The Effect of Adoption on Functioning and Psychosocial Well-Being in Patients With Congenital Upper-Extremity Differences.

PURPOSE: Adoption status has been investigated in numerous populations, identifying negative and positive effects on patient outcomes. This study compared parent-reported outcomes in adopted and nonadopted individuals with congenital upper-extremity (UE) anomalies to determine whether there was a measurable difference in parent perceptions of psychosocial health and functioning. METHODS: The Congenital Upper Limb Differences registry identified adopted individuals from a large cohort of patients. Each adopted patient was matched to 2 nonadopted patients by sex, age, and diagnosis of UE difference using the Oberg-Manske-Tonkin classification. Parent-reported scores on functional and psychosocial subjective outcomes were compared between the 2 cohorts using the Pediatric Outcome Data Collection Instrument. RESULTS: Ninety-one adopted pediatric patients with congenital UE differences were identified. Sixty had complete matches for comparison, and the remaining 31 patients were not able to be matched and were excluded from the analysis. Pediatric Outcome Data Collection Instrument scores for the UE function domain were worse in the adopted cohort as judged by minimally clinically important difference. In contrast, scores for Pediatric Outcome Data Collection Instrument domains of transfer and mobility, sports and physical function, pain and comfort, and happiness did not exceed the minimally clinically important difference, although the adopted cohort scores were all relatively lower than the nonadopted cohort scores. CONCLUSIONS: In pediatric patients with UE differences, adoption status is seen to affect only the parent-reported domain of UE function. While differences by specific congenital diagnosis call for additional investigation, overall, these findings should be reassuring to families planning to adopt children with UE differences, and they should be supported in their expectations of UE functioning. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.

Outcomes of Pediatric and Adolescent Carpal Tunnel Release.

PURPOSE: To investigate carpal tunnel syndrome (CTS) presentation and long-term outcomes of carpal tunnel release (CTR) in children and adolescents. METHODS: All pediatric and adolescent patients who underwent CTR between February 2003 and June 2018 were identified. Patients were grouped by etiology: lysosomal storage disease (11 hands), idiopathic (6 hands), acute traumatic (7 hands), delayed traumatic (5 hands) and tumorous (2 hands). Medical records were reviewed for presenting symptoms and preoperative treatments. Final outcomes were assessed via phone interviews, chart review, the Boston Carpal Tunnel Questionnaire (BCTQ), and Patient-Reported Outcomes Measurement Information System (PROMIS) scores. RESULTS: All 25 patients (31 hands) identified were included in the study; median age at surgery was 12.7 years (range, 2.5-23.3 years). Eighteen patients completed surveys at a median of 4.7 years after surgery (range, 8 months-16 years). Common presenting symptoms in lysosomal storage disease were numbness/tingling (7 hands); pain was only reported in 1 hand. The most frequent indication for acute traumatic CTR (7 hands) was palmar hand swelling at the carpal tunnel (4 hands). Delayed traumatic and idiopathic CTS most often presented with numbness/tingling (4 hands and 6 hands, respectively) and pain (3 hands, 4 hands, respectively). Of the original 4 lysosomal storage disease surgeries included in long-term follow-up, all experienced gradual recurrence of symptoms after years of relief (range, 3-14 years). Two patients underwent revision CTR and were symptom-free at follow-up. All patients with acute traumatic and tumorous etiologies had full resolution of symptoms. Delayed traumatic and idiopathic etiologies frequently experienced recurrent or recalcitrant symptoms (4 of 5 and 3 of 6 surgeries, respectively). CONCLUSIONS: Carpal tunnel release often alleviates symptoms in children with lysosomal storage disease for years to decades. Carpal tunnel release successfully relieves symptoms in acute traumatic cases, but is not always sufficient to relieve symptoms associated with delayed traumatic etiologies. Approximately half of patients with idiopathic CTS experience recalcitrant or recurrent symptoms. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Outcomes of Pediatric Syndactyly Repair Using Synthetic Dermal Substitute.

PURPOSE: Full-thickness skin grafts are classically used for areas of skin deficit in syndactyly reconstruction surgery. However, skin grafting requires additional time under anesthesia and includes donor site morbidity. Synthetic dermal substitute has produced favorable web creep and scar appearance outcomes in syndactyly reconstruction. We sought to validate these results using objective outcome measures. METHODS: All patients who had undergone syndactyly reconstruction with synthetic dermal substitute with 1-year follow-up were identified. We included 23 webs in 16 patients; 2 were lost to follow-up. Median age at surgery was 27 months; 7 patients were female. Five webs were revision surgeries. Two patients had a diagnosis of amniotic constriction band, and 3 had symbrachydactyly. All webs were assessed from blinded clinical photos. Outcome measures included web creep assessment (range, 0-5) and Vancouver Scar Scale. RESULTS: Of 21 webs, 2 had minimal creep and 16 had none; 3 had clinically relevant creep (grade 2). Vancouver Scar Scale scores for all webs averaged 1.19 (0 is normal). There was normal vascularity in 20 webs, pigmentation was normal in 17 webs, skin pliability was normal in 13 webs, and scar height was flat in 15 webs. On the visual analog scale assessment, surgeons rated the appearance of the 21 webs as an average of 8.8 (range, 5-10). There were no postoperative complications. CONCLUSIONS: Synthetic dermal substitute is an effective, efficient, and visually satisfactory option for coverage of skin deficits in syndactyly reconstruction. The current heterogeneous sample revealed that this approach can provide satisfactory outcomes for patients, families, and surgeons. Although no surgical complications were noted, the rate of integration and healing has yet to be determined. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Flexible Titanium Intramedullary Nail Displacement After Magnetic Resonance Imaging.

CASE: A previously healthy 7-year-old boy presented with midshaft radius and ulna malunion after 8 weeks of nonsurgical treatment. He underwent open reduction and internal fixation of both bones with titanium alloy nails and was placed in a long arm cast. Four weeks after surgery, the patient underwent sedated brain MRI and woke up from anesthesia with elbow pain. On cast removal, the ulnar flexible nail was noted to have displaced proximally by 1.5 cm. CONCLUSION: Despite meeting American Society for Testing and Materials standards, untethered titanium orthopaedic implants are at risk of clinically significant displacement in the early postoperative period.

Saving Money and Reducing Waste With a Tailored Hand Surgery Kit.

BACKGROUND AND OBJECTIVES: There is growing interest in containing cost and decreasing waste in the operating room. As part of a quality improvement initiative, we redesigned the supply kit used for 2 common surgical procedures (carpal tunnel release and trigger finger release) performed under local anesthesia. METHODS: A hand surgeon, a medical student, and an operating room nurse examined each item that would be necessary for performing carpal tunnel release and trigger finger release. A new disposable supply kit was formulated on the basis of their recommendations and was implemented over a 7-month period. Cost savings and waste avoidance were calculated. RESULTS: The streamlined kit ($43.40) produced a 53% cost savings relative to the standard hand pack ($92.83) per case. The local pack (2.896 kg) was 41% lighter than the standard pack (4.938 kg), translating to significant waste avoidance. The local hand pack was used for 46 cases from September 2020 to April 2021, saving a total of $2246.78 and avoiding 94 kg of waste. There have been no noted interruptions in delivery of surgical care. CONCLUSION: Our redesign of the local hand pack led to substantial cost savings and waste avoidance. We believe there are many opportunities for surgical teams to use similar strategies to decrease cost and environmental waste.

An Epidemic Amidst a Pandemic: Musculoskeletal Firearm Injuries During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic has substantially impacted the delivery of health care, both through direct care associated with COVID-19 and through more pervasive effects. Our goal was to evaluate whether the number of orthopaedic consultations for firearm injuries differed during the early months of the COVID-19 pandemic compared with the same period in prior years. We hypothesized that the initial months of the COVID-19 pandemic, compared with the same period in prior years, would have a higher number of orthopaedic consultations for firearm injuries and a lower rate of outpatient follow-up after consultations. METHODS: A prospectively collected database of orthopaedic trauma consultations at a level-I trauma center was queried for firearm injuries. We compared the number of orthopaedic consultations for firearm injury during the initial months of the COVID-19 pandemic (March 23, 2020, to September 30, 2020, referred to as the pandemic group) with identical dates from 2017 to 2019 (referred to as the pre-pandemic group). Outpatient follow-up rates, ZIP codes (and associated Area Deprivation Index), and demographic data were compared between the pandemic group and the pre-pandemic group. RESULTS: During the entire study period, 552 orthopaedic consultations for firearm injuries were identified. There was a 63% increase in the daily mean number of firearm injury consultations in the pandemic group, to 1.01, compared with the pre-pandemic group, 0.62 (p < 0.001). There was no difference in the rate of outpatient follow-up: 66% for the pandemic group and 72% for the pre-pandemic group. There was no difference in the percentage of patients from the most socially deprived decile: 45.3% in the pandemic group and 49.5% in the pre-pandemic group. Patients presenting during the pandemic were more often uninsured (75.8%) relative to the pre-pandemic group (67.9%), with a lack of health insurance significantly decreasing the likelihood of outpatient follow-up (p < 0.01). CONCLUSIONS: Compared with the same period in prior years, there was a significant increase in the number of orthopaedic consultations for firearm injuries during the early months of the COVID-19 pandemic in our community. Patient race, socioeconomic status, and outpatient follow-up were similar between the pandemic group and the pre-pandemic group. There was a higher proportion of uninsured patients within the pandemic group and a lower rate of follow-up among those without insurance.