Open versus arthroscopic treatment of the rheumatoid elbow arthritis: a comparison of complications at two years utilizing a nationally representative database.

PURPOSE: Symptomatic rheumatoid arthritis (RA) can be addressed surgically with open procedures or elbow arthroscopy. Previous studies comparing outcomes of open to arthroscopic arthrolysis for the management of RA did not utilize a large database study. The aim was to compare demographics and two-year complications, in RA patients undergoing open or arthroscopic elbow arthrolysis. METHODS: A retrospective, cohort study was performed utilizing a private, nationwide, all-payer database. We queried the database to identify patients undergoing open (n = 578) or arthroscopic (n = 379) arthrolysis for elbow RA. The primary goal of the study was to compare complications at two-years. Categorical variables were assessed utilizing the chi-squared test; while, continuous variables were analyzed using the Student's t-test. Multivariable logistic regression was performed to assess risk factors for infection following open or arthroscopic arthrolysis. RESULTS: RA patients undergoing open elbow arthrolysis were older (55 vs. 49 years, p < 0.001), predominately female (61.6% vs 60.9%, p = 0.895), and likely to have chronic kidney disease (20.4 vs. 12.9%), and DM (45.2 vs. 32.2%) (both p < 0.005). Open elbow arthrolysis was also associated with higher rates of infection (31.7 vs. 4.7%) and wound complications (26.8 vs. 3.4%) (both p = 0.001). Nerve injury rates were found to be similar (8.3 vs. 9.0%, p = 0.81). On multivariable logistic regression, open elbow procedures were associated with the highest risk for infection (OR: 8.43). CONCLUSIONS: Patients undergoing open arthrolysis for RA were at a higher risk of infection and wound complications compared to arthroscopic arthrolysis utilizing a nationally representative database. While there appears to be a difference in outcomes following these two procedures, higher level evidence is needed to draw more definitive conclusions. LEVEL OF EVIDENCE: Retrospective, Level III.

An anatomic study of the morphologic characteristics of the dorsal capitolunate ligament.

PURPOSE: There is consensus in favor of a description of the dorsal ligaments of the carpus as not including a direct ligament between the lunate and capitate. On the other hand, there is an anatomical formation which, according to the currently accepted description, corresponds to the dorsal midcarpal capsule, itself thickened by the dorsal intercarpal ligament. The question is whether the capsule at this point deserves to be called an individualizable ligament. In our operative experience of the dorsal carpus, we have encountered a stout structure adherent to the lunate and capitate. In this article, we present the anatomic evidence of this structure's existence. METHODS: Seven adult fresh frozen upper extremities were dissected. Three wrists were longitudinally sectioned in line with the middle finger metacarpal. The remaining 4 were dissected dorsally. Two representative samples of the stout structure connecting the lunate to the capitate were sent to pathology for histologic analysis and staining. RESULTS: In all 3 of the longitudinally sectioned wrists, a thick band of tissue could clearly be seen, originating on the lunate, spanning the dorsal interval between the lunate and the capitate, and inserting on the capitate. With this structure intact, dorsal dislocation of the capitate was not possible, but preliminary sectioning of the structure allowed dislocation. In the 4 dorsally dissected wrists, the same connection was observed, palmar to the dorsal intercarpal ligament, in every specimen. The average dimensions of the dorsal capitolunate were: 15.25 ± 1 mm long, 8.75 ± 1 mm wide at the midpoint, and 1.75 ± 1 mm thick. The two specimens sent to pathology after sectioning showed longitudinally oriented collagen fibers. This structure also stained positive for elastin and contained intrasubstance vascular structures. CONCLUSION: There is a stout ligamentous structure connecting the lunate to the capitate, palmar to the dorsal intercarpal ligament. Disruption of this structure appears to be necessary for dorsal dislocation of the capitate. Clinical studies are needed to gain better understanding of the exact function and importance of this structure.

Treatment of 2-part, 3-part, and 4-part proximal humerus fractures from 2016 to 2020: A nationally-representative database.

Introduction: Complex proximal humerus fractures pose challenges in elderly patients, as this common scenario can lead to unpredictable outcomes, regardless of treatment method. Given the evolving nature of the treatment for 3-and-4-part proximal humerus fractures, an epidemiological analysis offers a way to minimize the gap between appropriate understanding and effective intervention. As such, we aimed to i) evaluate the trends of nonoperative and operative management; and ii) compare the complication rates of ORIF to conversion ORIF (to RTSA). Methods: We utilized a national, all-payer database to include patients who underwent open reduction and internal fixation for 2-part (n = 2783), 3-part (n = 2170), 4-part (n = 1087) proximal humerus fractures between April 2016 to December 2022. Patients who failed ORIF to RTSA included n = 108 for 2-part fractures, n = 123 for 3-part fractures, and n = 128 for 4-part fractures. We collected demographic and postoperative medical and surgical complications at 90-days, in addition to time-interval between ORIF and RTSA. Results: The malunion and nonunion rates for ORIF between different types of proximal humerus fractures were similar (2-part fractures: 1.8 %, 4.7 %; 3-part fractures: 1.8 %, 3.5 %; 4-part fractures: 2.4 %, 3.7 %). The conversion rates of failed ORIF to RTSA were 1.9 %, 2.8 %, and 5.9 % for 2-part, 3-part, and 4-part fractures, respectively. The time interval from failed ORIF to RTSA was 190 days for 2-part fractures, 169 days for 3-part fractures, and 129 for 4-part fractures. Conclusion: An epidemiological analysis of proximal humerus fractures by fracture type demonstrated an increase in RTSA for 2-part, 3-part, and 4-part fractures while nonoperative treatment showed no change from 2016 to 2020. Additional research is needed to determine which fractures are best treated operatively while maximizing outcomes. In the setting of complex proximal humerus fractures, several options seem feasible depending on patient demographic characteristics.

Elevated risk of prosthetic infections in cannabis users after shoulder arthroplasty.

INTRODUCTION: An increasing number of states are beginning to legalize recreational cannabis use, and as such, more patients using cannabis are undergoing shoulder arthroplasty procedures. The present study sought to examine the impact of cannabis use on post-operative outcomes. The primary outcomes of interest were postoperative complications, which included infection, periprosthetic fractures, periprosthetic joint infections (PJI), dislocations, and aseptic loosening as well as medical complications. Secondary outcomes were risk factors for PJI and aseptic loosening at two-years. METHODS: A private, nationwide, all-payer database (Pearldiver Technologies) was queried to identify shoulder arthroplasty patients from 2010 to 2020. Those not using tobacco or cannabis ("control", n = 10,000), tobacco users (n = 10,000), cannabis users (n = 155), and concurrent tobacco and cannabis users (n = 9,842) were identified. Risk factors for PJI and aseptic loosening at two-years were further quantified utilizing multivariable logistic regression analysis. RESULTS: Compared to non-users, cannabis users experienced the highest odds for PJI and aseptic revisions, which were followed by concurrent cannabis and tobacco users and tobacco-only users. Concurrent users, as well as tobacco users were at higher risk for dislocation. Cannabis use was the most significant risk factor for PJI, followed by concurrent use and male sex. CONCLUSIONS: Our study found cannabis use to cause greater risk for superficial and deep infection. More research involving randomized trials are needed to fully elucidate the impact of cannabis use on shoulder arthroplasty procedures. Clinically, these findings can appropriately guide surgeons and patients alike regarding expectations prior to undergoing TSA.

Comparative analysis of open versus endoscopic carpal tunnel release in a comprehensive national database.

PURPOSE: Carpal tunnel syndrome is the most common compressive neuropathy. There is limited evidence to support endoscopic compared to open carpal tunnel release according to the 2016 American Academy of Orthopaedic Surgeons Clinical Practice Guideline on carpal tunnel syndrome. The purpose of the present study was to assess differences between the two procedures by comparing 30- and 90-day complications and mean hospital costs in a large patient population. METHODS: Using the national Mariner15 Database by PearlDiver Technologies, we retrospectively studied 27,192 carpal tunnel syndrome patients who received carpal tunnel release using an endoscopic or open surgical approach from 2010 to 2019. Patients who met the inclusion criteria were grouped and case-matched at a 1:1 ratio through the corresponding International Classification of Diseases codes (n = 13,596) and assessed for 30- and 90-day complications such as median nerve injury, superficial palmar arch injury, and revision carpal tunnel release surgery. Univariate analysis was used to compare outcomes and a multivariate regression was performed to identify risk factors associated with each outcome. RESULTS: Endoscopic carpal tunnel release was associated with a higher rate of median nerve injury than open release at 30 days (0.3% vs. 0.1% odds ratio, 2.21; 95% confidence interval, 1.29-3.81; p < 0.05) and 90 days (0.4% vs. 0.3%; odds ratio, 1.77; 95% confidence interval, 1.16-2.70; p < 0.05). Endoscopic release was also associated with a higher rate of superficial palmar arch injury (0.1% vs. 0%; odds ratio, 25.02; 95% confidence interval, 1.48-423.0; p < 0.05). CONCLUSIONS: In the present study, risk of median nerve injury and vascular injury was higher after endoscopic than open carpal tunnel release. At 90 days, all-cause revision rates were similar between techniques. Surgeons should understand these differences, to optimize surgical decision-making. LEVEL OF EVIDENCE: Therapeutic, IIIa.

Preoperative Corticosteroid Injections Within 4 Weeks of Arthroscopic Shoulder Procedures Are Associated With Increased Postoperative Infection Rates.

PURPOSE: To refine the understanding of the effect of timing of corticosteroid injections (CSIs) and shoulder arthroscopy on postoperative infection. METHODS: An insurance database was used to determine all patients who underwent shoulder arthroscopy for a 5-year period with an associated preoperative ipsilateral corticosteroid injection. Patients were stratified into cohorts based on timing of preoperative CSI: (1) 0-<2 weeks, (2) 2-<4 weeks, (3) 4-<6 weeks, and (4) 6-<8 weeks. Patients were pooled to include all patients who had a CSI less than 4 weeks and those longer than 4 weeks. A cohort of patients who never had a corticosteroid injection before undergoing arthroscopy were used as a control. All patients had a follow-up of 2 years. Multivariable regression analyses were performed using R Studio with significance defined as P < .05. RESULTS: Multivariate logistic regression showed a greater odds ratio (OR) for postoperative infection in patients who received CSI 0-<2 weeks before shoulder arthroscopy at 90 days (3.10, 95% confidence interval [CI] 1.62-5.57, P < .001), 1 year (2.51, 95% CI 1.46-4.12, P < .001), and 2 years (2.08, 95% CI 1.27-3.28, P = .002) compared with the control group. Patients who received CSI 2-<4 weeks before shoulder arthroscopy had greater OR for infection at 90 days (2.26, 95% CI 1.28-3.83, P = .03), 1 year (1.82, 95% CI 1.13-2,82, P = .01), and 2 years (1.62, 95% CI 1.10-2.47, P = .012). Patients who received CSI after 4 weeks had similar ORs of infection at 90 days (OR 1.15, 95% CI 0.78-1.69, P = .48) 1 year (OR 1.18, 95% CI 0.85-1.63 P = .33), and 2 years (OR 1.09, 95% CI 0.83-1.42, P = .54), compared with the control cohort. CONCLUSIONS: The present study shows the postoperative infection risk is greatest when CSIs are given within 2 weeks of shoulder arthroscopy, whereas CSIs given within 2-<4 weeks also portend increased risk, albeit to a lesser degree. The risk of postoperative infection is not significantly increased when CSIs are given more than 1 month before surgery. LEVEL OF EVIDENCE: Level III, retrospective comparative, prognosis study.

Postoperative Opioid Dependence in Patients Undergoing Either Total or Reverse Shoulder Arthroplasty for Proximal Humerus Fracture Fixation.

INTRODUCTION: In elderly patients who have proximal humerus fractures, treatment commonly involves total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA). Following these procedures, patients often require opioids for postoperative analgesia. This common scenario is of clinical and societal importance, as increased postoperative opioid usage has been shown to worsen outcomes and increase the likelihood for dependence. We aimed to compare postoperative opioid use in patients undergoing either TSA or RSA for fixation of their proximal humerus fracture. Specifically, we assessed: (1) postoperative opioid use at two, four, six, eight, and greater than eight weeks postoperatively; (2) aseptic revision rates at 90-days, one year, and two years postoperatively; and (3) periprosthetic joint infection (PJI) rates at 90-days, one year, and two years postoperatively between patients undergoing TSA or RSA for the surgical management of their proximal humerus fractures. MATERIALS AND METHODS: For this review, we queried a national all-payer database from October 1, 2015 to October 31, 2020 (n=1.5 million) for all patients who had a "proximal humerus fracture" diagnosis who underwent either TSA or RSA. There were two cohorts: patients undergoing TSA (n=731) and patients undergoing RSA (n=731). Bivariate Chi-square analyses. RESULTS: We found no differences (p>0.05) in opioid use postoperatively in patients undergoing RSA for proximal humerus management compared to patients undergoing TSA after two weeks. There was not a significant difference in aseptic revision or PJI rates between the two cohorts (all p>0.05). CONCLUSION: The evidence comparing opioid use in patients undergoing either TSA or RSA for proximal humerus fracture fixation is lacking. Our study specifically showed no differences in opioid use postoperatively in patients undergoing RSA for proximal humerus management compared to patients undergoing TSA.

Cannabis Use in Patients With Distal Radius Fractures: A Moment of Unity?

BACKGROUND: As legalization of cannabis spreads, an increasing number of patients who use cannabis are being seen in the clinical setting. This study examined the impact of cannabis and tobacco use on postoperative complications following open reduction and internal fixation (ORIF) of distal radius fractures. METHODS: A national, all-payer database was queried to identify patients who underwent ORIF of a distal radius fracture between 2015 and 2020 (n = 970 747). Patients were stratified into the following groups: (1) tobacco use (n = 86 941), (2) cannabis use (n = 898), (3) tobacco and cannabis use (n = 9842), and (4) neither tobacco nor cannabis use ("control", 747 892). Multivariable logistic regression was used to identify risk factors for infection, nonunion, and malunion within the first postoperative year. RESULTS: Concomitant use of tobacco and cannabis was associated with a higher rate of nonunion (5.0%) compared to tobacco or cannabis use alone (P < .001). Multivariate analysis identified cannabis-only use (odds ratio [OR] 1.25), tobacco-only use (OR 2.17), and concurrent tobacco and cannabis use (OR 1.78) as risk factors for infection within the first postoperative year. Similarly, cannabis-only use (OR 1.47), tobacco-only use (OR 1.92), and concurrent tobacco and cannabis use (OR 2.52) were associated with an increased risk of malunion. CONCLUSIONS: Cannabis use is associated with an elevated risk of infection and malunion following operative management of a distal radius fracture. Concomitant use of cannabis and tobacco poses an elevated risk of nonunion and malunion compared to tobacco use alone.

Open versus arthroscopic elbow arthrolysis for primary osteoarthritis: A comparison of demographics and complications at two years.

Introduction: Open techniques have traditionally been utilized in the surgical management of elbow osteoarthritis (OA). However, advances in elbow arthroscopy, in conjunction with the movement towards minimally invasive surgery, have led to an increase in the utilization of an arthroscopic approach. The primary aim of this investigation was to compare demographics and complication rates between patients undergoing open or arthroscopic arthrolysis for elbow OA with a secondary objective of identifying risk factors for infection with each treatment. Methods: A retrospective review of a private, all-payer database was performed to identify patients undergoing either open (n = 1482) or arthroscopic (n = 2341) arthrolysis for elbow osteoarthritis. The primary outcome was 2-year complications, which included infection, wound complications, and nerve injuries. Categorical variables were compared utilizing chi-square analyses, while continuous variables were compared using independent sample t-tests. Odd ratios (OR) were ascertained to quantify the risk attributed to open arthrolysis compared to arthroscopic. Multivariable logistic regression was performed to assess risk factors for infection following open or arthroscopic arthrolysis of an elbow with OA. Results: Age was significantly higher in the open cohort (55 ± 13.4 years) compared to the arthroscopic cohort (52 ± 13.1 years) (p < 0.001). The open cohort was more likely to be female (32.0 vs. 22.9%, p < 0.001) and have a Charlson Comorbidity Index (CCI) greater than three (9.2 vs. 7.1%, p < 0.001). Open procedures were associated with an increased risk of nerve injury (OR: 1.50) and wound complications (OR: 7.70) compared to arthroscopic arthrolysis. Multivariable logistic regression identified open procedures as a risk factor for infection (OR: 11.15). Moreover, diabetes (OR: 1.48), chronic kidney disease (OR: 1.89) and tobacco use (OR: 2.29) were found as risk factors for infection among the open cohort. Conclusions: This study found patients undergoing open arthrolysis of OA to be older and have a greater number of medical comorbidities compared to those undergoing arthroscopic arthrolysis. Open arthrolysis was associated with an increased rate of infection, nerve injury and wound complications compared to arthroscopic arthrolysis. After controlling for age and comorbidities with multivariable logistic regression, open arthrolysis remained a risk factor for infection. Arthroscopic elbow arthrolysis is associated with a lower risk of complications, including infection and may be favored for the management of OA of the elbow. Level of Evidence: III (retrospective cohort study).

Selective Thumb Carpometacarpal Joint Denervation Versus Trapeziectomy and Ligament Reconstruction With Tendon Interposition for Painful Arthritis: A Prospective Study With 2 Years of Follow-Up.

PURPOSE: Thumb carpometacarpal (CMC) joint denervation is a relatively novel method for the management of osteoarthritis-associated pain by selective transection of articular nerve branches of the CMC joint. This study compared functional/patient-reported outcomes after CMC denervation with those after trapeziectomy and ligament reconstruction with tendon interposition (T + LRTI) over a 2-year follow-up period. We hypothesized that the outcomes of denervation and T + LRTI would be similar over the course of the study and at the final 2-year follow-up. METHODS: Adults with Eaton stage 2-4 disease, no evidence of CMC subluxation, and no history of thumb injury/surgery were included. Pain scores, brief Michigan Hand Questionnaire (bMHQ), Kapandji score, 2-point discrimination, and grip/key/3-point pinch strength were measured at 3-, 6-, 12-, and 24-months after surgery. On average, T + LRTI patients underwent 7 weeks of splinting, with release to full activity at 3 months; denervation patients were placed in a soft postoperative dressing for 2 weeks, with release to full activity as tolerated at 3 weeks. RESULTS: Thirty-three denervation and 20 T + LRTI patients were included. Preoperative characteristics were similar between both groups. Two denervation patients underwent secondary T + LRTI during the study period; one denervation patient underwent fat grafting to the CMC joint at an outside institution. Data prior to secondary surgeries were included in the analysis. The average tourniquet times (minutes) for denervation and T + LRTI were 43.5 ± 11.8 and 82.7 ± 14.2 minutes, respectively. For denervation and T + LRTI, the postoperative bMHQ scores were significantly higher than those at baseline at all time points. No significant differences were found between both groups for bMHQ, sensation, or strength measures. CONCLUSIONS: Carpometacarpal denervation is well tolerated, with shorter tourniquet times and faster return to full activity than T + LRTI. For the study cohort, the conversion rate to T + LRTI at 2 years was 9%. Both procedures demonstrated durable improvement in bMHQ compared with the preoperative state with similar long-term outcomes over 2 years of follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

The temporal effect of corticosteroid injections into large joints prior to trigger finger release on infection.

BACKGROUND: Trigger finger may be treated with open surgical release. Local corticosteroid injections have also demonstrated success. Studies suggest recipients of flexor sheath corticosteroid up to 90-days prior to open surgery are at increased risk of post-operative infection. However, the possible link between large joints corticosteroid prior to trigger finger release remains unexplored. Therefore, this study aimed to provide complication risks for trigger finger release recipients after large joint corticosteroid. METHODS: We reviewed a national, all-payer database and examined patients who did not receive and did receive corticosteroid two, four, or six weeks prior to trigger finger release. Primary outcomes assessed were 90-day risk for antibiotics, infection, and irrigations and debridement. Multivariate logistic analyses compared cohorts using odds ratios with 95% confidence intervals. RESULTS: No trends were found regarding antibiotic requirements, infection, as well irrigations and debridement within 90-days for recipients of corticosteroid into large joints two, four, or six weeks prior to open trigger finger release. Elixhauser Comorbidity Index, alcohol abuse, diabetes mellitus, and tobacco use were identified as independent risks for requiring antibiotics as well as irrigations and debridement (all Odds Ratios > 1.06, all p ≤ 0.048). CONCLUSIONS: Patients who underwent trigger finger release after receiving a corticosteroid into a large joint two, four, or six weeks prior has no association with 90-day antibiotics, infection, or irrigations and debridement. While the comfort levels for individual surgeons vary, optimizing these comorbidities prior to surgery is an important goal discussed with patients to lower risks for infections. RETROSPECTIVE: Level III.

Rare peripheral nerve tumor of the median nerve.

Peripheral nerve tumors of the median nerve are uncommon. We present a case of a large atypical intraneural perineurioma of the median nerve. In our case, a 27-year-old man with a history of Asperger's and Autism who was diagnosed with a lipofibromatous hamartoma of the median nerve after a biopsy and treated conservatively presented to clinic due to the slowly growing size of his lesion. He was treated with excision of the lesion with associated resection of healthy median nerve and extensor indicis pollicis oppponenplasty. The pathology of the excision reported the lesion as an intraneural perineurioma instead of a lipofibromatous hamartoma perhaps presenting evidence of a reactive process.

Partial Resection of First Dorsal Compartment Extensor Retinaculum in De Quervain's Stenosing Tendovaginitis Release.

Various surgical techniques exist to treat de Quervain's stenosing tendovaginitis. Specific surgical techniques for de Quervain's are designed to avoid complications including injury to branches of the superficial branch of the radial nerve, inadequate decompression, reflex sympathetic dystrophy, and palmar subluxation of the released tendons. A simple dorsal incision through the extensor retinaculum is advocated by many as a means to release the compartment while preventing postoperative subluxation. A single incision through the retinaculum limits exposure of the compartment and could lead to reannealing of the retinaculum and recurrent symptoms. Partial resection of the extensor retinaculum provides a more complete release and has not been found to lead to palmar tendon subluxation.

Operative Versus Nonoperative Treatment for Closed Displaced Midshaft Clavicle Fractures.

BACKGROUND: Nonoperative treatment for clavicle fractures has historically been standard of care, but with a concomitant rise in recent operative fixation for displaced midshaft clavicle fractures (MCF), a re-evaluation of treatment modalities is necessary. The purpose of this study was to compare nonunion rates among operative and nonoperative treatment of closed displaced MCF. Specifically, we assessed the following between operative and nonoperative management: (1) 90-day to 1-year nonunion and malunion incidence; (2) 90-day medical complications; and (3) 90-day to 1-year total costs of care. METHODS: An all-payer national database was retrospectively reviewed for closed displaced MCF from 2010 to 2020 (n = 173 188). Of these, patients undergoing operative fixation within 30 days of a displaced MCF were identified (n = 17 452). Nonoperative displaced MCF patients were matched with operative patients at a 3:1 ratio. Outcomes at 90 days and 1 year included: nonunion, total cost, and complications. RESULTS: Closed displaced MCF with operative fixation resulted in significantly increased nonunion rates at 1 year compared with nonoperative treatment (3.97% vs 1.63%, odds ratio = 2.50 [2.26-2.77], P < .001). Kaplan-Meier survivorship and log-rank score demonstrated the same for a 1-year nonunion endpoint (P < .001). As expected, the operative cohort incurred higher median total costs of care at 90 days ($3255.00 vs $1024.00, P < .001) and 1 year ($1978.00 vs $4799.50, P < .001) compared with nonoperative treatment. CONCLUSION: Our study found higher nonunion incidence after operative fixation of displaced MCF. These results may serve as a catalyst for future high-quality prospective studies comparing treatment options for closed displaced MCF.

Rare septic arthritis of the wrist and carpus primary osteoarticular manifestation of Mycobacterium tuberculosis: A case report.

Mycobacterium tuberculosis is one of the oldest and most studied infections, yet it remains one of the most common causes of infection-related death worldwide. The majority concern pulmonary tuberculosis. Therefore, extrapulmonary cases are rare and are often neglected in the differential diagnosis, especially in chronic musculoskeletal complaints. Nevertheless, osteoarticular manifestation of tuberculosis can cause disabling destruction of bone, cartilage, and surrounding soft tissues which may be exacerbated by a delay in diagnosis. This case report documents a case of primary osteoarticular tuberculosis causing septic arthritis of the wrist and carpus. In our case, the patient had no pulmonary burden of tuberculosis, which further delayed diagnosis and lead to irreversible damage to the wrist as well as carpus. This case illustrates the need to consider this diagnosis in at risk populations in order to prevent a delay in diagnosis and treatment.

Impact of Missing Data on Identifying Risk Factors for Postoperative Complications in Hand Surgery.

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

Relative Value Unit Compensation Rates for Hospital-Based Shoulder/Elbow Surgery Versus Hand Surgery.

Upper extremity surgeons perform diverse operations, including hand surgery, microsurgery, and shoulder/elbow arthroscopy and arthroplasty. Declining orthopedic reimbursement rates may encourage surgeons to adjust their case mix, favoring a shift toward procedures with higher compensation. To determine whether upper extremity surgeons and hand-fellowship trainees may be financially incentivized to perform more shoulder/elbow procedures than hand procedures in a hospital-based setting, relative value unit (RVU) compensation rates were compared for these 2 fields. Using Centers for Medicare & Medicaid Services-assigned work RVUs (wRVU) and National Surgical Quality Improvement Program operative time data, wRVU compensation rates per minute of operative time were determined for common shoulder/elbow surgeries. Overall nonweighted and weighted wRVU/min averages were calculated for hospital-based shoulder/elbow and hand surgery. A total of 27 shoulder/elbow procedures and 53 hand surgery procedures were analyzed. Nonweighted comparison showed shoulder/elbow surgery had a higher wRVU/min (0.19±0.03 vs 0.14±0.05, P<.0001) vs hand surgery. When weighted by procedure frequency, shoulder/elbow surgery also had higher wRVU/min (0.19±0.02 vs 0.15±0.05, P<.0001). Fourteen of the 27 shoulder/elbow procedures were compensated either the same wRVU/min or more than all hand procedures except for epicondyle debridement and flexor tendon bursectomy. Almost half of commonly performed shoulder/elbow procedures were compensated at greater rates than most hand procedures in a hospital-based setting. This disproportionate compensation may affect upper extremity surgeons' case mix and motivate providers and hand-fellowship trainees to seek additional training in shoulder arthroplasty and arthroscopy to supplement their practice. [Orthopedics. 2021;44(3):e373-e377.].

Scapholunate Ligament: Comparing the Native Strength of the Ligament to an All-suture Anchor Construct.

Our aim was to compare the tensile strength of the native scapholunate ligament (SLL) with that of an all-suture anchor construct in a cadaveric model. The scaphoid and lunate were isolated, preserving all segments of the SLL. Using a servohydraulic testing machine, we increased the load until peak load-to-failure of the native SLL was reached in nine specimens (mean ± standard deviation, 273 ± 132 N). Using the same specimens, two JuggerKnot 1.4-mm suture anchors (Zimmer Biomet) were placed into the lunate and tensioned through transosseous tunnels in the scaphoid. Sutures were tied over the radial nonarticular aspect of the scaphoid. Load-to-failure testing was repeated. The mean peak load-to-failure for the all-suture anchor constructs was 172 ± 59 N versus 231 ± 117 N for the native group (p = 0.157). This represents approximately 75% of the native ligament strength. (Journal of Surgical Orthopaedic Advances 29(3):169-172, 2020).

Equivalent PROMIS Scores after Nonoperative or Operative Treatment of Trapeziometacarpal Osteoarthritis.

BACKGROUND: Patient-Reported Outcomes Measurement Information System (PROMIS) scores can quantify symptoms and limitations after upper extremity surgery. Our objective was to determine how these scores compare amongst patients with trapeziometacarpal osteoarthritis treated either nonoperatively or operatively. METHODS: In this retrospective comparative study, we compared PROMIS scores (upper extremity function [UEF], pain interference, and depression) between 43 patients who underwent nonoperative treatment (nonsteroidal anti-inflammatory drugs/splinting/injections) and 33 patients who underwent trapeziectomy with ligament reconstruction and tendon interposition for trapeziometacarpal osteoarthritis (minimum 6-month recovery period) by 4 surgeons from 2014-2018. PROMIS scores were compared across all patients by Eaton-Littler staging. We used linear regression to assess correlations between time-since-surgery and each PROMIS domain. Multivariable linear regression was used to identify patient and disease factors independently associated with PROMIS scores. RESULTS: Surgery was not associated with better UEF (37 vs. 40, P=0.23), less pain interference (58 vs. 56, P=0.42), or fewer symptoms of depression (47 vs. 46, P=0.59). Similarly, no differences were observed across all patient by Eaton-Littler stage for UEF (P=0.49), pain (P=0.48), or depression (P=0.90). For the operative group, greater time-since-surgery, or patient recovery period, correlated moderately with worse UEF (R=0.41) and increased pain (R=0.37). CONCLUSION: In small retrospective comparative cohorts, surgery was not associated with better UEF, pain, or depression scores compared with nonoperative treatment for trapeziometacarpal osteoarthritis.