Union of Radiocarpal Fusion With and Without Proximal Row Carpectomy: A Systematic Review.

PURPOSE: Wrist fusion provides a solution to the painful, arthritic wrist, and can be concomitantly performed with or without a proximal row carpectomy (PRC). The benefits of combining a PRC with fusion include a large amount of local bone graft for fusion and a lower number of joints needed to fuse. We hypothesized that wrist fusion combined with PRC will have a higher fusion rate than wrist fusion performed without PRC. METHODS: A systematic review was performed to identify all papers involving wrist arthrodesis using the following databases: PubMed, Ovid, Scopus, Web of Science, and COCHRANE. A literature search was performed using the phrases "wrist" OR "radiocarpal" and "fusion" OR "arthrodesis". Inclusion criteria included complete radiocarpal fusion performed for rheumatoid, posttraumatic, or primary arthritis; union rates available; English-language study. Studies were excluded if case reports; diagnoses other than the ones listed previously; inability to abstract the data. Data collected included wrist fusions with PRC or without PRC, union rate, patient age, underlying diagnosis, and method of fixation. RESULTS: A total of 50 studies were included in the analysis. There were 41 studies with no PRC, 8 studies with PRC, and 1 study with and without PRC. There were 347 patients with a PRC and 339 patients had a successfully fused wrist (97.7%). There were 1,355 patients who had a wrist fusion with no PRC, and1,303 patients had successful wrist fusion (96.2%). The difference in fusion rate between the 2 groups, 97.7% versus 96.2%, was not statistically significant. CONCLUSIONS: There is no statistically significant difference with regards to union rate in wrist fusion with a PRC versus wrist fusion without a PRC. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Distal biceps ruptures in National Football League players: return to play and performance analysis.

BACKGROUND: Distal biceps ruptures are rare injuries that tend to occur at a younger age in high-level athletic populations. Data analyzing athletes' ability to return to play, as well as performance, after surgery for a distal biceps rupture are lacking. METHODS: All National Football League (NFL) players from the 2000-2016 seasons who were found to have a surgically treated distal biceps rupture were included. Analysis of performance and career length was conducted with a control group matched for position, age, experience, and performance statistics. Data for the cohort vs. control group, as well as before vs. after injury, were analyzed with the paired-samples Student t test, with P < .05 deemed statistically significant. RESULTS: We identified 35 NFL players for the study; 33 (94%) were able to return to sport at an average of 351.4 ± 123.9 days. Offensive linemen undergoing surgery played fewer games per season compared with the control group (P = .04). However, the average number of seasons after surgery and after the index date was not found to be significant (P > .05). Mean career length, as well as number of games per season, did not differ in the postsurgical group vs. control group (P > .05) for all other positions. Performance scores within skill players did not prove to be significant between the postoperative and control groups (P > .05). CONCLUSIONS: Distal biceps ruptures treated surgically in NFL players allow for return to play at a high rate. The level of performance after surgery is similar to that of the player before injury. On average, NFL career length does not appear to be affected after distal biceps surgery.

What Is the Normal Ulnar Bow in Adult Patients?

BACKGROUND: Rotation of the forearm is a result of the complex interaction among the radius, ulna, and interosseous membrane. Although the radius is recognized as curved, the ulna is generally thought of as a "straight bone." To better describe normal anatomy, which may lead to more successful anatomic fixation of forearm fractures, we aimed to apply a method of measuring the normal ulnar bow and determine the mean ulnar bow in adults. QUESTIONS/PURPOSES: (1) To what degree is the ulna bowed in the coronal and sagittal planes in normal adult forearms? (2) To what degree is the radius bowed in the coronal plane in normal adult forearms? METHODS: Radiographs of the forearms of adults taken during a 1-year period were initially obtained retrospectively. These radiographs were performed for various reasons, including forearm pain and routine radiographic follow-up. Radiographs were excluded if evidence of a fracture or post-fracture fixation was found, if a patient had missing AP or lateral images, or if a suboptimal technique was used. The coronal and sagittal bow of the ulna was measured with a method adapted from previous studies that assessed radial bow using AP and lateral radiographs, respectively. Similar measurements were made in the coronal plane for the radius. All measurements were performed independently by the four authors. There was excellent interobserver reliability for ulnar bow in the coronal and sagittal planes (interclass correlation coefficient = 0.96 and 0.97, respectively) and for radial bow in the coronal plane (interclass correlation coefficient = 0.90). RESULTS: The mean maximal coronal ulnar bow was 7 ± 2 mm and was located at 75% of the ulnar length, measured proximally to distally. The location of coronal bow was consistently distal to the radial bow location. The mean maximal sagittal ulnar bow was 6 ± 3 mm and was located at 39% of the ulnar length. The mean maximal coronal bow of the radius was 14 ± 2.0 mm and was 59% of the total length of the radius from proximal to distal. CONCLUSIONS: The ulna is not a "straight bone," as is commonly thought, but rather has a bow in both the coronal and sagittal planes. CLINICAL RELEVANCE: Knowledge of the standard ulnar bow may be pivotal to prevent malunion of the ulna during surgery. Future research using these data in preoperative planning may lead to changes in plate contouring and clinical outcomes in forearm fracture management.

Four-Corner Arthrodesis Versus Proximal Row Carpectomy for Scapholunate Advanced Collapse: A Systematic Literature Review and Meta-analysis.

BACKGROUND: Scapholunate advanced collapse (SLAC) of the wrist is one of the most common patterns of degenerative arthritis in the wrist. Surgical intervention is warranted for individuals with symptomatic SLAC and degenerative disease that affects the radioscaphoid joint. The most popular options for motion-preserving reconstruction and treatment of this disease include 4-corner arthrodesis and proximal row carpectomy. The purpose of this article was to conduct a systematic literature review and meta-analysis to identify any differences in the clinical outcomes of 4-corner arthrodesis and proximal row carpectomy for the treatment of SLAC. METHODS: An electronic literature search of PubMed, Embase, OVID, and the Cochrane Library was conducted to identify studies evaluating the clinical outcomes of 4-corner arthrodesis versus proximal row carpectomy for the treatment of SLAC. Primary outcome measures included flexion/extension range of motion, grip strength, and level of pain. RESULTS: Eight studies encompassing 311 patients met the inclusion criteria for the meta-analysis. Our meta-analysis indicated that when compared with 4-corner arthrodesis, patients who underwent proximal row carpectomy had statistically significantly increased flexion/extension range of motion by 6.2 degrees, significantly increased grip strength by 1.52%, and reduced level of pain by 0.3. CONCLUSIONS: This study demonstrated that in comparative studies, there was a statistical difference favoring proximal row carpectomy to 4-corner arthrodesis for the treatment of SLAC. Although these differences were statistically significant, they remain very small and lack clinical relevance. This study further supports that both of these treatment options are equivalent for the treatment of this disease. Although not clinically significant, compared with 4-corner arthrodesis, patients treated with proximal row carpectomy had increased range of motion, increased grip strength, and decreased pain. Limitations to these findings are the small number of studies available and the increased heterogeneity between the studies. Further studies need to be conducted to confirm these findings.

Is Insurance Status Associated with the Likelihood of Operative Treatment of Clavicle Fractures?

BACKGROUND: Most closed clavicle fractures are treated nonoperatively. Research during the past decade has reported differences in the treatment of clavicle fractures based on insurance status in the US and may highlight unmet needs in a vulnerable population, particularly because new data show that surgery may lead to improved outcomes in select populations. Large-scale, national data are needed to better inform this debate. QUESTIONS/PURPOSES: (1) Does the likelihood of operative fixation of closed clavicle fractures vary among patients with different types of insurance? (2) What demographic and socioeconomic factors are associated with the likelihood of clavicle fracture surgery? (3) Has the proportion of operative fixation of clavicle fractures changed over time? METHODS: A retrospective analysis of the Nationwide Inpatient Sample 2001-2013 database was performed. This database is the largest publicly available all-payer inpatient database in the US that provides pertinent socioeconomic data on a nationwide scale. Data were queried for patients with closed clavicle fractures using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes, and surgery was determined using ICD-9 procedural codes. A total of 252,109 patients were included in the final analysis after 158,619 patients were excluded because of missing demographic or insurance data, ambiguous fracture location, or age younger than 19 years. Of the 252,109 included patients, 21,638 (9%) underwent surgical fixation of clavicle fractures. A chi-square analysis was performed to determine variables to be included in a multivariable analysis. A binary logistic regression analysis was used to examine demographic and other important variables, with a significance level of p < 0.01. Poisson's regression and a t-test were used to analyze trends over time. Results were recorded as odds ratios (OR) and incidence rate ratios. RESULTS: After controlling for demographic and potentially relevant variables, such as the median income and fracture location, we found that patients with Medicare, Medicaid, and no insurance had a lower likelihood of undergoing operative fixation of clavicle fractures than did those with private insurance. Patients without insurance were the least likely to undergo surgery (OR, 0.63; 95% CI, 0.60-0.66; p < 0.001), followed by those with Medicare (OR, 0.73; 95% CI, 0.70-0.78; p < 0.001) and those with Medicaid (OR, 0.74; 95% CI, 0.69-0.78; p < 0.001). Women, black, and Hispanic patients were also less likely to undergo surgery than men and white patients (OR, 0.95; p = 0.003; OR = 0.67; p < 0.001; and OR = 0.82; p < 0.001, respectively) There was an increase in the overall proportion of patients undergoing surgery, from 5% in 2001 to 11% in 2013 (incidence rate ratio, 2.99; p < 0.001). CONCLUSIONS: We believe that the greater use of surgery among adult patients with clavicle fractures who have private insurance than among those with nonprivate or no insurance-as well as among men and white patients compared with women and patients of color-may be a manifestation of important health care disparities in the inpatient population. This may be owing to variable access to care or a difference in the likelihood that a surgeon will offer surgery based on a patient's insurance status. Because operative fixation of closed clavicle fractures increases in the adult population, future research should elucidate conscious and subconscious motivations of patients and surgeons to better inform the discussion of health care disparities in orthopaedics. LEVEL OF EVIDENCE: Level III, therapeutic study.

The Incidence of Snow Blower-Related Injuries to the Hand in the United States.

BACKGROUND: Snow blowers represent a highly preventable and increasingly common mechanism of hand injury. This study examines current safety features and their impact on decreasing the incidence of snow blower-related injuries. METHODS: The National Electronic Injury Surveillance System was queried to look for injuries related to the use of snow throwers or blowers between 2001 and 2016. From all of the injuries related to snow blowers, we collected information on identifying characteristics, location of injury, and type of injury (i.e., avulsion). Chi-squared tests were used for categorical variable comparisons, and Student t tests were used for continuous variable comparisons. Data analysis was performed using SAS statistical software, version 9.3 (SAS Institute, Inc., Cary, NC). The Consumer Product Safety Commission's provided SAS algorithm was used to calculate all national injury estimates and variances. Statistical significance was determined based on P < 0.05. RESULTS: Within the study period, there were 3,550 reported injuries. The extrapolated national incidence was 92,799, with an average annual incidence of 5,800 or 1.9 injuries per 100,000 US population per year. The most commonly injured body part was the finger followed by the hand. Most common types of injuries were fractures, lacerations, and amputations. CONCLUSIONS: The incidence of snow blower injuries increased from 2001 to 2016. Unlike with other power tools, Consumer Product Safety Commission-mandated guidelines for safer operation and improvements in equipment have not been successful in producing a decrease in the incidence of snow blower injuries to the upper extremity. Based on this, further equipment modifications are necessary and should be aimed at preventing operators from placing their hand into the exit chute while the machine is still running. Physicians should take an active role in their practice as well as in their professional societies to educate and counsel patients to prevent further injury.

The Impact of Safety Regulations on the Incidence of Upper-Extremity Power Saw Injuries in the United States.

PURPOSE: Over 50,000 power saw-related injuries occur annually in the United States. Numerous safety measures have been implemented to protect the users of these tools. This study was designed to determine which interventions, if any, have had a positive impact on the safety of the consumer or laborer. METHODS: We queried the National Electronic Injury Surveillance System database for hand and upper-extremity injuries attributed to power saws from 1997 to 2014. Demographic information including age, sex, date of injury, device, location, body part involved, diagnosis, and disposition was recorded. We performed statistical analysis using interrupted time series analysis to evaluate the incidence of injury with respect to specific safety guidelines as well as temporal trends including patients' age. RESULTS: An 18% increase in power saw-related injuries was noted from 1997 (44,877) to 2005 (75,037). From 2006 to 2015 an annual decrease of 5.8% was observed. This was correlated with regulations for power saw use by the Consumer Safety Product Commission (CPSC) and Underwriters Laboratories. Mean age of injured patients increased from 48.8 to 52.9 years whereas the proportion of subjects aged less than 50 years decreased from 52.8% to 41.9%. These trends were most pronounced after the 2006 CPSC regulations. CONCLUSIONS: The incidence of power saw injuries increased from 1997 to 2005, with a subsequent decrease from 2006 to 2015. The guidelines for safer operation and improvements in equipment, mandated by the CPSC and Underwriters Laboratories, appeared to have been successful in precipitating a decrease in the incidence of power saw injuries to the upper extremity, particularly in the younger population. CLINICAL RELEVANCE: The publication of safety regulations has been noted to have an association with a decreased incidence in power saw injuries. Based on this, clinicians should take an active role in their practice as well as in their professional societies to educate and counsel patients to prevent further injury.

Reduction Loss After Distal Radius Fracture Fixation With Locked Volar Plates.

Distal radius fractures are among the most common injuries in the upper extremity. While many studies have looked at the maintenance of reduction with volar locking plates, there is a paucity of literature comparing the ability of different plates to maintain reduction over time. This study reviews the ability of various plates to maintain radiographic reduction at union after distal radius fracture treatment. Loss of some aspect of fracture reduction was routinely observed following locked volar plating regardless of implant. However, choice of implant did have a significant impact on final radiographic alignment, particularly with respect to volar tilt and ulnar variance. Yet, selecting between a fixed angle versus a variable angle was not found to make a difference in maintaining reduction. The authors recommend that surgeons take these findings into consideration when selecting a volar locking plate. (Journal of Surgical Orthopaedic Advances.

Recurrent cubital tunnel syndrome treated with revision neurolysis and amniotic membrane nerve wrapping.

BACKGROUND: Perineural scarring of the ulnar nerve is a predominant cause of symptom recurrence after surgical treatment for primary cubital tunnel syndrome (CuTS). We report our preliminary experience in revision ulnar nerve decompression and nerve wrapping with an amniotic membrane allograft adhesion barrier for treatment of recurrent CuTS. METHODS: We performed a retrospective review with prospective follow-up of patients with recurrent CuTS who were treated with revision neurolysis with amniotic membrane nerve wrapping. Preoperative elbow motion, grip and pinch strengths, pain level on the visual analog scale level, and the 11-item version of the Disabilities of the Arm, Shoulder and Hand functional outcome score were compared with postoperative values using paired t testing. Symptom characteristics, physical examination findings, complications, and level of satisfaction were also obtained. RESULTS: Eight patients (mean age, 47.5 years) who had undergone at least 2 prior ulnar nerve operations satisfied study inclusion. At mean postoperative follow-up of 30 months, significant improvements were noted across all patients in visual analog scale pain levels (-3.5 vs. preoperatively; P < .0001), 11-item version of the Disabilities of the Arm, Shoulder and Hand scores (-30 vs. preoperatively; P < .0001), and grip strength (+25 pounds vs. preoperatively; P < .0001). Pinch strength and elbow motion were also significantly improved for those patients with comparative preoperative data available. All patients expressed subjective satisfaction with their results. No adverse reactions or complications occurred in any patients. CONCLUSIONS: Ulnar nerve wrapping with amniotic membrane allograft, when combined with revision neurolysis, was a safe and subjectively effective treatment for patients with debilitating recurrent CuTS.

Accuracy of measurement of hand compartment pressures: a cadaveric study.

PURPOSE: To determine the accuracy of digital palpation for clinical assessment of elevated intracompartmental pressure compared with needle manometry in a simulated compartment syndrome of the hand. METHODS: Three cadaveric hands were configured with interstitial fluid infusion and an arterial line pressure monitor to create and continuously measure intracompartmental pressure in the thenar and hypothenar compartments. Seventeen assessors clinically judged the presence or absence of compartment syndrome based on digital palpation for firmness and then measured pressures with a handheld manometer. An intracompartmental pressure threshold of 30 mm Hg or greater was used to diagnose compartment syndrome. RESULTS: The sensitivity and specificity of digital palpation of the thenar eminence were 49% and 79%, respectively, with a positive predictive value (PPV) of 86% and negative predictive value (NPV) of 37%. Using the handheld manometer, the sensitivity and specificity increased to 97% and 86% with a PPV of 95% and NPV of 92%. The sensitivity and specificity of digital palpation of the hypothenar eminence were 62% and 83%, respectively, with improvement of 100% and 100%, respectively, with a handheld manometer. For the hypothenar compartment, use of a handheld manometer improved the PPV from 92% to 100% and the NPV from 40% to 100% compared with digital palpation. CONCLUSIONS: Digital palpation alone was insufficient to detect elevated compartment pressures in hands at risk for compartment syndrome. Handheld invasive pressure measurement was a useful adjunct for detecting elevated interstitial tissue pressures and may aid in diagnosing compartment syndrome. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Does the ulnar nerve enlarge after surgical transposition?

OBJECTIVES: The purpose of this study was to test the hypothesis that symptomatic transposed ulnar nerves have a larger average cross-sectional area (CSA) than symptomatic in situ ulnar nerves. METHODS: We conducted a retrospective review of the charts and sonograms of 68 patients who had failed ulnar nerve transposition compared to 48 patients with cubital tunnel syndrome who had not undergone surgical management. In addition, postoperative sonograms were compared with preoperative studies when available. Failure was defined as persistence or recurrence of symptoms of ulnar neuropathy postoperatively. The cross-sectional area of the nerve, subjective echogenicity, and residual sites of compression were recorded. Groups were subsequently compared by t tests. RESULTS: The failed ulnar nerve transposition group showed a mean cross-sectional area ± SD of 17.26 ± 9.93 mm(2), whereas the control group showed a mean cross-sectional area of 13.45 ± 7.33 mm(2). This difference was statistically significant (P= .018). Nontransposed nerves were more likely to have identifiable sites of compression (P< .05). There was a trend toward postoperative enlargement in the 6 patients with available preoperative imaging (P = .17). No difference in subjective echogenicity was found in this analysis. CONCLUSIONS: Patients with failed ulnar nerve transposition show a significantly enlarged cross-sectional area when compared to symptomatic nerves in situ. Although a specific etiology for this difference cannot be determined, the data suggest that the reference ranges for the cross-sectional area of the ulnar nerve may need to be revised for those who have undergone surgery.

Radiation exposure to hand surgeons' hands: a practical comparison of large and mini C-arm fluoroscopy.

PURPOSE: To determine and compare the radiation exposure to surgeons' hands with large and mini C-arm fluoroscopy in a practical, clinically based model. METHODS: Two hand surgeons monitored radiation exposure to their hands with a ring dosimeter over a 14-month period using large and mini C-arm fluoroscopic units. One surgeon performed all cases with a large C-arm unit in a hospital setting, and the other performed all cases with mini C-arms in surgical centers. For each case, fluoroscopic time, the output displayed by the unit, radiation by time, and ring dosimeter absorption were recorded and analyzed. RESULTS: A total of 160 consecutive cases were reviewed with 71 cases and 89 cases in the large and mini C-arm groups, respectively. The median output displayed by the large C-arm was 0.7 mGy/case, and the median output displayed by the mini C-arm was 10.0 mGy/case. With output as a product of time, the median calculated values were 0.02 mGy/s for the large C-arm group and 0.28 mGy/s for the mini C-arm group. Cumulative ring dosimeter absorption to the surgeons' hands was found to be 380 mrem for 71 cases in the large C-arm group versus 1,000 mrem for 89 cases in the mini C-arm group. CONCLUSIONS: In our model, the use of the mini C-arm resulted in more than a 10-fold increase in the rate of output and approximately double the dosimeter absorption to the surgeon's hand compared with the large C-arm. Although it has been shown that the mini C-arm produces less radiation scatter, in a practical model, it may not be a safer alternative with respect to the surgeon's hands. Based on these findings, we recommend that surgeons be more aware of radiation exposure risk, know their C-arm unit's specifications, and try to minimize radiation exposure. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Nitinol Compression Staple Versus Headless Compression Screw Fixation for Scaphoid Waist Fractures.

Background: There are a variety of ways to surgically manage patients with scaphoid waist fractures. The purpose of this study is to compare the rate of union achieved with a nitinol compression staple versus that of a headless compression screw in the treatment of scaphoid waist fractures. Methods: We performed a retrospective review of patients with middle-third scaphoid fractures treated surgically. Patients were stratified into 2 groups based on fixation device: a nitinol compression staple or headless compression screw (HCS). Primary outcome was radiographic union. Secondary outcomes included time from surgery to union, development of avascular necrosis (AVN), complication rate, and need for revision. Results: Forty-one patients were included in the final analysis. The median follow-up time was 5.7 months. Twenty patients were treated with staples, 21 with HCS. Thirty-seven patients achieved union. All who failed to unite were treated with HCS. Eight patients had postoperative complications, including postoperative AVN, all of whom were in the HCS cohort. This treatment group had a higher rate of revision surgery as well. Staples required less time to achieve union and fewer weeks of immobilization. Postoperative scapholunate angles were similar between the groups. Conclusions: Fixation of scaphoid waist fracture with nitinol compression staples is at least as likely to achieve union as fixation with HCS in patients without prior surgical intervention. This treatment also demonstrated equivalent or better secondary outcomes, including postoperative AVN, complication and revision rates, time to union, and weeks immobilized.

Scaphoid Fractures Requiring Bone Graft: Does Graft Source Matter?

Background: Treatment of scaphoid fractures often requires bone grafting. In such cases, bone graft is traditionally harvested from the iliac crest, but utilizing the distal radius carries less morbidity and is becoming more popular. The purpose of this study is to compare the outcomes of treatment of scaphoid waist fractures with the use of distal radius and iliac crest bone grafts. Methods: A retrospective chart review of patients undergoing repair of a scaphoid waist fracture with bone graft at our institution between 2010 and 2020 was completed. Bone graft was used in patients with nonunion, humpback deformity, or for correction of scaphoid alignment. The primary outcome was rate of union as determined by postoperative X-ray or computed tomography scan. Fisher exact tests, Student t tests, and Mann-Whitney U tests were used as appropriate. Results: Thirty-nine patients were included in the study. Twenty-nine patients were treated with distal radius bone graft, and 10 were treated with an iliac crest graft. There was no statistical difference in union rate between the distal radius and iliac crest cohorts (97% vs 80%, P = .16). There was no significant difference for complication rates, rate of unplanned secondary surgery, time to union, postoperative scapholunate angle, or duration of immobilization. Conclusions: In the fixation of scaphoid waist fractures with bone graft, there is no significant difference in union rate between distal radius and iliac crest grafts. With the well-documented morbidity associated with iliac crest grafts, surgeons should consider using distal radius grafts instead of iliac crest grafts.

Hospital teaching status is an independent predictor of surgical intervention of distal radius fractures.

Background: Distal radius fractures are among the most common orthopaedic injuries and are managed both surgically and non-surgically. To date, no study has examined the role hospital teaching status plays in the rates of surgical intervention. Methods: The Nationwide Inpatient Sample (NIS) was queried for years 2003-2014. Patients with a distal radius fracture were identified using International Classification for Disease, Ninth Revision (ICD-9) disease codes. Surgical intervention was determined using ICD-9 procedure codes. Exclusion criteria were patients younger than age 18, polytrauma, open fractures, records with missing data, and records where the primary procedure was something other than open reduction of a radius or ulna fracture, closed reduction of a radius or ulna fracture, or blank. Chi-squared tests were run for demographic and socioeconomic data to identify significant variables. Significant variables were then included alongside hospital teaching status in a binomial logistic regression model. Significance was defined as P < 0.05. Results: A weighted total of 98,831 patients were included in the study. Of those, 45,234 (45.8 %) were treated at teaching hospitals. Patients in teaching hospitals were more likely to be younger, male, non-white, and non-Medicare insured than non-teaching hospitals. Injuries were treated surgically in 64.6 % of total cases. Surgical intervention was more common in teaching hospitals than non-teaching hospitals (69.1 % vs. 60.8 %, P < 0.01). After controlling for demographic and socioeconomic factors, patients at teaching hospitals were 31 % more likely to undergo surgical treatment than those at non-teaching hospitals. Other factors that were independently predictive of surgical treatment were age, race, and insurance type. Conclusion: In the setting of distal radius fractures, teaching hospitals have higher rates of surgical intervention than non-teaching hospitals. These results suggest that the involvement of medical trainees may play a role in the surgical decision-making process.

"Top 20" residency-trained academic orthopaedic surgeons have higher academic productivity and funding in their careers.

"Top 20" status on Doximity, an online networking service for medical professionals, is an indicator of the reputation of a residency program. The study assesses how training at a Top 20 (T20) orthopaedic residency program impacts career productivity and funding. Fellowship and Residency Electronic Interactive Database was used in 2022 to identify active orthopaedic residency programs. Demographic and training data was collected for each orthopaedic surgeon using institutional websites and Doximity. The Residency Navigator feature on Doximity was used to rank residency programs by "reputation." Programs were categorized as either T20 or non-T20. The relative citation ratio (RCR) was calculated using the NIH iCite tool and Hirsch index (h-index) was calculated using Scopus. Industry funding was collected from the Centers for Medicare & Medicaid Services Open Payments Program (CMS) for all available years (2014-2020). A total of 2812 academic orthopaedic surgeons were included in the study. Among academic orthopaedic surgeons in the United States, T20 trained orthopedists had more publications and citations (p < 0.001), along with higher h-indices (p < 0.001), RCR (p < 0.001), and industry funding (p = 0.043). Additionally, T20 trained orthopedists were 1.375 times more likely to obtain professor status (95% confidence interval: 1.150-1.645, p < 0.001). Even after propensity-matched analysis, T20 trained orthopedists maintained these differences. Training at a T20 residency program is associated with promotion, productivity, and funding. These findings are especially of concern to medical students who must consider the importance of a residency program's reputation when deciding where to apply for residency.

Which Pre-Operative, Modifiable Risk Factors are Most Predictive of Complications in orthopedic Upper Extremity Surgery?

Objectives: Identification of modifiable comorbid conditions in the preoperative period is important in optimizing outcomes. We evaluate the association between such risk factors and postoperative outcomes after upper extremity surgery using a national database. Methods: The National Surgical Quality Improvement Program (NSQIP) 2006-2016 database was used to identify patients undergoing an upper extremity principle surgical procedure using CPT codes. Modifiable risk factors were defined as smoking status, use of alcohol, obesity, recent loss of >10% body weight, malnutrition, and anemia. Outcomes included discharge destination, major complications, bleeding complications, unplanned re-operation, sepsis, and prolonged length of stay. Chi square and multivariable logistic regressions were used to identify significant predictors of outcomes. Significance was defined as P<0.01. Results: After applying exclusion criteria, 53,780 patients were included in the final analysis. Preoperative malnutrition was significantly associated with non-routine discharge (OR=4.75), major complications (OR=7.27), bleeding complications (OR=7.43), unplanned re-operation (OR=2.44), sepsis (OR=10.22), and prolonged length of stay (OR=5.27). Anemia was associated with non-routine discharge (OR=2.67), bleeding complications (OR=13.27), and prolonged length of stay (OR=3.26). In patients who had a weight loss of greater than 10%, there was an increase of non-routine discharge (OR=2.77), major complications (OR=2.93), and sepsis (OR=3.7). Smoking, alcohol use, and obesity were not associated with these complications. Conclusion: Behavioral risk factors (smoking, alcohol use, and obesity) were not associated with increased complication rates. Malnutrition, weight loss, and anemia were associated with an increase in postoperative complication rates in patients undergoing upper limb orthopaedic procedures and should be addressed prior to surgery, suggesting nutrition labs should be part of the initial blood work.

Nail Bed Injury Repair: Nail Plate Replacement Versus Non-replacement.

Background: Although nail bed injuries are common, there is no consensus on the proper course of treatment in regard to nail plate replacement. Nail plate replacement risks infection and injury of the germinal matrix. It is our hypothesis that functional and cosmetic outcomes of the nail will not differ by nail plate replacement following nail bed repair. Methods: This is a single institution, prospective, randomized control study comparing nail plate replacement versus non-replacement in patients undergoing nail bed repair. Primary outcome included nail growth and cosmesis using the Zook classification system. Secondary outcomes were pain, functional limitation, and patient satisfaction. Statistical significance was set at P < .05. Results: Fifty patients were enrolled, 26 (52%) randomized to the non-replacement group and 24 (48%) to the replacement group. All patients who followed up had nail growth by 4 months after nail bed repair (N = 28). In the non-replacement group 4 patients continued to have pain in the affected nail bed compared with 2 patients in the replacement group (P = .66). One patient in each group reported continued functional limitation related to nail pain (P = 1.00). Patient satisfaction was not statistically different between the groups (P = 1.00). As a result of patient follow- up, we have been able to score 17 patients via the Zook criteria. In the non-replacement group, 3 nails were scored as excellent, 3 very good, 3 good, 1 fair, and 2 poor. In the replacement group, the nail was classified as excellent in 4 patients and very good in 1 patient. There was no difference in the likelihood of these outcomes with regard to treatment group (P = .18). There was moderate agreement between patient satisfaction and the Zook criteria scoring (κ = .45, 95% CI: -0.15-1.00). Conclusions: Statistical and clinical differences were not identified in regard to cosmesis, pain, functional use of the hand, or patient satisfaction. There are established risks involved in nail plate replacement such as infection and injury to the germinal matrix. If outcomes are not different based on nail plate replacement following nail bed repair, non- replacement may be the preferable treatment option so as to avoid these complications.

The Experience of the Virtual Interview Process for Hand Fellowship Program Directors.

Purpose: Due to the Coronavirus Disease-19 pandemic, the fellowship application process has transitioned from in-person interviews to virtual interviews. Although several studies have assessed the impact of Coronavirus Disease-19 on residency and fellowship interviews, fewer studies have investigated the program director's perspective. Therefore, the aim of this study was to assess the experience of virtual interviews on hand fellowship program directors and understand some of the important factors that may make an applicant more competitive. Methods: A 21-question survey was conducted through Google Forms and distributed through a standardized email to hand fellowship program directors and coordinators. Questions used a 5-point Likert scale with the opportunity for respondents to answer some questions in a free-response format. Statistical analysis was conducted with significance assigned to P values < .05. Results: Ninety-three surveys were distributed, of which 35 responses were obtained, corresponding to a 37.6% survey response rate. Program directors reported that they tended to place more emphasis on applicant's curriculum vitae, calls from colleagues, and applicants that they had previously met. In addition, program directors felt that applicants were able to accurately represent themselves through the virtual format. Finally, most program directors stated that they were highly likely to continue to offer virtual interviews. Conclusions: With several parenting organizations and program directors affirming that they are comfortable with proceeding with virtual interviews, it is essential for hand fellowship applicants to understand what factors program directors may perceive as more important. It is possible that the virtual interview process may effectively achieve suitable matches between applicants and institutions. Type of study/level of evidence: Decision analysis IIIb.

Retainment of U.S. Orthopaedic Surgeons in Academia from 2016 to 2022.

Background: Academic medical centers greatly benefit from retaining their physicians; that ensures continuity in patient care, enhances resident education, and maintains a pool of experienced clinicians and researchers. Despite its importance, little research has been published on the retainment of academic faculty in orthopaedics. To address this gap, this study investigates the demographic trends of academic orthopaedic surgeons from 2016 to 2022. By analyzing data pertaining to gender distribution, years of practice, research productivity, and institutional rankings, we aimed to gain insights into the factors influencing faculty retainment, institution changes, and new entrants into academic orthopaedics. Methods: A retrospective cross-sectional analysis of U.S. academic orthopaedic surgeons affiliated with programs under the Accreditation Council for Graduate Medical Education (ACGME) in 2016 and 2022 was performed. Faculty present in both the 2016 and the 2022 data were classified as being "retained" in academia; those present only in 2016, as having "left" academia; and those present only in 2022, as being "new" to academia. The retained group was then divided into movers (those who moved to other institutions) and non-movers. Results: Retained orthopaedists had fewer years of practice, a higher h-index (Hirsch index), and more publications. Non-fellowship-trained orthopaedists had less retainment in academia, and orthopaedists with fellowships in oncology had more retainment in academia. Additionally, movers also had fewer years in practice but an equal level of scholarly productivity when compared with non-movers. Lastly, higher-ranked academic programs retained a greater proportion of orthopaedic surgeons. Conclusions: Over the study period, a majority of orthopaedists (56.99%) chose to remain in academia. Those retained tended to be in the earlier stages of their careers, yet demonstrated higher research output. Notably, the representation of female orthopaedists in academic orthopaedics is on the rise. Conversely, lower-ranked programs faced higher turnover rates, highlighting the challenges that they encounter in retaining faculty members. Clinical Relevance: Academic medical centers benefit from retaining orthopaedic surgeons by maintaining patient relationships, having consistency in resident education, and building on clinical and research expertise. Likewise, orthopaedists benefit from understanding the trends in current academic employment, in order to optimize career planning decisions.