched by age, sex, and Soong grade. Enrolled patients returned for a research-related office visit for a clinical examination and bilateral wrist ultrasound. We measured plate-tendon distance, plate-tendon contact, sonographic changes in the FPL tendon, and postoperative radiographic parameters in the operatively treated wrist and the uninjured wrist., Results: Forty patients with Soong grade-1 or 2 plate prominence underwent bilateral wrist ultrasound examination; all of the patients had distal radial fracture fixation, 20 with the standard volar locking plate and 20 with the FPL volar locking plate. Similar proportions of patients with the FPL plate (65%) and those with the standard plate (79%) had plate-tendon contact (p = 0.48); however, the FPL volar locking plate group had significantly less of the FPL tendon in contact with the volar plate than the standard volar locking plate group at wrist extension at both 0° (p < 0.001) and 45° (p < 0.001). There was no difference (p = 0.5) in the proportion of patients with sonographic changes in the FPL tendon between the FPL volar locking plate group (25%) and the standard volar locking plate group (21%). The postoperative volar tilt was significantly lower in patients with FPL plate-tendon contact (p = 0.01) and correlated moderately with the percentage of FPL tendon-plate contact at 0° (r = -0.51; p < 0.001) and 45° (r = -0.53; p < 0.001). There were no cases of tendon rupture in the cohort., Conclusions: We found that the FPL volar locking plate and increased volar tilt significantly reduced the plate-tendon contact area compared with the standard volar locking plate. In our asymptomatic cohort, we were unable to find a difference in sonographic changes in the FPL tendon. Further studies are needed to determine the clinical importance of decreased tendon-plate contact area seen in modified volar locking plate designs., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Purpose: Pain-related psychological factors, including pain catastrophizing and dispositional mindfulness, have been shown to influence patient pain levels and outcomes after orthopedic surgery. Less is known about the relationship between these factors and postoperative opioid use after hand surgery. The purpose of this study was to examine the association between preoperative pain catastrophizing and mindfulness and postoperative opioid use in patients undergoing ambulatory hand surgery., Methods: Patients undergoing ambulatory hand surgery at our institution between May 2017 and January 2018 were prospectively enrolled in an ongoing clinical trial. Patients completed the Pain Catastrophizing Scale (PCS) and Mindfulness Attention Awareness Scale (MAAS) before surgery. Patients completed a pain medication diary for 2 weeks after surgery and were contacted on postoperative days 3, 8, and 15 to review their medication usage and pain levels. Analyses were performed to evaluate the association between PCS, MAAS scores, and postoperative opioid use, average patient reported pain levels, and refill rates., Results: A total of 85 patients were included in the analysis. Higher PCS scores (representing more pain catastrophizing) were associated with increased number of opioid pills consumed, higher average pain levels during the first postoperative week, and higher refill rates. Higher MAAS scores (representing more mindfulness) were associated with lower average week-1 pain levels but not significantly associated with opioid use or refill rates., Conclusions: Patients demonstrating higher PCSs before surgery used more opioids after surgery after a range of ambulatory hand surgeries. In the setting of the opioid epidemic, hand surgeons should be aware of pain-related psychological factors that can influence postoperative opioid use., Type of Study/level of Evidence: Prognostic II., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Aims: The aim of this study was to determine the general postoperative opioid consumption and rate of appropriate disposal of excess opioid prescriptions in patients undergoing primary unilateral total knee arthroplasty (TKA)., Patients and Methods: In total, 112 patients undergoing surgery with one of eight arthroplasty surgeons at a single specialty hospital were prospectively enrolled. Three patients were excluded for undergoing secondary procedures within six weeks. Daily pain levels and opioid consumption, quantity, and disposal patterns for leftover medications were collected for six weeks following surgery using a text-messaging platform., Results: Overall, 103 of 109 patients (94.5%) completed the daily short message service (SMS) surveys. The mean oral morphine equivalents (OME) consumed during the six weeks post-surgery were 639.6 mg (sd 323.7; 20 to 1616) corresponding to 85.3 tablets of 5 mg oxycodone per patient. A total of 66 patients (64.1%) had stopped taking opioids within six weeks of surgery and had the mean equivalent of 18 oxycodone 5 mg tablets remaining. Only 17 patients (25.7%) appropriately disposed of leftover medications., Conclusion: These prospectively collected data provide a benchmark for general opioid consumption after uncomplicated primary unilateral TKA. Many patients are prescribed more opioids than they require, and leftover medication is infrequently disposed of appropriately, which increases the risk for illicit diversion. Cite this article: Bone Joint J 2019;101-B(7 Supple C):98-103.

Introduction: The Accreditation Council for Graduate Medical Education (ACGME) mandates certain procedural minimums for graduating residents of orthopaedic surgery programs and provides residency programs with comparative data on surgical case volume. It provides much less guidance and feedback to programs regarding the amount of time residents should spend on different rotations during residency. Comparative data regarding how much time residents are spending on general and subspecialty rotations may be of use to educational leadership as they consider curriculum changes and alternative training structures. The purpose of this study is to summarize the subspecialty rotation exposure across ACGME-accredited orthopaedic residency programs and to correlate the subspecialty rotation exposure with available program-specific factors., Methods: This study contacted 162 ACGME-accredited orthopaedic residency programs and received rotation schedules from 115 programs (70.1%). Rotation schedules for postgraduate year 2 to 5 residents were categorized into the number of months spent on the following rotations: general orthopaedics, trauma, pediatrics, hand, sport, foot and ankle, arthroplasty, oncology, spine, research, and elective. The percentage of residency spent in each category was then calculated as the number of months divided by 48 months. Differences in the percent of residency spent on subspecialty rotations were compared for the following variables: program size and presence of subspecialty fellowships at the institution., Results: On average, the greatest percentage of residency spent was in the following categories: trauma (16.6%; 8.0 months), general orthopaedics (13.7%; 6.6 months), and pediatrics (12.5%; 6.0 months). Rotations with the highest variation between programs included the following: general orthopaedics (SD 5.8 months; range 0 to 30 months), sport (SD 2.5 months; range 0 to 15 months), and arthroplasty (SD 2.3 months; range 0 to 11.8 months). Sixty-seven programs (63.2%) had dedicated blocks for research, and 25 programs (23.6%) had dedicated blocks for electives. No notable correlations were found between subspecialty exposure and program size or availability of subspecialty fellowship training at the program., Conclusion: Variability exists between ACGME-accredited orthopaedic surgery residency programs in subspecialty rotation exposure. Summarizing the subspecialty rotation exposure across accredited orthopaedic residency programs is useful to graduate medical education leadership for comparative purposes because they design and modify resident curricula.

Purpose: The purpose of this study was to identify associations between the clinical manifestations of carpal tunnel syndrome (CTS) and the sonographic measurements of the median nerve in the carpal tunnel. We hypothesized that sonographic changes in the median nerve from proximal to distal along the carpal tunnel would be associated with symptom severity scores., Methods: We report on 38 patients with clinical signs and symptoms of CTS in a prospective investigation. Subjects underwent sonographic evaluation with measurement of median nerve cross-sectional area (CSA) at 3 locations: the level of the pronator quadratus, pisiform, and hamate. In addition, we measured dimensions of the carpal tunnel at the levels of the pisiform (inlet) and hamate (outlet). Finally, we recorded maximal thickness of the transverse carpal ligament (TCL). Patients underwent routine clinical evaluation and 31 patients had electrodiagnostic examination. Patients completed the Levine Katz Questionnaire (LKQ) to characterize severity of clinical symptoms. Each clinician was blinded to symptom severity scores. Pearson correlation coefficients were calculated to measure the relationship between LKQ score and sonographic measures., Results: Median nerve CSA decreased over the course of the carpal tunnel from proximal to distal in 30 of 38 wrists. A greater absolute change in CSA of the median nerve over the course of the carpal tunnel between the pisiform and the hamate as well as between the pronator quadratus and the hamate correlated with increased severity of clinical symptoms. Increased thickening of the TCL also correlated with greater symptom severity scores., Conclusions: Changes in CSA of the median nerve as well as thickening of the TCL correlate with CTS severity., Type of Study/level of Evidence: Diagnostic II., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Objective: Patients with lumbar spine pathology are at high risk for opioid misuse. Standardizing prescribing practices through an institutional intervention may reduce the overprescribing of opiates, leading to a decrease in the risk for opioid misuse and the number of pills available for diversion. Without quantitative data on the "minimum necessary quantity" of opioids appropriate for postdischarge prescriptions, the optimal method for changing existing prescribing practices is unknown. The purpose of this study was to determine whether mandatory provider education and prescribing guidelines could modify prescriber behavior and lead to a decreased amount of opioids prescribed at hospital discharge following lumbar spine surgery., Methods: Qualified staff were required to attend a mandatory educational conference, and a consensus method among the spine service was used to publish qualitative prescribing guidelines. Prescription data for 2479 patients who had undergone lumbar spine surgery were captured and compared based on the timing of surgery. The preintervention group consisted of 1177 patients who had undergone spine surgery in the period before prescriber education and guidelines (March 1, 2016-November 1, 2016). The postintervention group consisted of 1302 patients who had undergone spine surgery after the dissemination of the guidelines (February 1, 2017-October 1, 2017). Surgeries were classified as decompression or fusion procedures. Patients who had undergone surgeries for infection and patients on long-acting opioids were excluded., Results: For all lumbar spine surgeries (decompression and fusion), the mean amount of opioids prescribed at discharge was lower after the educational program and distribution of prescribing guidelines (629 ± 294 oral morphine equivalent [OME] preintervention vs 490 ± 245 OME postintervention, p < 0.001). The mean number of prescribed pills also decreased (81 ± 26 vs 66 ± 22, p < 0.001). Prescriptions for 81 or more tablets dropped from 65.5% to 25.5%. Tramadol was prescribed more frequently after prescriber education (9.9% vs 18.6%, p < 0.001). Refill rates within 6 weeks were higher after the institutional intervention (7.6% vs 12.4%, p < 0.07)., Conclusions: Qualitative guidelines and prescriber education are effective in reducing the amount of opioids prescribed at discharge and encouraging the use of weaker opioids. Coupling provider education with prescribing guidelines is likely synergistic in achieving larger reductions. The sustainability of these changes is yet to be determined.

Purpose: Recent studies demonstrated the overprescription of opioids after ambulatory hand surgery in the setting of a national opioid epidemic. Prescriber education has been shown to decrease these practices on a small scale; however, currently no nationally standardized prescriber education or postoperative opioid prescribing guidelines exist. The purpose of this study was to evaluate the effect of prescriber opioid education and postoperative opioid guidelines on prescribing practices after ambulatory hand surgery., Materials and Methods: This retrospective study was performed at an academic orthopedic hospital. In November, 2016, all prescribers were mandated to undergo a 1-hour opioid education program. Prescribing guidelines for the hand service were formulated based on literature review and expert opinion and were released in February, 2017. We reviewed all postoperative opioid prescriptions for patients who underwent ambulatory hand and upper-extremity surgery 4 months before the mandatory education (preeducation group) and 4 months (immediate postguideline group) and 9 to 11 months (intermediate postguideline group) after the guideline dissemination., Results: A total of 1,348 ambulatory hand surgeries (435 in the preeducation, 490 in the immediate postguideline group, and 423 in the intermediate postguidelines groups) with postoperative opioid prescriptions met inclusion criteria. Mean reduction in total prescribed oral morphine equivalents was 52.3% after guidelines disseminated. The number of opioid pills prescribed to patients decreased significantly in the postguideline groups when stratified by procedure type and surgery level., Conclusions: Prescriber education and postoperative opioid guideline dissemination led to significant decreases in the number of opioid pills prescribed after ambulatory hand surgery. Development and dissemination of nationally standardized prescriber education and opioid guidelines may significantly reduce the amount of opioid medications prescribed after hand surgery., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Prospective collection of patient-reported opioid consumption and pain levels post-surgically may hold value in highlighting solutions related to the opioid crisis. Traditional methods for collecting patient-reported outcomes after surgery, such as paper surveys, often have poor response rates, and electronic messaging may offer more convenience and therefore yield more robust data., Questions/purposes: The purpose of this study was to evaluate whether a novel mobile phone short message service (SMS) platform would lead to better patient response rates to surveys on pain and opioid use than data-collection tools., Methods: An SMS text messaging platform was created and implemented between September 2017 and May 2018 at an orthopedic specialty hospital. The purpose was to collect reports on opioid consumption and pain levels twice a day for 6 weeks post-surgery from patients who had undergone total hip or knee arthroplasty or a single-level lumbar microdiscectomy or decompression spine surgery. Patients who responded to fewer than 50% of the text messages were excluded., Results: Our mobile phone text messaging platform was used by 183 patients, demonstrating a significantly higher response rate (96.1%) than our institution's post-operative email registry capture, as well as the majority of published response rates for post-operative outcomes captured through electronic and traditional data-collection systems. Response rate remained consistently high among the various surgeons and across patients, regardless of age., Conclusions: This application of a widely available technology can improve the measurement of post-operative patient-reported outcomes. Such data can in turn be used in the development of strategies to reduce post-operative opioid use. The adoption of novel technologies at a patient level will play a key role in combating the opioid epidemic., Competing Interests: Jeffrey G. Stepan, MD, Msc, Cynthia A. Kahlenberg, MD, and Jason L. Blevins, MD, declare that they have no conflicts of interest. Ajay Premkumar, MD, MPH, and Francis C. Lovecchio, MD, report a surgeon-in-chief grant from the Hospital for Special Surgery in support of this study. Todd J. Albert, MD, reports personal fees from Biomet, FacetLink, Gentis, JP Medical Publishers, Saunders/Mosby-Elsevier, United Healthcare, and Thieme; grants and personal fees from DePuy; stock ownership in ASIP, Biometrix, Breakaway Imaging, Crosstree, FacetLink, Gentis, In ViVo Therapeutics, Paradigm Spine, Spinicity, and Vertech; salary from Weill-Cornell Medical College (professor) and Hospital for Special Surgery (surgeon-in-chief); non-financial support from Scoliosis Research Society (president), Cervical Spine Research Society (past-president), American Orthopaedic Association; grants from AO Foundation/Association for the Study of Internal Fixation, Patient-Centered Outcomes Research Institute, International Spine Study Group, and National Institute of Arthritis and Musculoskeletal and Skin Diseases, all outside the submitted work. Michael B. Cross, MD, reports personal fees from Link Orthopaedics, Smith & Nephew, and Zimmer; personal fees and research support from Acelity, Exactech, Inc., and Flexion Therapeutics; stock or stock options from Imagen, Insight Medical, and Parvizi Surgical Innovation; and personal fees, research support, and stock or stock options from Intellijoint, all outside the submitted work.All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.Informed consent was obtained from all patients for being included in this study.Disclosure forms provided by the authors are available with the online version of this article.

Background: In the midst of the nationwide opioid epidemic, our institution began an effort to improve the education of opioid prescribers and disseminate procedure-specific guidelines for the number of opioid pills to prescribe post-operatively for total joint arthroplasty. The number of opioid pills suggested for total hip or knee replacement was 70 tablets., Questions/purposes: We sought to evaluate the impact of the new institutional guideline on opioid prescribing practices, hypothesizing that it would lead to a decrease in the number of pills prescribed but an increase in patient call volume after discharge., Methods: After the new guidelines were implemented in February 2018, we retrospectively reviewed all opioid prescriptions written for patients on the joint-replacement service from March 2016 to March 2018. In addition, we tabulated post-operative telephone calls made to the nurse practitioner service before and after guideline implementation. The majority of calls to the nurse practitioner service are for opioid renewals., Results: We included 9514 patients in the analysis. Prior to guideline implementation, the mean number of pills prescribed after primary total joint arthroplasty was 91 ± 26.6 pills and after it was 65 ± 16.3 pills. The monthly number of unique patient telephone interactions was statistically significantly lower after the implementation of the new guidelines., Conclusion: An institutional guideline for opioid prescribing after total joint arthroplasty significantly reduced the number of pills prescribed to patients without causing a significant increase in the number of phone calls to the service., Competing Interests: Cynthia A. Kahlenberg, MD, Jeffrey G. Stepan, MD, Ajay Premkumar, MD, MPH, and Francis D. Lovecchio, MD, declare that they have no conflicts of interest. Michael B. Cross, MD, reports receiving grants or personal fees from or owning stock in Acelity, Exactech, Inc., Intellijoint, Link Orthopaedics, Smith & Nephew, Zimmer, Flexion Therapeutics, Imagen, Insight Medical, and Parvizi Surgical Innovation, as well as serving on the editorial or governing boards of Bone and Joint Journal 360, Journal of Orthopaedics and Traumatology, and Techniques in Orthopaedics, all outside the submitted work.All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.Informed consent was waived from all patients for being included in this study.Disclosure forms provided by the authors are available with the online version of this article.

Background: Current research on opioid use within orthopedic surgery has focused on efforts to identify patients at risk for chronic opioid use. Studies addressing prevention of opioid misuse related to orthopedic care are lacking. Evidence-based interventions to reduce the reliance on opioids for post-operative pain relief will be a key component of any comprehensive institutional opioid policy., Questions/purposes: The purpose of this systematic review was to evaluate institutional strategies that reduce opioid administration or consumption after orthopedic surgery., Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, a search was conducted of the PubMed database for English-language articles that analyzed interventions by physicians, nurses, pharmacists, physical therapists, or other hospital staff to reduce post-operative opioid use or narcotic prescription amounts after surgery. Studies that contained objective outcome measures (i.e., no expert opinion articles) were selected. Investigations on the effect of pharmacologic adjuvants, cryotherapy, or regional nerve blockades on opioid use were excluded., Results: The initial search yielded 6598 titles, of which 13 full-text articles were ultimately selected for inclusion in this systematic review. The review identified two major categories of interventions-patient-focused and provider-focused (e.g., physicians, nurses, physical therapists, pharmacists). Formal patient education programs were most effective in reducing opioid use. On the provider side, prescribing guidelines appear to decrease the overall number of pills prescribed, often without changes in patient satisfaction or requests for refills., Conclusions: Researchers are just beginning to establish the most effective ways for institutions to reduce opioid use and promote responsible post-operative prescribing. Institutional prescribing guidelines, standardized bedside pain-management programs, and formal patient education curriculums are all evidence-based interventions that can achieve these goals. The available research also supports an interprofessional approach in any institutional opioid-reduction strategy., Competing Interests: Francis Lovecchio, MD, Ajay Premkumar, MD, MPH, and Jeffrey G. Stepan, MD, MSc, declare that they have no conflicts of interest. Todd J. Albert, MD, reports receiving royalties from Zimmer Biomet, DePuy Synthes, JP Medical Publishers, Saunders/Mosby-Elseveir, and Thieme; owning stock in Gentis, Vital 5, Bonovo Orthopedics Inc., Biomerix, InVivo Therapeutics, Spinicity, Crosstrees Medical, Paradigm Spine LLC, Invuity, ASIP, PMIG, Pioneer, and Vertech; receiving personal fees from Nuvasive, Gentis, United Health Care, and Facet Link and non-financial support from Scoliosis Research Society; receiving salary from Hospital for Special Surgery and Weill Cornell Medical College and grants from Patient-Centered Outcomes Research Institute, ISSG, Alan L. and Jacqueline B. Stuart Spine Research Center, all outside the submitted work.N/AN/ADisclosure forms provided by the authors are available with the online version of this article.

Background: Our institution developed a 1-hour mandatory narcotics-prescribing education program as well as postoperative opioid-prescribing guidelines in response to the opioid epidemic. The purpose of this study was to evaluate the effect of this hospital-wide opioid education and subsequent institution of postoperative opioid guidelines on opioid-prescribing practices after ambulatory surgery., Methods: This retrospective study was performed at 1 academic orthopaedic hospital. In November 2016, a 1-hour mandatory opioid education program was completed by all hospital prescribers. Postoperative opioid guidelines were then developed and were disseminated in February 2017. All postoperative narcotic prescriptions after ambulatory procedures performed by 3 separate services (hand, sports, and foot and ankle services) were evaluated over 4 months prior to and after the mandatory opioid education and subsequent release of service-specific guidelines., Results: Overall, there was a significant decrease in pills and total oral morphine equivalents prescribed after dissemination of guidelines compared with the pre-intervention cohort procedures (p < 0.001) performed by the sports and hand services. With regard to the sports medicine service, the mean difference in pills prescribed was 6.47 pills (95% confidence interval [CI], 5.4 to 7.5 pills) for knee arthroscopy, 5.6 pills (95% CI, 2.5 to 8.7 pills) for shoulder arthroscopy, and 16.3 pills (95% CI, 13.6 to 19.1 pills) for hip arthroscopy. With regard to the hand service, the mean difference in pills prescribed was 13.0 pills (95% CI, 10.2 to 15.8 pills) for level-1 procedures, 12.4 pills (95% CI, 9.9 to 15.0 pills) for carpal tunnel release, and 21.7 pills (95% CI, 18.0 to 25.3 pills) for distal radial fractures. The decrease in pills prescribed in the post-intervention cohort amounts to almost 30,000 fewer opioid pills prescribed per year after these 6 procedures alone. There was no significant change (p > 0.05) in either the number of pills or the oral morphine equivalents prescribed after any of the 3 procedures performed by the foot and ankle service (ankle arthroscopy, bunion surgery, and Achilles tendon repair)., Conclusions: We developed a prescriber education program and followed up with consensus-based guidelines for postoperative opioid prescriptions. These interventions caused a significant decrease in excessive opioid-prescribing practices after ambulatory orthopaedic surgery at our hospital. We urge initiatives by national orthopaedic organizations to develop and promote education programs and procedure and disease-specific opioid-prescribing guidelines.

Purpose: Prognostic factors associated with Manipulation under anesthesia (MUA) failure remain unknown., Methods: A systematic review of the literature was performed to identify studies that reported prognostic factors associated with MUA for postoperative stiffness., Results: 7 studies analyzing prognostic factors associated with MUA outcomes were included. Several studies note pre-MUA ROM to be a significant prognostic factor affecting post-MUA ROM at final follow-up. Knees with <70° of flexion pre-MUA had less final flexion arc than those with >70°., Conclusions: The strongest prognostic factor for decreased ROM after MUA is severe pre-MUA stiffness.

Diabetes mellitus (DM) is associated with the development of carpal tunnel syndrome, Dupuytren disease, trigger digits, and limited joint mobility. Despite descriptions of poorer response to nonsurgical treatment, previous studies have not shown increased complication rates in diabetic patients after hand surgery. Few studies, however, differentiate between insulin-dependent (IDDM) and non-insulin-dependent (NIDDM) diabetes mellitus. The purpose of this study was to evaluate the impact of insulin dependence on the postoperative risk profile of diabetic patients after hand surgery using a national database., Materials and Methods: The data were obtained through the National Surgical Quality Improvement Program (NSQIP) database. Patients undergoing surgery from the distal humerus to the hand, between 2005 and 2015, were identified using 297 distinct Current Procedural Terminology codes. Thirty-day postoperative complications were collected and categorized into medical complications, surgical site complications, and readmission. Surgical complications, medical complications, and readmissions were compared between patients with NIDDM or IDDM to those without DM using multivariable logistic regression, adjusting for baseline patient and operative characteristics., Results: The study cohort included 52,727 patients. Patients with IDDM had a 5.7% overall complication rate compared with 2.3% and 1.5% in NIDDM and nondiabetic patients, respectively. After controlling for differences in patient and surgical characteristics, patients with IDDM had a statistically significant increased rate of any complication, surgical site complications, superficial surgical site infections, and readmission. There was no significant difference in complication rates between patients with NIDDM and nondiabetic patients., Conclusions: Our data demonstrate a greater risk of complications following hand and upper extremity surgery for patients with IDDM, specifically surgical site infections. The NIDDM patients did not have an increased rate of complications relative to nondiabetic patients. These findings are important for patient risk stratification and may guide further investigation to decrease complication rates in IDDM patients after upper extremity surgery., Type of Study/level of Evidence: Prognostic II., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Prescription opioid abuse is an epidemic in the United States; multimodal analgesia has been suggested as a potential solution to decrease postoperative opioid use. The primary aim of this study was to determine the effect of perioperative celecoxib on opioid intake. Secondary goals were to determine whether perioperative administration of celecoxib decreased postoperative patient-reported pain and whether patient demographic characteristics could predict postoperative pain and opioid intake., Methods: This prospective cohort study enrolled patients undergoing mass excision or carpal tunnel, trigger finger, or de Quervain release by 1 of 3 fellowship-trained hand surgeons. Patients in the experimental group were given 200 mg celecoxib tablets taken twice a day starting the day before surgery and continued for 5 days after surgery. Both groups received hydrocodone-acetaminophen tablets 5 mg/325 mg as needed after surgery. After surgery, patients completed daily opioid consumption and pain logs for 7 days and underwent a pill count. Outcomes included morphine milligram equivalents (MME) consumed and postoperative pain., Results: A total of 123 patients were enrolled: 68 control patients and 54 celecoxib patients. Fifty (74%) and 37 (69%) patients, respectively, completed the study. Overall, the median number of MMEs consumed was 25 (range, 0-330). During the first postoperative week, patients in the celecoxib and control groups were similar with respect to postoperative pain experienced (median visual analog scale score, 2.0 vs 1.4, respectively) and amount of opioid taken (median MMEs = 30 vs 20, respectively)., Conclusions: Patients taking perioperative celecoxib had similar postoperative pain and opioid intake compared with patients not prescribed celecoxib in the study. Regardless of study group, 4 to 10 hydrocodone tablets were sufficient to control postoperative pain for most patients undergoing soft tissue ambulatory hand surgery. This may be the result of the limited duration and mild nature of pain after outpatient elective hand surgery., Type of Study/level of Evidence: Therapeutic II., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Optimal treatment of chronic scapholunate (SL) instability remains controversial. Many surgical techniques have been proposed with varied results in subsequent case series; however, there is limited evidence demonstrating the relative effectiveness of the different treatment options., Questions/purposes: We conducted a systematic review of the English literature to compare outcomes from capsulodesis and ligament reconstruction for treatment of chronic scapholunate instability., Methods: An electronic database search using keywords associated with scapholunate ligament instability was performed. A total of 511 studies were identified. All studies with scapholunate ligament tears >4 weeks after the initial injury were included in the review. Data extracted included patient demographics, wrist range of motion, and radiographic outcome measures., Results: A total of 308 patients from 11 studies met the inclusion criteria and were included in the study. The average time to surgery from initial injury was 11 months. There was no significant difference in wrist flexion or extension after capsulodesis or reconstruction. The weighted mean for postoperative wrist extension/flexion was 56°/45.6° in the capsulodesis group and 40.9°/47.3° in the reconstruction group. Pooled means of SL angle and SL gap were 60.3° and 3.44 mm after capsulodesis and 56.5 and 2.72 mm after reconstruction, respectively., Conclusions: This systematic review failed to demonstrate any significant difference in outcomes from capsulodesis or reconstruction for treatment of chronic scapholunate instability. However, the retrospective studies examined were notably heterogeneous in design with high estimates of variance. Further prospective trials are necessary to determine an ideal treatment strategy.

Background: In clinical research, minimizing patients lost to follow-up is essential for data validity. Researchers can employ better methodology to prevent patient loss. We examined how orthopedic surgery patients' contact information changes over time to optimize data collection for long-term outcomes research., Methods: Patients presenting to orthopedic outpatient clinics completed questionnaires regarding methods of contact: home phone, cell phone, mailing address, and e-mail address. They reported currently available methods of contact, if they changed in the past 5 and 10 years, and when they changed. Differences in the rates of change among methods were assessed via Fisher's exact tests. Whether participants changed any of their contact information in the past 5 and 10 years was determined via multivariate modeling, controlling for demographic variables., Results: Among 152 patients, 51% changed at least one form of contact information within 5 years, and 66% changed at least one form within 10 years. The rate of change for each contact method was similar over 5 (15%-28%) and 10 years (26%-41%). One patient changed all four methods of contact within the past 5 years and seven within the past 10 years. Females and younger patients were more likely to change some type of contact information., Conclusion: The type of contact information least likely to change over 5-10 years is influenced by demographic factors such as sex and age, with females and younger participants more likely to change some aspect of their contact information. Collecting all contact methods appears necessary to minimize patients lost to follow-up, especially as technological norms evolve.

Background: The quality of medical information on the Internet has come under scrutiny. This study investigates the quality, accuracy, and readability of online information regarding ulnar collateral ligament (UCL) injuries., Methods: Three search terms ("elbow ulnar collateral ligament injury," "tommy john injury," and "pitcher's elbow") were entered into 3 Internet search engines. Three independent reviewers evaluated the content and accuracy of the information with a set of predetermined scoring criteria. Website quality was further assessed by the Journal of the American Medical Association benchmark criteria and Health on the Net Foundation certification. Website readability was ascertained with the Flesch-Kincaid score., Results: We evaluated 113 unique websites. The average quality for all websites was 8.88 ± 6.8 (maximum, 32 points). Website quality and accuracy were lower with use of the search term "pitcher's elbow" as compared with "elbow ulnar collateral ligament injury" or "tommy john injury" (P ≤ .001). Sites certified by the Health on the Net Foundation had higher quality scores than non-certified sites (P = .034). The mean reading grade level was 10.7. Reading level was significantly correlated with website accuracy and quality (P ≤ .001) and physician authorship (P = .012). Forty-three websites (38.1%) described surgical reconstruction; of these, 16 (37.2%) mentioned improved pitching performance postoperatively., Conclusions: Online information on UCL injuries is often inaccurate and written at an inappropriate reading level. Information quality depends on the search term used, website authorship, and commercial bias. Clinicians must be aware of factors influencing website quality in order to direct patients to appropriate resources., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

The purpose of this study was to determine if simultaneous bilateral carpal tunnel release (CTR) is a cost-effective strategy compared with bilateral staged CTR for the treatment of bilateral carpal tunnel syndrome., Methods: A decision analytic model was created to compare the cost effectiveness of three strategies (ie, bilateral simultaneous CTR, bilateral staged CTR, and no treatment). Direct medical costs were estimated from 2013 Medicare reimbursement rates and wholesale drug costs in US dollars. Indirect costs were derived from consecutive patients undergoing unilateral or simultaneous bilateral CTR at our institution and from national average wages for 2013. Health state utility values were derived from a general population of volunteers using the Short Form-6 dimensions (SF-6D) health questionnaire., Results: Both surgical strategies were cost effective compared with the no-treatment strategy. Bilateral simultaneous CTR had lower total costs and higher total effectiveness than bilateral staged CTR, and had an incremental cost-effectiveness ratio of $921 per quality-adjusted life year compared with the no-treatment strategy. The conclusions of the analysis remained unchanged though all sensitivity analyses, displaying robustness against parameter uncertainty., Conclusions: Surgical management is cost effective for the treatment of bilateral carpal tunnel syndrome. Bilateral simultaneous CTR, however, has lower total costs and higher total effectiveness compared with bilateral staged CTR., Level of Evidence: Economic and Decision Analysis I.

Objective: This study aims to evaluate all sports and recreation injuries that present to an emergency department, identify the activity and injury patterns associated with hospital admission, and determine injuries that could be better treated in alternative care settings., Methods: This is a retrospective review of all sports injuries that presented to the emergency department of a high volume, urban, tertiary referral center from 1/1/2010 to 12/31/2011. These were identified by a sports term search algorithm applied to all emergency department records. The main outcome measured was hospital admission status after sports injury. Univariate and multivariate regression analysis was performed to identify risk factors for hospital admission in the sports injury population., Results: 1,101 of the 191,259 encounters (0.6%) had 1,210 sports injuries. 84 were admitted (7.6%). Basketball injuries were most prevalent (31.6%). All-terrain vehicle (ATV) related injuries was most often admitted (46.4%). Logistic regression identified ATV riding (95% CI 6.15-23.37, p < 0.001) and age over 50 years-old (4.09-17.40, p < 0.001) as independent risk factors for admission while basketball (0.101-0.985, p = 0.047) and black race (0.17-0.77, p = 0.008) were independently protective. Isolated sprains/strains and soft tissue injuries (4/649, 0.6%) rarely required admission., Conclusions: The 7.6% admission rate is higher than previously reported, likely because the study institution is a tertiary referral center. ATV riding is associated with higher severity injuries that are more likely to require hospital admission. Most sports injuries that present to an emergency department, specifically isolated soft tissue injuries of the extremities, may be more efficiently treated in a non-emergent setting.

Background: Fast-pitch softball is one of the fastest growing sports, but there is little research regarding pitcher fatigue. Currently, there are no pitch limits or game counts., Questions/purposes: To study the effect of fatigue on youth fast-pitch softball pitchers during a high school season, we hypothesized increased games pitched during the season would correlate with increased player-reported pain and fatigue and decreased with upper extremity strength and range of motion (ROM)., Methods: This prospective cross-sectional study evaluated pre- and postgame shoulder and elbow strength, ROM, pain, and fatigue in 17 high school fast-pitch softball pitchers. These measures were recorded at two games, one at the beginning and one at the end of the season. Pitch count and number of games pitched during the season were recorded. We compared pre- and postgame measurements and measurements made at the beginning and end of the season., Results: Supraspinatus, forward flexion strength, and external rotation strength in abduction decreased significantly postgame compared to pregame. Pregame pain and fatigue increased with a greater number of games pitched during the season. Forward flexion, supraspinatus, and external rotation strength decreased with increasing number of games pitched during the season., Conclusions: Fast-pitch softball pitchers experience increased pain and fatigue during a single game and over the entire season. The increase in fatigue may predispose the player to injury. Further studies are needed to understand the relationship of pain and fatigue with predisposition to injury.

Background: Soccer athletes are at risk for anterior cruciate ligament (ACL) injury. To date, there are limited studies on the mechanisms of ACL injuries in soccer athletes and no video-based analysis or sex-based comparison of these mechanisms., Hypothesis: There is no difference in ACL injury mechanisms among soccer athletes by sex., Study Design: Case series., Level of Evidence: Level 4., Methods: Fifty-five videos of ACL injuries in 32 male and 23 female soccer players were reviewed. Most athletes were professionals (22 males, 4 females) or collegiate players (8 males, 14 females). Visual analysis of each case was performed to describe the injury mechanisms in detail (game situation, player behavior, and lower extremity alignment)., Results: The majority of ACL injuries occurred when the opposing team had the ball and the injured athlete was defending (73%). Females were more likely to be defending when they injured their ACLs (87% vs 63% for males, P = 0.045). The most common playing action was tackling (51%), followed by cutting (15%). Most injuries occurred due to a contact mechanism (56%) with no significant difference for sex. Females were more likely to suffer a noncontact injury in their left knee (54%) than males (33%) (P = 0.05)., Conclusion: Soccer players are at greatest risk for ACL injury when defending, especially when tackling the opponent in an attempt to win possession of the ball. Females are more likely to injure their ACLs when defending and are at greater risk for noncontact injuries in their left lower extremity., Clinical Relevance: Soccer ACL injury prevention programs should include proper defending and tackling techniques, particularly for female athletes.

Purpose: To compare the tensile properties of 4-strand modified Kessler flexor tendon repairs using a looped or single-stranded suture., Methods: We evaluated the mechanical properties of 4-strand Kessler zone II core suture repairs using either looped or single-stranded suture in human flexor digitorum profundus and flexor pollicis longus tendons. Forty repairs were performed on tendons from bilateral cadaveric hands: 20 matched tendons were divided into equal groups of 3-0 looped and 3-0 single-strand repairs and 20 additional matched tendons were divided into equal groups of 4-0 looped and 4-0 single-strand repairs. Repaired tendons were tested in uniaxial tension to failure to determine mechanical properties and failure modes. Data were analyzed to determine the effect of repair type (ie, looped vs single-stranded) for each suture caliber (ie, 3-0 and 4-0)., Results: Single-strand repairs with 3-0 suture demonstrated a significantly greater maximum load to failure and a significantly higher force at 2-mm gap compared with repairs with looped 3-0 suture. All 8 looped repairs with 3-0 suture failed by suture pullout whereas 7 of 8 repairs with 3-0 single-stranded suture failed by suture breakage. The mechanical properties of looped versus single-stranded repairs with 4-0 caliber suture were not statistically different. Repairs with 4-0 caliber suture failed by suture breakage in 8 of 10 single-strand repairs and failed by suture pullout in 6 of 10 repairs with looped suture., Conclusions: In a time-0 ex vivo human cadaveric core suture model, the mechanical properties of a 4-strand repair using 3-0 single-stranded suture were significantly better than the same 4-strand repair performed with looped suture., Clinical Relevance: Four-strand flexor tendon repairs with 3-0 suture are mechanically superior when performed with single-strand suture versus looped suture., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Objective: To determine if high-activity older adults are adversely affected by distal radius malunion., Design: Cross-sectional study., Setting: Hand clinics at a tertiary institution., Participants: Ninety-six patients 60 years or older at the time of fracture were evaluated at least 1 year after distal radius fracture., Intervention: Physical Activity Scale of the Elderly scores stratified participants into high- and low-activity groups. Malunions were defined radiographically by change of ≥20 degrees of lateral tilt, ≥15 degrees radial inclination, ≥4 mm of ulnar variance, or ≥4 mm intra-articular gap or step-off, compared with the uninjured wrist., Main Outcome Measure: Patient-rated disability of the upper extremity was measured by the QuickDASH and visual analog scales (VAS) for pain/function. Strength and motion measurements objectively quantified wrist function., Results: High-activity participants with a distal radius malunion were compared with high-activity participants with well-aligned fractures. There was no significant difference in QuickDASH scores, VAS function, strength, and wrist motion despite statistically, but not clinically, relevant increases in VAS pain scores (difference 0.5, P = 0.04) between the groups. Neither physical Activity Scale of the Elderly score (β = 0.001, 95% confidence interval: -0.002 to 0.004) nor malunion (β = 0.133, 95% confidence interval: -0.26 to 0.52) predicted QuickDASH scores in regression modeling after accounting for age, sex, and treatment. Operative management failed to improve outcomes and resulted in decreased grip strength (P = 0.05) and more frequent complications (26% vs. 7%, P = 0.01) when compared with nonoperative management., Conclusions: Even among highly active older adults, distal radius malunion does not affect functional outcomes. Judicious use of operative management is warranted provided heightened complication rates., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: The outcomes literature on proximal phalanx fractures in children is sparse. The purpose of this study is to report the complications and outcomes of displaced proximal phalanx fractures after treatment with closed reduction and percutaneous pinning (CRPP)., Methods: A retrospective chart review identified 105 patients treated with CRPP of displaced proximal phalanx fractures. Specific complications were recorded for all patients. Thirty-one of these patients returned >1 year after surgery for assessment including visual analogue scales (VAS) of pain level, functional ability, and esthetics. Objective measurements included range of motion, grip and pinch strength, and finger deformity. Radiographs were taken to assess deformity., Results: Five of the 105 patients (4.8%) had a complication including infection, pin site complication, or malunion. Of the entire group, 36 had stiffness and 31 ultimately underwent hand therapy to regain motion. Subcondylar fractures were associated with a greater likelihood of stiffness. In the 31 patients returning for assessment, the median VAS score was 0 for pain (none), function (full), and esthetics (perfect). Range of motion, grip, and pinch strength were equivalent to the contralateral side. Seven of the 31 patients (22.6%) had a measureable coronal plane deviation averaging 5 degrees (range, 3 to 13 degrees) on radiographs. Deviation was associated with subcondylar fractures and a worse esthetic VAS. Deviation was not associated with worse outcomes overall., Conclusions: Pediatric patients with a displaced proximal phalanx fracture treated with CRPP have an initial notable complication rate related to stiffness; subcondylar proximal phalanx fractures are more commonly affected. At >1-year follow-up, patients had full motion, no pain, and were happy with both function and appearance despite minor deformity in some. These complication data may help better inform patients and families before surgical intervention., Level of Evidence: Level IV-therapeutic.

Purpose: To compare the rates of postoperative complications in obese and nonobese patients following elbow, forearm, and hand surgeries., Methods: This case-control study examined 436 patients whose body mass index (BMI) was over 35 and who underwent hand, wrist, forearm, or elbow surgery between 2009 and 2013. Controls were patients (n = 433) with a BMI less than 30 who had similar surgeries over the same period, and who were frequency-matched by type of surgery (ie, bony, soft tissue, or nerve), age, and sex. Postoperative complications were defined as infection requiring antibiotic or reoperation, delayed incision healing, nerve dysfunction, wound dehiscence, hematoma, and other reoperation. Medical comorbidities (e.g., hypertension, diabetes, stroke, vascular disease, kidney disease, and liver disease) were recorded. Chi-square analyses were performed to explore the association between obesity and postoperative complications. Similar analyses were performed stratified by surgery type and BMI classification. Logisticregression modeling was performed to identify predictors of postoperative complications accounting for surgery type, BMI, the presence of comorbidities, patient age, and patient sex. This same model was also run separately for case and control patients., Results: The overall complication rate was 8.7% with similar rates between obese and nonobese patients (8.5% vs. 9.0%). Bony procedures resulted in the greatest risk of complication in both groups (15% each group). Multivariate analysis confirmed surgery type as the only significant predictor of complications for nonobese patients. However, among obese patients, both bony surgery and increasing BMI were associated with greater complication rates., Conclusions: Not all obese patients appear to be at any higher risk for complications after elbow, forearm, and hand surgery compared with nonobese patients. However, there appears to be a dose-dependent effect of BMI among obese patients such that increasing obesity heightens the risk of complications, especially for those with a BMI greater than 45., Type of Study/level of Evidence: Prognostic II., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Introduction: Solid pseudopapillary tumour of the pancreas is a rare lesion with low malignant potential occurring predominantly in young women. This is a report of an extremely rare occurrence of synchronous presentation of pseudopapillary tumour in the pancreatic head and tail of a 16-year-old female patient., Case Presentation: The patient presented with a three-month intermittent upper abdominal pain and swelling. Computed tomography scan showed two separate masses, involving the pancreatic head and tail. The patient underwent surgery, where successful tumour enucleation of both tumours was performed. Histological report confirmed solid pseudopapillary tumour of the pancreas with the low malignant potential., Conclusion: To the best of our knowledge, this is the first report of synchronous presentation of pseudopapillary tumour of the pancreas., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: Over 60% of patients with carpal tunnel syndrome present with symptoms and findings of nerve compression in both hands. Our goal was to compare patient-rated difficulties in performing activities of daily living in the early postoperative period between those undergoing bilateral carpal tunnel release and those undergoing unilateral carpal tunnel release., Methods: This prospective cohort study enrolled consecutive patients with bilateral carpal tunnel syndrome undergoing bilateral carpal tunnel release (n = 47) or unilateral carpal tunnel release (n = 41). Patient function and disease severity were measured by an abbreviated form of the Disabilities of the Arm, Shoulder and Hand questionnaire, QuickDASH, and the Boston Carpal Tunnel Questionnaire at baseline, at postoperative visit 1 at a mean time (and standard deviation) of 10 ± 3 days, and at postoperative visit 2 at a mean time (and standard deviation) of 30 ± 6 days. Patients rated their difficulty in completing fifteen activities of daily living each day for the first postoperative week. Patients reported the factors that influenced their choice of surgery., Results: There was no difference in baseline function or disease severity between the two groups with regard to QuickDASH and the Boston Carpal Tunnel Questionnaire. Patients in both groups improved after carpal tunnel release with no difference between groups either at postoperative visit 1 for QuickDASH (p = 0.97) and the Boston Carpal Tunnel Questionnaire (p = 0.86) or at postoperative visit 2 for QuickDASH (p = 0.43) and the Boston Carpal Tunnel Questionnaire (p = 0.34). Patients undergoing bilateral carpal tunnel release had more difficulty only during postoperative days 1 to 2 in opening jars (p = 0.03), cooking (p = 0.008), and doing household chores (p = 0.02). Patients in the two groups did not differ (p > 0.05) in their abilities to perform activities of daily living necessary for personal hygiene or independence on any day during the first seven days following surgery with regard to using the bathroom, bathing, dressing, or eating. Although the most common reason why patients chose bilateral carpal tunnel release was to avoid two surgical procedures (42%), the most common reason why patients chose unilateral carpal tunnel release was concern for self-care (36%)., Conclusions: Patients with bilateral carpal tunnel syndrome can anticipate more severe functional impairment during the first few postoperative days with bilateral carpal tunnel release compared with unilateral carpal tunnel release, but limitations beyond postoperative day 2 or 3 are similar for bilateral and unilateral carpal tunnel release., Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Prior studies have suggested that patient-rated hand function is impacted by depression and pain catastrophization. We studied the impact that these comorbidities have on treatment outcomes., Methods: Two hundred and fifty-six patients presenting to an orthopaedic hand clinic were followed in this prospective cohort investigation. Patients who were prescribed treatment for atraumatic hand/wrist conditions were eligible for inclusion. At enrollment, all patients completed the Center for Epidemiologic Studies Depression (CES-D) scale, the Pain Catastrophizing Scale (PCS), and the Michigan Hand Outcomes Questionnaire (MHQ; scale of 0 to 100, with 100 indicating the best hand performance). One month and three months after treatment, patients again completed the MHQ. Participants' psychological comorbidity status was categorized as either affected (a CES-D score of ≥16, indicating depression, or a PCS score of ≥30, indicating catastrophization) or unaffected (a CES-D score of &lt;16 and a PCS score of &lt;30). Diagnoses and treatments for both the affected and unaffected groups were examined. The effect of time and patient status, and their interaction, on MHQ scores was evaluated by mixed modeling., Results: Fifty patients were categorized as affected and 206 as unaffected. Diagnoses and treatments differed minimally between the two groups. At the time of enrollment, the mean MHQ score of the unaffected group (64.9; 95% confidence interval [CI], 62.5 to 67.3) was significantly higher than that of the affected group (48.1; 95% CI, 43.3 to 53.0). Both groups demonstrated similar significant absolute improvement over baseline at three months after treatment (an increase of 12.5 points [95% CI, 7.5 to 17.4] in the affected group and 12.8 points [95% CI, 10.4 to 15.3] in the unaffected group). Thus, at the time of final follow-up, the rating of hand function by the affected patients (60.6 [95% CI, 55.0 to 66.2]) was still significantly poorer than the rating by the unaffected patients (77.7 [95% CI, 75.0 to 80.5])., Conclusions: Although patients affected by depression and/or pain catastrophization reported worse self-rated hand function at baseline and at the time of follow-up, these patients showed similar absolute improvement in self-rated hand function following treatment compared with patients with unaffected status., Level of Evidence: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Purpose: To quantify diabetic patients' change in blood glucose levels after corticosteroid injection for common hand diseases and to assess which patient-level risk factors may predict an increase in blood glucose levels., Methods: Patients were recruited for this case-crossover study in the clinic of fellowship-trained hand surgeons at a tertiary care center. Patients with diabetes mellitus type 1 or 2, who received a corticosteroid injection, recorded the morning fasting blood glucose levels for 14 days after the injection. Fasting glucose levels on days 1 to 7 after injection qualified as case data; levels on days 10 to 14 provided control data. A mixed model with a priori contrasts was used to compare postinjection blood glucose levels with baseline levels. We used a linear regression model to determine patient predictors of a postinjection rise in blood glucose levels., Results: Of 67 patients recruited for the study returned, 40 (60%) completed blood glucose logs. There was a significant increase in fasting blood glucose levels after injection limited to postinjection days 1 and 2. Among patient risk factors in the linear regression model, type 1 diabetes and use of insulin each predicted a postinjection increase in blood glucose levels from baseline, whereas higher glycated hemoglobin levels did not predict increases., Conclusions: Corticosteroid injections in the hand transiently increase blood glucose levels in diabetic patients. Patients with type 1 diabetes and insulin-dependent diabetics are more likely to experience this transient rise in blood glucose levels., Type of Study/level of Evidence: Therapeutic III., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)