Permanent Peripheral Nerve Stimulator for Complex Regional Pain Syndrome of the Forearm and Hand.

A 51-year-old woman with diabetes and depression was referred to the anesthesia pain clinic with a 15-year history of complex regional pain syndrome type I of the right forearm and hand in the radial sensory nerve distribution. There was no recognized antecedent trauma and she had failed both medical treatment and radial sensory nerve decompression surgery. An ultrasound-guided local anesthetic block of the radial nerve in the upper arm resulted in partial and temporary improvement in pain. She subsequently underwent trial of a peripheral nerve stimulator (PNS) followed by permanent PNS implant placement over the radial nerve proper proximal to the elbow. Within the first month of use, she endorsed substantially improved pain and strength in her right hand. These improvements were sustained for more than 1 year. Applications of PNS technology for treatment of extremity complex regional pain syndrome and neuropathic extremity pain in general are reviewed.

Medicare in the 21 st Century: Understanding the Program to Promote Improvements.

Medicare is the largest single purchaser of health care in the United States and currently helps to pay medical expenses for approximately one-fifth of the US population. The impetus for Medicare to move away from fee-for-service and toward value-based care payments reflects the need to incentivize and improve healthcare quality while containing increasing costs. This primer provides a detailed overview of several interrelated topics for an improved understanding of the Medicare program for orthopaedic surgeons, other clinicians, healthcare administrators, policymakers, and business leaders. An improved understanding may stimulate additional ideas for successful program advancements.

An Investment in Knowledge: Personal Finance Education for Medical Students.

The financial burden of pursuing a medical education continues to grow, with the average medical student now owing over $240,000 in total student loan debt by the time they graduate. This burden peaks at a time when trainees are making some of the most consequential decisions of their careers. Additionally, many students are simultaneously making important financial decisions related to personal aspirations, all before a drastic change in earning potential once they begin practicing as attending physicians. Medical trainees' financial stress is linked to specialty choice, mental quality of life, and physician burnout, with additional implications of such stress for patient health and safety.1- 3 Despite these issues, there are few examples of medical schools providing direct personal finance education to their students. Given the lack of personal finance education opportunities for medical students, the authors designed and implemented a medical student-specific personal finance curriculum at their home institution in conjunction with the Association of American Medical Colleges' (AAMC) Financial Information, Resources, Services, and Tools program. The curriculum, which is primarily delivered through interactive lectures, covers topics ranging from the basics of saving and investment to clinicians' potential future roles as administrators and innovators. The authors (1) present details regarding the creation of their personal finance education program; (2) invite fellow medical trainees and their respective institutions to start their own personal finance education programs or add similar curriculum to their health sciences coursework; and (3) call for recommendations by the American Medical Association (AMA) and AAMC in support of formal personal finance instruction for medical students on a national level.

Impact of an Electronic Health Record Pain Medication Prescribing Tool on Opioid Prescriptions for Postoperative Pain in Hand, Orthopedic, Plastic, and Spine Surgery Across a Health Care System.

PURPOSE: We hypothesized that a pain management prescribing tool embedded in the electronic health record system of a multihospital health care system would decrease prescription opioids for postoperative pain by hand, orthopedic, plastic, and spine surgeons. METHODS: A prescribing tool for postoperative pain was designed for hand, orthopedic, plastic, and spine surgeons and implemented into electronic discharge order sets in a 10-hospital health care system. Stakeholders were educated on tool use in person and/or by email on 2 occasions. A dashboard was created to monitor opioid pill quantities and morphine milligram equivalents (MMEs) prescribed. Overall compliance with the suggested opioid amounts was assessed for 20 months after tool implementation. A subgroup of 6 hand surgeons, one of whom was instrumental in designing the tool, were evaluated for MMEs prescribed, opioid refills, patient emergency room visits, and patient readmissions within 30 days after discharge. Comparisons in this subgroup were made from 12 months before to 15 months after tool implementation. RESULTS: The mean system-wide compliance with the suggested opioid pill quantities and MMEs prescribed in all 4 specialties improved by less than 5%. In the subgroup of hand surgeons, 5 of whom championed tool use, prescribed MMEs decreased by 10% during each of the 4 quarters before launching the tool and contracted an additional 26% in the first quarter after tool implementation. Opioid refills held steady at 5%, and there were no emergency room visits or readmissions within 30 days after discharge in this patient subgroup. CONCLUSIONS: The prescribing tool had a negligible impact on system-wide compliance with suggested prescription opioid pill quantities and MMEs. In a small group of surgeons who championed the use of the tool, there was a significant and sustained decline in MMEs prescribed without adversely impacting patient refills, emergency room visits, or readmissions. CLINICAL RELEVANCE: An electronic prescribing tool to assist surgeons in lowering opioid prescription pill quantities and MMEs may have a negligible impact on prescribing behavior in a multihospital health care system.

Determining the Impact of the COVID-19 Pandemic on Hand Surgery Fellowship Education.

The purpose of this study is to report the impact of COVID-19 on hand surgery fellow learning and preparedness for practice. A multi-dimensional questionnaire was distributed to current hand fellows and fellowship directors across the United States. Survey questions included fellowship location, institutional response, impact on practice, education and job search. Thirty-two hand surgery fellows and 14 fellowship directors completed the survey. Of fellows, 59% reported a greater than 75% decrease in case volume. Mean hours worked per week per fellow decreased by 52%. All fellowship directors and 94% of fellows did not expect COVID-19 to impact their ability to graduate, and nearly all fellows felt prepared to start practice after fellowship training. However, many fellows expressed concern about job opportunities. The work hours and exposure of hand surgery fellows to elective surgical cases have been adversely impacted by COVID-19. Nevertheless, current hand fellows feel prepared to enter practice. (Journal of Surgical Orthopaedic Advances 31(1):048-052, 2022).

Risk of Infection in Thumb Carpometacarpal Surgery After Corticosteroid Injection.

PURPOSE: The purpose of this study was to determine whether patients who had an intra-articular corticosteroid injection into the thumb carpometacarpal (CMC) joint for the treatment of arthritis within the 3 months before CMC joint arthroplasty or arthrodesis were at increased risk for wound complication/infection and/or repeat surgery for wound complication/infection in comparison with patients who did not receive an injection within 6 months or who received an injection between 3 and 6 months before surgery. METHODS: We identified 5,046 patients in the Humana claims database who underwent surgery for CMC joint arthritis. The patients were stratified into 3 groups: (1) no thumb injection within 6 months of CMC joint surgery, (2) thumb injection between 3 and 6 months before CMC joint surgery, and (3) thumb injection within 3 months before CMC joint surgery. The primary outcome was wound complication/infection within 90 days after surgery. The secondary outcome was repeat surgery for wound complication/infection within 90 days after surgery. Multivariable logistic regression was performed to assess the associations between the timing of injection and wound complication/infection and repeat surgery for wound complication/infection. RESULTS: The rates of wound complication/infection within 90 days after surgery were similar among the 3 study groups. However, patients who received an intra-articular corticosteroid injection within 3 months before surgery had a 2.2 times greater likelihood of repeat surgery for a wound complication/infection compared with patients who did not have an injection within 6 months before surgery. CONCLUSIONS: Patients who receive an intra-articular corticosteroid injection within the 3 months before surgery for CMC joint arthritis may be at increased risk of repeat surgery to treat a wound complication/infection in the 90-day postoperative period. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

An unusual case of Staphylococcus pasteuri osteomyelitis.

Staphylococcus pasteuri is a gram-positive organism found in food products as well as naturally occurring in air and on surfaces. We present the first known case of Staphylococcus pasteuri osteomyelitis caused by machine injection injury. The patient was treated with emergent surgical debridement as well as doxycycline for a soft tissue infection. Despite targeted therapy, the infection progressed to osteomyelitis and was treated successfully with additional surgical debridement and trimethoprim-sulfamethoxazole. There is sparse information on both infections and treatment of Staphylococcus pasteuri. We present our case report as well as a review of the literature on the epidemiology, susceptibility and treatment recommendations for Staphylococcus pasteuri infections.

Phalanx fractures and dislocations in athletes.

PURPOSE OF REVIEW: Phalangeal fractures, dislocations, and fracture-dislocations in the hand are common injuries. We review the current literature on the diagnosis and treatment of these injuries in the athlete. An understanding of the anatomy and its relationship to the mechanism of injury may help to direct appropriate management. Return to play remains an important concern to the patient-athlete. RECENT FINDINGS: Findings from recently published articles reinforce previously established treatment methods in the management of finger phalangeal fractures, dislocations, and fracture-dislocations. The majority of these injuries can be treated non-operatively. Technological advances in implant designs may conceivably allow for earlier rehabilitation and, in turn, a more expeditious return to sport. Management of phalangeal injuries in the elite athlete often necessitates special treatment considerations. The majority of phalangeal bone and joint injuries in the athlete can be treated in a comparable manner to the non-athlete. The goals of treatment are restoration of bone and joint alignment and stability in order to hasten a return to competition. Surgery as a means to expedite return to play in the high-level athlete should be determined on a case by case basis. Technological improvements in surgical implants may enable accelerated postoperative recovery. However, to our knowledge, there are no published studies to definitively support this assumption.

Comparing Morbidities of Bone Graft Harvesting from the Olecranon Process and the Distal Radius.

UNLABELLED: The aim of this study is to compare donor-site morbidities between patients who underwent bone graft harvesting from either the olecranon process (OP) or the distal radius (DR). METHODS: We evaluated 44 patients who underwent bone graft harvesting from the OP (25 cases) or the DR (19 cases) for various procedures in the ipsilateral upper extremity. Follow-up averaged 14 (OP group) and 19 months (DR group). Outcome measures included visual analog scales (VAS) for graft harvest-site pain and scar appearance, joint motion, and x-rays of the graft harvest and recipient sites. The VAS scores ranged from 0 to 10 with a low score reflecting no pain and excellent satisfaction and a high score reflecting severe pain and poor satisfaction. RESULTS: The VAS scores for pain averaged 0.4 (OP) and 0.5 (DR), and the VAS scores for scar appearance averaged 0.3 (OP) and 0.7 (DR). These differences were not significant. Within each group, there were no significant differences between the operative and nonoperative limbs for elbow or wrist motion. Early graft harvest-site complications involved 1 superficial wound infection (OP) and 1 wound dehiscence (DR). A graft harvest-site defect was detected by x-ray in 84% of OP cases and in 67% of DR cases. Bone healing at the graft recipient sites was observed in more than 87% of cases in both groups. CONCLUSIONS: Bone graft harvesting from either the OP or the DR led to comparable patient- and evaluator-determined outcomes with low risks of complications. Surgeons can safely use either option.

Surgical Techniques for Correction of Traumatic Hyperextension Instability of the Proximal Interphalangeal Joint: A Biomechanical Study.

PURPOSE: To compare the biomechanical strengths of 5 surgical techniques for treatment of traumatic hyperextension instability of the proximal interphalangeal (PIP) joint. METHODS: Thirty-six cadaveric fingers were randomly assigned to 6 groups: normal control, volar plate repair, flexor digitorum superficialis tenodesis (FDST), single lateral band transfer (SLBT), double lateral band transfer, and dual split lateral band transfer. For each experimental specimen, the volar plate and accessory collateral ligaments were transected, the PIP joint was hyperextended to 90°, and a PIP joint stabilizing procedure was completed. The ultimate strength of each procedure was ascertained by loading to failure, and the fingers were dissected to determine the pathoanatomy of failure. Force-displacement curves were used to estimate the stiffness of each group, and multiple pairwise statistical comparisons were performed. RESULTS: The mean PIP joint stiffness in the control group was significantly greater than the mean PIP joint stiffness in the FDST and SLBT groups, but not significantly different from the mean PIP joint stiffness in the other 3 groups. There were no significant differences in the mean PIP joint stiffness between the 5 joint stabilizing techniques. The SLBT, double lateral band transfer, and dual split lateral band transfer repairs all failed by massive disruption of the flexor tendon sheath, whereas the volar plate repairs and FDST repairs failed by either suture anchor pullout or suture breakage. CONCLUSIONS: The stiffness of 5 surgical techniques to stabilize a traumatic hyperextensible PIP joint did not vary significantly. CLINICAL RELEVANCE: The 5 described techniques to stabilize a posttraumatic PIP joint hyperextension deformity may provide for equal restraint to PIP joint hyperextension instability in the early postoperative period. The choice of procedure should take into consideration other factors not studied, including the potential for PIP joint flexion contracture and long-term durability.

Comparisons of three radiographic views in assessing for scapholunate instability.

BACKGROUND: Multiple wrist x-ray images have been described to assess for scapholunate (SL) instability. Some views may be redundant. The purpose of this study was to compare three plain x-ray views in identifying a traumatic diastasis of the SL interval. METHODS: Nineteen patients (19 wrists) with a positive scaphoid shift test and surgically confirmed SL ligament damage were identified. There were 15 males and 4 females with a mean age of 39 years. Pre-operative x-rays were reviewed, including posteroanterior (PA) neutral and PA ulnar deviation views of the injured wrist, and PA clenched fist views of the injured and uninjured wrists. Dynamic SL instability was defined by an SL mid-interval gap of <3 mm and static SL instability by a gap of ≥3 mm in the PA neutral views. The mid-interval measurements were compared between x-ray images. RESULTS: There were 10 dynamic and 9 static SL instability cases. The PA ulnar deviation and the PA clenched fist views showed significantly greater SL gaps in comparison to the PA neutral views in dynamic but not static SL instability cases. In both categories of instability, there was no significant difference in the SL gaps between the two stress images. The PA clenched fist view of the uninjured wrist revealed SL gapping of >3 mm in 50% of patients but with generally greater gapping in the clenched fist view of the injured wrist. CONCLUSIONS: The PA ulnar deviation and clenched fist stress views were equally effective in showing a dynamic SL diastasis following wrist injury. Neither view was more effective than a neutral PA view in diagnosing static SL instability.

Masquelet technique for treatment of segmental bone loss in the upper extremity.

A relatively simple technique to address large segmental bone defects in the upper extremity is described, along with a case example.

Surgical Management of Symptomatic Olecranon Traction Spurs.

BACKGROUND: There is a paucity of information pertaining to the pathoanatomy and treatment of symptomatic olecranon traction spurs. PURPOSE: To describe the pathoanatomy of olecranon traction spur formation, a technique for spur resection, and a series of patients who failed conservative care and underwent operative treatment. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Eleven patients (12 elbows) with a mean age of 42 years (range, 27-62 years) underwent excision of a painful olecranon traction spur after failing conservative care. Charts and imaging studies were reviewed. All patients returned for evaluation and new elbow radiographs at an average of 34 months (range, 10-78 months). Outcome measures included the Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire; the Mayo Elbow Performance Score (MEPS); visual analog scales (VAS) for pain and patient satisfaction; elbow motion; elbow strength; and elbow stability. RESULTS: The traction spur was found in the superficial fibers of the distal triceps tendon in all cases. The mean QuickDASH score was 3 (range, 0-23), the mean MEPS score was 96 (range, 80-100), the mean VAS pain score was 0.8 (range, 0-3), and the mean VAS satisfaction score was 9.6 (range, 7-10). Average elbow motion measured 3° to 138° (preoperative average, 5°-139°). All patients exhibited normal elbow flexion and extension strength, and all elbows were deemed stable. Early postoperative complications involved a wound seroma in 1 case and olecranon bursitis in 1 case: both problems resolved without additional surgery. Two patients eventually developed a recurrent traction spur, 1 of whom underwent successful repeat spur excision 48 months after the index operation. CONCLUSION: Short- to mid-term patient and examiner-determined outcomes after olecranon traction spur resection were acceptable in our experience. Early postoperative complications and recurrent enthesophyte formation were uncommon. CLINICAL RELEVANCE: This study provides the treating physician with an improved understanding of the pathoanatomy of olecranon traction spur formation, a technique for spur resection, and information to review with patients regarding the outcome of surgical management.

Flexor pollicis longus dysfunction after volar plate fixation of distal radius fractures.

PURPOSE: To evaluate the natural history and etiology of decreased thumb interphalangeal (IP) joint flexion after volar plate fixation of distal radius fractures. METHODS: A total of 46 patients who underwent volar plating of 48 distal radius fractures by a single surgeon were retrospectively studied. Of those patients, 24 (24 wrists) exhibited loss of thumb IP joint flexion (group 1) and 22 (24 wrists) retained thumb IP joint flexion (group 2) with attempted thumb opposition to the small finger after surgery. All patients were seen at regular intervals until IP joint flexion returned and fracture healing was confirmed radiographically. Patient demographics, fracture patterns, surgical variables, and final radiographs were compared between groups. Twenty patients in group 1 were seen after a mean of 6.5 months (range, 5-12 mo) for specific outcome measurements. Eight cadaveric specimens were used to replicate the flexor carpi radialis approach to the distal radius and evaluate flexor pollicis longus tendon excursion. RESULTS: There were no significant differences in fracture pattern, patient age or sex, injured extremity dominance, time to surgery, incision length, plate composition, plate length, tourniquet time, or final wrist radiographs between groups. In group 1, active thumb IP joint flexion returned on average 52 days (range, 19-143 d) postoperatively. At final evaluation in this group, mean IP joint flexion was 11° less than the contralateral thumb IP joint; however, patient-determined outcomes were favorable in most cases. In the cadaveric specimens, excursion of the flexor pollicis longus tendon decreased with sequential soft tissue dissection and retraction. CONCLUSIONS: Loss of thumb IP joint flexion after volar plating of distal radius fractures was common, and motion returned to near normal in most cases within 2 months. Partial stripping of the flexor pollicis longus muscle from investing fascia and bone and retraction of soft tissues are likely etiological factors.

Clinical and radiographic comparisons of two different radial head implant designs.

BACKGROUND: There is little comparative data to guide implant choice for radial head replacements. The purpose of this study was to evaluate the clinical and radiographic results between patients who received a smooth-stemmed bipolar radial head implant and patients who received an in-growth monopolar prosthesis. METHODS: Twenty-seven patients requiring a metallic radial head implant in the management of acute or chronic elbow trauma were evaluated. Fourteen patients received a smooth-stemmed bipolar prosthesis and 13 patients received a press-fit monopolar prosthesis. Patients returned for follow-up at an average of 33 months (range, 18-57). Outcome assessments included joint motion, elbow stability, grip strength, pain, the Mayo Elbow Performance Index, and the Disability of Arm, Shoulder and Hand questionnaire. Radiographs were reviewed for joint congruence, ectopic bone, periprosthetic osteolysis, degenerative arthritis, and capitellar wear, and selected patients were tested for inflammatory markers and metal ion levels. RESULTS: The differences between patient groups for elbow flexion and forearm pronation averaged 10° or less. There were no other pertinent differences between groups for standardized patient and examiner-determined outcomes. There was a trend for ectopic bone to develop more commonly around the smooth-stemmed implants, while periprosthetic osteolysis was more pronounced in cases with the press-fit design. Inflammatory markers were normal, and metal ion levels did not exceed values reported for a well-functioning hip arthroplasty. CONCLUSION: Outcomes at short- to mid-term follow-up were similar with either implant design. Loosening of a press-fit prosthesis may lead to extensive osteolysis, but of undetermined clinical consequence.

Hand surface landmarks and measurements in the treatment of trigger thumb.

PURPOSE: To determine hand surface landmarks and measurements that may be useful in localizing the A1 pulley and digital neurovascular structures in the treatment of trigger thumb. METHODS: We highlighted 4 surface landmarks in 20 adult cadaveric hands: the radial border of the index finger, the ulnar border of the thumb, the thumb interphalangeal joint flexion creases, and the thumb metacarpophalangeal joint creases. We injected the radial arteries with red latex and dissected the thumbs. RESULTS: The proximal margin of the A1 pulley was located an average of 0.3 mm proximal (range, 3.2 mm proximal to 2.3 mm distal) to the most proximal metacarpophalangeal joint flexion crease. The ratio of measurements from the thumb tip to the midpoint of the interphalangeal joint flexion creases and from this point to the proximal margin of the A1 pulley averaged 1.1:1. The radial digital nerve crossed obliquely over the flexor pollicis longus tendon and approached the proximal margin of the A1 pulley at a mean distance of 2.7 mm (range, 0-12.9 mm). The ulnar digital nerve was located deep to intersecting lines drawn along the radial border of the index finger and the ulnar border of the thumb and coursed parallel to the A1 pulley at a mean distance of 5.4 mm (range, 0-11.1 mm). At the level of the A1 pulley, the digital arteries were positioned dorsal to the digital nerves, and both nerves were located 1.0 to 4.2 mm from the skin surface. CONCLUSIONS: The findings from our study clarify hand surface landmarks in localizing the thumb A1 pulley and digital neurovascular structures. CLINICAL RELEVANCE: Awareness of topographical landmarks in localizing the A1 pulley and digital neurovascular structures and the relationships between the digital neurovascular structures and the A1 pulley may improve the safety and efficacy of trigger thumb treatment.