Efficacy of Intra-Articular Corticosteroid Injection for Nonsurgical Management of Trapeziometacarpal Osteoarthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

PURPOSE: As osteoarthritis (OA) of the trapeziometacarpal (TMC) joint leads to a high degree of disease burden with compromises in rudimentary and fine movements of the hand, intra-articular injections may be a desirable treatment option. However, because there are no evidence-based guidelines, the choice of intra-articular injection type is left to the discretion of the individual surgeon in collaboration with the patient. The purpose of our study was to perform a systematic review and meta-analysis using level I studies to compare outcomes following corticosteroid and alternative methods of intra-articular injections for the management of TMC OA. Our hypothesis was that intra-articular corticosteroid injections were no more effective than other methods of intra-articular injections for the management of TMC OA. METHODS: A systematic literature search was performed. Eligible for inclusion were randomized control trials reporting on intra-articular corticosteroid injection for the management of TMC OA. Clinical outcomes were recorded. RESULTS: The 10 included studies comprised 673 patients. The mean age was 57.8 ± 8.3 years, with a mean follow-up of 6.4 ± 2.7 months. There was no significant difference in visual analog scale scores, grip strength and tip pinch strength between corticosteroids and hyaluronic acid at short- and medium-term follow-up. Further, there was no difference in visual analog scale pain scores at rest at medium-term follow-up between corticosteroids and platelet-rich plasma. CONCLUSIONS: Despite short-term improvement with intra-articular corticosteroid injections, there was no significant difference in pain and functional outcomes following intra-articular corticosteroid injections compared to hyaluronic acid or platelet-rich plasma administration. Given the affordability, ease of administration, and efficacy associated with corticosteroids, they are a favorable option when considering the choice of intra-articular injection for the management of TMC OA. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Evaluation of Online Artificial Intelligence-Generated Information on Common Hand Procedures.

PURPOSE: The purpose of this study was to analyze the quality and readability of the information generated by an online artificial intelligence (AI) platform regarding 4 common hand surgeries and to compare AI-generated responses to those provided in the informational articles published by the American Society for Surgery of the Hand (ASSH) HandCare website. METHODS: An open AI model (ChatGPT) was used to answer questions commonly asked by patients on 4 common hand surgeries (carpal tunnel release, cubital tunnel release, trigger finger release, and distal radius fracture fixation). These answers were evaluated for medical accuracy, quality and readability and compared to answers derived from the ASSH HandCare materials. RESULTS: For the AI model, the Journal of the American Medical Association benchmark criteria score was 0/4, and the DISCERN score was 58 (considered good). The areas in which the AI model lost points were primarily related to the lack of attribution, reliability and currency of the source material. For AI responses, the mean Flesch Kinkaid Reading Ease score was 15, and the Flesch Kinkaid Grade Level was 34, which is considered to be college level. For comparison, ASSH HandCare materials scored 3/4 on the Journal of the American Medical Association Benchmark, 71 on DISCERN (excellent), 9 on Flesch Kinkaid Grade Level, and 60 on Flesch Kinkaid Reading Ease score (eighth/ninth grade level). CONCLUSION: An AI language model (ChatGPT) provided generally high-quality answers to frequently asked questions relating to the common hand procedures queried, but it is unclear when or where these answers came from without citations to source material. Furthermore, a high reading level was required to comprehend the information presented. The AI software repeatedly referenced the need to discuss these questions with a surgeon, the importance of shared decision-making and individualized care, and compliance with surgeon treatment recommendations. CLINICAL RELEVANCE: As novel AI applications become increasingly mainstream, hand surgeons must understand the limitations and ramifications these technologies have for patient care.

The Value Added of Advanced Imaging in the Diagnosis and Treatment of Triangular Fibrocartilage Complex Pathology.

PURPOSE: Pathology of the triangular fibrocartilage complex is a prevalent cause of ulnar-sided wrist pain that presents a diagnostic challenge. We hypothesized that a history and physical examination (H&P) would be more cost-effective alone or with diagnostic injection than with magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA) in the diagnosis and treatment of a symptomatic triangular fibrocartilage complex abnormality. METHODS: A simple-chain decision analysis model was constructed to assess simulated subjects with ulnar-sided wrist pain and normal radiographs using several diagnostic algorithms: H&P alone, H&P + injection, H&P with delayed advanced imaging (MRI or MRA), and H&P + injection with delayed advanced imaging (MRI or MRA). Three years after diagnosis, effectiveness was calculated in Disabilities of the Arm, Shoulder, and Hand-adjusted life years. Costs were extracted from a commercial insurance database using US dollars. A probabilistic sensitivity analysis with 10,000 second-order trials with sampling of parameter distributions was performed. One-way and 2-way sensitivity analyses were performed. RESULTS: All strategies had similar mean effectiveness between 2.228 and 2.232 Disabilities of the Arm, Shoulder, and Hand-adjusted life years, with mean costs ranging from $5,584 (H&P alone) to $5,980 (H&P, injection, and MRA). History and physical examination alone or with injection were the most cost-effective strategies. History and physical examination alone was the most preferred diagnostic strategy, though H&P + injection and H&P with delayed MRA were preferred with adjustments in willingness-to-pay and parameter inputs. As willingness-to-pay increased considerably (>$65,000 per Disabilities of the Arm, Shoulder, and Hand-adjusted life year), inclusion of MRA became the most favorable strategy. CONCLUSIONS: Advanced imaging adds costs and provides minimal increases in effectiveness in the diagnosis and treatment of a symptomatic triangular fibrocartilage complex abnormality. The most cost-effective strategy is H&P, with or without diagnostic injection. Magnetic resonance arthrogram may be favored in situations with a high willingness-to-pay or poor examination characteristics. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis IV.

Isolated Scaphoid Dislocation With Radial-Axial Instability: A Treatment Strategy Utilizing Spanning Wrist Plates.

Isolated dislocation of the scaphoid is a rare injury with only a few case reports in the literature. We report on 2 complex scaphoid dislocations demonstrating concomitant axial instability with disruption of the capitohamate articulation as well as the long-ring metacarpal relationship. Both of these patients underwent reduction and fixation using a wrist spanning plate, which was removed approximately 2 months after injury. Follow-up of these patients demonstrated maintenance of reduction, axial stability, and return of painless range of motion.

Outcomes Associated With Scapholunate Ligament Injury Following Intra-Articular Distal Radius Fractures.

PURPOSE: The purpose of this study was to evaluate a series of intra-articular distal radius fractures (DRFs) to determine whether patients without radiographic evidence of scapholunate (SL) ligament injury have a difference in outcomes in comparison with patients with radiographic evidence of SL ligament injury and no ligament repair or reconstruction. Our hypothesis is that there are no significant differences in outcomes between patients after treatment of their intra-articular DRF. METHODS: A retrospective analysis of patients from a single institution who sustained an intra-articular DRF from January 2006 through January 2019 with minimum 12-month (n = 192) and 24-month (n = 100) follow-up was performed. Patient demographic, clinical, and outcome variables were compared between SL angles less than 70° (cohort 1) and SL angles 70° or greater (cohort 2). Radiographic parameters were measured and recorded at 3 time points: baseline in the contralateral wrist, following closed reduction but prior to surgical intervention, and at final follow-up. Outcomes collected included Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Modified Global Assessment of Function (mGAF), and a visual analog scale (VAS) for pain. RESULTS: One hundred ninety-two patients were included. Of these 192 patients, cohort 1 (n = 110) was observed to have median (range) SL angles of 58° (42°-68°) and cohort 2 (n = 82) median (range) SL angles of 74.5° (70°-87°) after closed reduction. Cohort 2 had statistically significant increases in median SL angles from closed reduction to final follow-up (74.5° [range, 70°-87°) to 78.5° (range, 71°-107°). There were no statistically significant differences in QuickDASH disability scores, mGAF scores, and VAS pain scores between the cohorts at initial and final follow-ups. CONCLUSIONS: Patient-reported outcomes at 12 and 24 months do not differ between patients without radiographically apparent SL ligament injury (SL angles < 70°) and patients with radiographically apparent SL ligament injury(SL angles ≥ 70°) who do not undergo ligament repair or reconstruction following treatment of their intra-articular DRF. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The Critical Portions of Carpal Tunnel Surgery: A Comparison Between Opinions of Surgeons and the General Public.

PURPOSE: Attending surgeons must participate in critical and key portions of procedures and otherwise be immediately available. However, surgeon-defined standards of the critical and key portions of surgery have been questioned, potentially affecting trainee graduated responsibility. This study compares the opinions of surgeons and the general public regarding what constitutes the critical portions of carpal tunnel release (CTR). METHODS: A survey was devised inquiring about the appropriateness of surgical trainee execution of each step of CTR. Surgeons who perform CTR were queried (n = 112) and 32 (29%) responded. The survey was modified to compare responses from a sample of 184 nonmedical respondents (NMRs). The NMRs were excluded if they indicated having a career in health care. RESULTS: Of the surgeon respondents, 94% (n = 30) had completed hand fellowship training, 53% (n = 17) declared themselves academic or affiliated with academia, and 53% (n = 17) utilized concurrent operating rooms. The NMR average age was 35.3 ± 10.3 years, 40% were female (n = 73), and they represented various regions of the United States including an assortment of socioeconomic and ethnic groups. Surgeons demonstrated significantly more hesitation with trainees performing surgical steps. Academic surgeons were significantly more comfortable having trainees performing surgical steps than nonacademic surgeons. Critical portions of CTR as agreed upon by surgeons and NMRs included incision, dissection, transverse carpal ligament division, and inspection of the median nerve for injury/complete release. CONCLUSIONS: Surgeons are significantly less comfortable with trainee performance of CTR steps than the general public. Surgeons who regularly work with trainees are more accepting of trainee involvement than those who do not. CLINICAL RELEVANCE: Understanding the opinions of surgeons as well as NMRs with respect to surgical trainee participation in the operating room is important to optimize the informed consent process as well as influence hospital policies that affect graduated surgical trainee autonomy.

Hand transplantation in the United States: A review of the Organ Procurement and Transplantation Network/United Network for Organ Sharing Database.

Hand transplantation is the most common application of vascularized composite allotransplantation (VCA). Since July 3, 2014, VCAs were added to the definition of organs covered by federal regulation (the Organ Procurement and Transplantation Network (OPTN) Final Rule) and legislation (the National Organ Transplant Act). As such, VCA is subject to requirements including data submission. We performed an analysis of recipients reported to the OPTN to have received hand transplantation between 1999 and 2018. Forty-three patients were identified as having been listed for upper extremity transplantation in the United States. Of these, 22 received transplantation prior to July 3, 2014 and 10 from then to December 31, 2018. Of patients transplanted after 2014, posttransplant functional scores included a decrease in Disabilities of the Arm, Shoulder and Hand questionnaire in 3 of 10 patients, Carroll test scores ranging from 9 to 60 of 99, and monofilament testing with protective sensation achieved in 4 of 6 patients. Complications included rejection in nine recipients with Banff scores from II-IV. One patient experienced graft failure 5 days after transplantation. Of the remaining patients, two were reported as receiving monotherapy and seven receiving dual or triple immunosuppression therapy. The inclusion of VCA in the OPTN Final Rule standardized parameters for safe implementation and data collection.

Three-dimensional characterization of trabecular bone mineral density of the proximal ulna using quantitative computed tomography.

BACKGROUND: Although previous studies have measured general proximal forearm bone mineral density (BMD), no study has systematically mapped the 3-dimensional trabecular BMD of the proximal ulna. The aim of this study was to describe the 3-dimensional distribution of the trabecular bone density of the proximal ulna. We hypothesize a variable distribution of proximal ulna trabecular BMD depending on the region of interest (ROI). METHODS: Computed tomographic (CT) scans of 9 fresh-frozen cadaveric proximal ulna specimens with a mean age of 59.3 ± 8.1 years were studied. Each CT file was converted from DICOM to a QCT file that could be analyzed using QCT software (QCT Pro Version 6.1, Model 4 CT Calibration Phantom; MindWays Software Inc, Austin, TX, USA). The ROIs were defined as spheres of trabecular bone 3 mm in diameter located throughout the proximal ulna. RESULTS: ROIs proximal to the trochlear notch demonstrated higher BMD than ROIs distal to the trochlear notch. Furthermore, volar ROIs adjacent to the ulnohumeral joint tended to have higher BMD than dorsal ROIs. The highest BMD was found in the tip of the olecranon. CONCLUSION: Hardware in fixation constructs for proximal ulnar fractures should be directed toward ROIs with the highest BMD to maximize purchase. Hardware should approach the ulnohumeral joint without penetrating the joint to capture trabecular bone with the highest BMD. The most important fixation in such a construct will be that which captures trabecular bone with maximum BMD proximal to the trochlear notch (eg, the tip of the olecranon).

Youth Baseball Pitch Counts Vastly Underestimate High-effort Throws Throughout a Season.

BACKGROUND: The primary purpose of this study was to compare the number of pitches thrown by youth baseball players under the official league guidelines versus the number of "high-effort" throws recorded by a validated digital sensor worn by the players during a season. METHODS: In total, 11 and 12-year-old youth baseball players from a single league were provided an elbow sleeve and sensor to wear each time they threw a baseball for an entire baseball season. The sensor tracked total throws and pitch-equivalent high-effort throws for the season. Official pitch counts were collected at each game from the official scorekeepers. RESULTS: A total of 19 players participated in the study. The sensor-determined mean total throw count (1666.2±642.2) and mean high-effort throw count (576.9±329.3) per player were both significantly higher, P<0.0001 and P=0.02, respectively, than the mean official pitch count (168.1±122.4). CONCLUSIONS: Our findings demonstrate that youth players make significantly more total throws and high-effort, or pitch-equivalent, throws, than what is recorded by the official pitch counts. Further research is needed to determine a safe annual "throw count" for young throwing athletes and to determine which types of throws, in addition to pitches, put youth throwers at risk for injury. LEVEL OF EVIDENCE: Level IV.

Preliminary Report-The Long Leg Cast With a Pelvic Band: A Novel Approach to Treatment of Pediatric Femur Fractures.

OBJECTIVES: The aim of the study was to describe the long leg cast with a pelvic band (LLCPB), a novel alternative to spica casting for treating femur fractures in patients aged 6 months to 6 years which requires no casting above the waist, allows for hip flexion adjustments after it is applied, and does not require an operating room for placement. METHODS: Seven children aged 7.9 months to 3.7 years with femur fractures treated with the LLCPB at a single institution were retrospectively studied. All children were casted in the emergency department under conscious sedation. Radiographic and subjective outcomes were recorded. RESULTS: All 7 children achieved acceptable reduction of their fractures without the need for re-reduction or cast wedging. Five of the 7 children were discharged from the emergency department; 1 child required 1 night of hospitalization and another child required 2 nights of hospitalization. There were no complications. The cost of placing an LLCPB at our institution was $430.46. The cost of placing a spica cast in the operating room was $5427.54 to $6465.00. CONCLUSIONS: The long leg cast with a pelvic band seems to be an acceptable treatment for children aged 8 months to 4 years with spiral femur fractures. This technique has significant advantages over traditional and modified spica casts including allowing for uninhibited toileting, weight bearing on the unaffected leg, adjustment of hip flexion at any point after placement, and easier access to the perineum, abdomen, and chest for hygienic and medical purposes. Furthermore, treatment with an LLCPB presents significant potential for cost savings.

Trends in Revision Elbow Ulnar Collateral Ligament Reconstruction in Professional Baseball Pitchers.

PURPOSE: To determine the frequency of revision elbow ulnar collateral ligament (UCL) reconstruction in professional baseball pitchers. METHODS: Data were collected on 271 professional baseball pitchers who underwent primary UCL reconstruction. Each player was evaluated retrospectively for occurrence of revision UCL reconstructive surgery to treat failed primary reconstruction. Data on players who underwent revision UCL reconstruction were compiled to determine total surgical revision incidence and revision rate by year. The incidence of early revision was analyzed for trends. Average career length after primary UCL reconstruction was calculated and compared with that of players who underwent revision surgery. Logistic regression analysis was performed to assess risk factors for revision including handedness, pitching role, and age at the time of primary reconstruction. RESULTS: Between 1974 and 2014, the annual incidence of primary UCL reconstructions among professional pitchers increased, while the proportion of cases being revised per year decreased. Of the 271 pitchers included in the study, 40 (15%) required at least 1 revision procedure during their playing career. Three cases required a second UCL revision reconstruction. The average time from primary surgery to revision was 5.2 ± 3.2 years (range, 1-13 years). The average length of career following primary reconstruction for all players was 4.9 ± 4.3 years (range, 0-22 years). The average length of career following revision UCL reconstruction was 2.5 ± 2.4 years (range, 0-8 years). No risk factors for needing revision UCL reconstruction were identified. CONCLUSIONS: The incidence of primary UCL reconstructions among professional pitchers is increasing; however, the rate of primary reconstructions requiring revision is decreasing. Explanations for the decreased revision rate may include improved surgical technique and improved rehabilitation protocols. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Comparison Between Intramedullary Nail and Percutaneous Pin Fixation in Proximal Phalanx Fractures.

BACKGROUND: Percutaneous pinning has been the predominant technique for fixation of proximal phalanx fractures, but stiffness is a reported complication. The introduction of intramedullary (IM) nail fixation of proximal phalanx fractures provides a stronger biomechanical fixation for amenable fracture patterns with the added benefit of not tethering the soft tissue. The goal of this study was to compare the surgical outcomes of IM nail and percutaneous pin fixation in isolated proximal phalanx fractures. METHODS: A retrospective review was performed at our institution between the years 2018 and 2022 for patients treated for proximal phalanx fractures. Patients that underwent fixation with IM nails or percutaneous fixation for isolated extraarticular proximal phalanx fractures were included. Patients were excluded if they had concomitant hand fractures, tendon injury, or intraarticular extension. RESULTS: A total of 50 patients were included in this study. Twenty-eight patients received percutaneous pin fixation, and 22 patients underwent IM nail or screw fixation. There was no significant difference in injury patterns or demographics between these two groups. Patients that underwent IM nail fixation had a significantly quicker return to active motion, shorter duration of orthosis treatment, and fewer occupational therapy visits. In addition, patients in the IM fixation group had significantly improved range of motion (ROM) at 6 weeks postoperatively. CONCLUSIONS: This study demonstrates that patients receiving percutaneous pin or IM nail fixation have equivocal union and complication rates. The IM nail fixation group was able to have quicker return to mobilization, fewer required occupational therapy visits, and improved early ROM.

Proximal Interphalangeal Joint Fractures: Various Approaches to Fixation.

There are numerous operative and nonoperative options for the management of proximal interphalangeal joint fractures and fracture dislocations. The treatment of choice should be guided by the fracture pattern and joint stability. The authors highlight a contemporary option for open reduction and internal fixation techniques, but all the techniques presented are viable options under the right circumstances. It is also important to set patient expectations as most of these patients will note post-injury stiffness and potential functional limitations.

Dermal Regenerative Templates in Orthopaedic Surgery.

Management of soft-tissue injuries is a critical principle in the treatment of orthopaedic trauma. Understanding the options for soft-tissue reconstruction is vital for successful patient outcomes. Application of dermal regenerative templates (DRTs) in traumatic wounds has created a new rung in the reconstructive ladder bridging the gap between skin graft and flap coverage. There are multiple DRT products with specific clinical indications and mechanisms of action. This review outlines the up-to-date specifications and uses of DRT in commonly seen orthopaedic injuries.

Recalcitrant Neuropathies in the Upper Extremity.

Carpal and cubital tunnel syndrome can cause debilitating pain and weakness in the hand and upper extremities. Although most patients have a resolution of their symptoms after primary decompression, managing those with recalcitrant neuropathies is challenging. The etiology of persistent, recurrent, or new symptoms is not always clear and requires careful attention to the history and physical examination to confirm the diagnosis or consider other causes prior to committing to surgery. Nevertheless, revision surgery is often needed in the setting of recalcitrant neuropathies in order to improve patients' symptoms. Revision surgery typically entails wide exposure and neurolysis to release residual compression. In addition, vascularized tissue and nerve wraps have been routinely used to create a favorable perineural environment that decreases recurrent scar formation. This review discusses the etiologies of recalcitrant upper extremity neuropathies, the current treatment options, and surgical outcomes.

Lunate Revascularization With Temporary Internal Radiocarpal Spanning Fixation for Kienböck Disease.

BACKGROUND: The goal in the treatment of stages II and III Kienböck disease is to restore lunate vascularity and halt the progression of avascular necrosis. METHODS: We report the outcomes for patients with stages II and III Kienböck disease treated with fourth extensor compartment artery vascularized bone grafting and temporary radiocarpal spanning internal fixation. Nine patients with a mean age of 28.8 years were included. Mean clinical and radiographic follow-up were 4.9 and 1.9 years, respectively. RESULTS: Six patients had no change in Lichtman stage, 2 patients regressed 1 stage, and 1 patient progressed 1 stage. Mean postoperative quick disabilities of the arm, shoulder, and hand (QuickDASH) was 17.4. Mean postoperative visual analogue pain scale (VAS) was 1.8. Patients under age 25 trended toward improved clinical outcomes compared with patients over age 25. Two patients, aged 33 and 65, underwent proximal row carpectomy at a mean 30.5 months postoperatively. CONCLUSIONS: In conclusion, the use of local vascularized bone graft with temporary internal radiocarpal spanning fixation provides a treatment option with outcomes comparable to existing literature with benefits inherent to internal immobilization.

Management of Complex Hand and Wrist Ligament Injuries.

Ligamentous injuries in the hand and wrist are often underdiagnosed and can present with significant functional limitations if there is untimely recognition of injury. Adequate repair or reconstruction is critical in restoring joint stability and mobility. The purpose of this review is to provide an overview of the metacarpophalangeal joint, scapholunate interosseous ligament (SLIL), and non-SLIL carpal ligament anatomy, diagnosis, imaging, treatment consideration and options, as well as surgical techniques encompassing repair, reconstruction, and fusion.

Impact of Time to Fixation on Outcomes of Operative Treatment of Intra-articular Distal Radius Fractures.

BACKGROUND: The incidence of operative treatment of distal radius fractures (DRFs) has increased recently, but the optimal timing for surgical fixation remains unclear. We hypothesized that: (1) an increase in time to fixation of intra-articular DRFs would increase the likelihood of postoperative complications; and (2) increased time from injury to fixation would lead to longer surgical time and worse range of motion (ROM) outcomes. METHODS: We retrospectively reviewed 299 fractures in 284 adult patients who underwent open reduction and internal fixation (ORIF) of a closed, intra-articular DRF at our institution over a 10.5-year period. Demographic information, time to surgery (TTS) from injury, surgical time, tourniquet time, complications, and final postoperative ROM were collected for logistic regression modeling to predict the risk of postoperative complication. RESULTS: Twenty-seven (9.0%) patients experienced postoperative complications. The median TTS (Q1-Q3) for all patients was 7.0 (4.0-12.0) days. Patients who experienced an early postoperative complication had significantly longer median TTS (10.0 days) than those who did not (7.0 days). Patients with longer TTS were more likely to experience a complication (odds ratio, 1.11; 95% confidence interval, 1.04-1.19; P = .006). Tourniquet time and final wrist ROM were not related to TTS. A logistic regression analysis found that early complication rate doubles at 7.0 days after injury (from 3.5% to 6.9%). CONCLUSIONS: Patients with operative intra-articular distal radius fractures should ideally be fixed within 7 to 10 days of injury to minimize the risk of early postoperative complications. The tourniquet time and final ROM were not associated with time to surgery.

Outcomes associated with proton pump inhibitors and distal radius fractures: A post-hoc comparative analysis.

Long-term, high-dose, daily proton pump inhibitors (PPI) may impact outcomes associated with distal radius fractures (DRF). The hypothesis was that differences existed in patient demographics, but there existed no differences in injury patterns, interventions, post-operative complications, and patient-reported outcomes between patients not on a PPI and patients on a PPI with a DRF. METHODS: An IRB-approved, post-hoc analysis of patients with DRF from 2012 through 2018 was performed. Patients included were age ≥18 years, sustained a DRF, had completed medical and medication records, Quick Disabilities of the Arm, Shoulder and Hand (DASH) scores, Global Assessment of Functioning (GAF) scores, visual analogue scale (VAS) pain scores, and a minimum of 1-year follow-up. Patients were stratified into two cohorts. Cohort one patients had no prescription or over-the-counter PPI use (no PPI cohort). Cohort two patients had adherence to a long-term, high-dose, daily PPI (PPI cohort). RESULTS: Two hundred and eighty-one DRF patients were included. Of these 281 patients, 240 were in the no PPI cohort and 41 were in the PPI cohort. Patients in the PPI cohort had more median nerve injuries (12% versus 3%, p = 0.025) and radial shaft fractures (5% versus 0%, p = 0.020), less contralateral upper extremity injuries (0% versus 4%, p = 0.001), and more post-operative nonunions (7% versus 1%, p = 0.029) compared to patients in the no PPI cohort. CONCLUSIONS: Long-term, high-dose, daily PPI's may be associated with more median nerve injuries and radial shaft fractures, less contralateral upper extremity injuries, and more post-operative nonunions compared to DRF patients not on a PPI.

Platelet-Rich Plasma Versus Corticosteroid Injections for the Treatment of Mild-to-Moderate Carpal Tunnel Syndrome: A Markov Cost-Effectiveness Decision Analysis.

BACKGROUND: Platelet-rich plasma (PRP) or corticosteroid injections may be used to conservatively treat mild-to-moderate carpal tunnel syndrome (CTS). We evaluated the cost-effectiveness of PRP injections versus corticosteroid injections for the treatment of mild-to-moderate CTS. METHODS: Markov modeling was used to analyze the base-case 45-year-old patient with mild-to-moderate CTS, unresponsive to conservative treatments, never previously treated with an injection or surgery, treated with a single injection of PRP, or methylprednisolone/triamcinolone 40 mg/mL. Transition probabilities were derived from level-I/II studies, utility values from the Tufts University Cost-Effectiveness Analysis Registry reported using visual analog scale (VAS), Boston Carpal Tunnel Questionnaire Symptom severity (BCTQ-S), and Boston Carpal Tunnel Questionnaire Functional status (BCTQ-F), and costs from Medicare, published studies, and industry. Analyses were performed from healthcare/societal perspectives. Outcomes were incremental cost-effectiveness ratios (ICER) and net monetary benefits (NMB). Willingness-to-pay thresholds were $50 000 and $100 000. Deterministic/probabilistic sensitivity analyses were performed. RESULTS: From a healthcare perspective, compared to PRP injections, the ICER for corticosteroid injections measured by VAS: -$13.52/quality-adjusted-life-years (QALY), BCTQ-S: -$11.88/QALY, and BCTQ-F: -$16.04/QALY. PRP versus corticosteroid injections provided a NMB measured by VAS: $428 941.12 versus $375 788.21, BCTQ-S: $417 115.09 versus $356 614.18, and BCTQ-F: $421 706.44 versus $376 908.45. From a societal perspective, compared to PRP injections, the ICER for corticosteroid injections measured by VAS: -$1024.40/QALY, BCTQ-S: -$899.95/QALY, and BCTQ-F: -$1215.51/QALY. PRP versus corticosteroid injections provided a NMB measured by VAS: $428 171.63 versus $373 944.39, BCTQ-S: $416 345.61 versus $354 770.36, and BCTQ-F: $420 936.95 versus $375 064.63. CONCLUSIONS: PRP injections were more cost-effective than methylprednisolone/triamcinolone injections from healthcare and societal perspectives for mild-to-moderate CTS.