Postoperative Elbow Instability: Options for Revision Stabilization.

Persistent and recurrent postoperative elbow instability includes a spectrum of pathologies ranging from joint incongruity and subluxation to dislocation. Restoration of osseous anatomy, particularly the coronoid, is a priority in restoring elbow alignment and maintaining ulnohumeral joint stability. After managing bony deficiencies, soft-tissue and ligamentous structures are typically addressed. When required, both static and dynamic adjunctive stabilization procedures have been described, which aid in maintaining a concentric reduction. In these complex procedures, both complication avoidance and early recognition of postoperative complications assist in obtaining a good result. In this review, we discuss current treatment options for revision stabilization for patients with persistent and recurrent elbow subluxation or dislocation after primary stabilization.

Impact of Bracing and Therapy Services on Perioperative Costs for Patients Undergoing Distal Biceps Tendon Repair.

PURPOSE: This study aimed to quantify and assess perioperative costs in an integrated healthcare system for patients undergoing distal biceps tendon (DBT) repair with and without the use of postoperative bracing and formal physical (PT) or occupational (OT) therapy services. In addition, we aimed to define clinical outcomes after DBT repair using a brace-free, therapy-free protocol. METHODS: We retrospectively reviewed all cases of DBT repairs within our integrated system from 2015 to 2021. We performed a retrospective review of a series of DBT repairs utilizing the brace-free, therapy-free protocol. For patients with our integrated insurance plan, a cost analysis was conducted. Claims were subdivided to assess total charges, costs to the insurer, and patient costs. Three groups were created for comparisons of total costs: (1) patients who had both postoperative bracing and PT/OT, (2) patients who had either postoperative bracing or PT/OT, and (3) patients who had neither postoperative bracing nor PT/OT. RESULTS: A total of 36 patients had our institutional insurance plan and were included in the cost analysis. For patients using both bracing and PT/OT, these services contributed 12% and 8% of the total perioperative costs, respectively. Implant costs accounted for 28% of the overall cost. Forty-four patients were included in the retrospective review with a mean follow-up of 17 months. The overall QuickDASH was 12; two cases resulted in unresolved neuropraxia, and there were no cases of re-rupture, infection, or reoperation. CONCLUSIONS: Within an integrated healthcare system, postoperative bracing and PT/OT services increase the cost of care for DBT repair and account for 20% of the total perioperative charges in cases where bracing and therapy are used. Considering the results of prior investigations indicating that formal PT/OT and bracing offer no clinical advantages over immediate range of motion (ROM) and self-directed rehabilitation, upper-extremity surgeons should forego routine brace and PT/OT utilization after DBT repair. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Lateral Ulnar Collateral Ligament Repair With Suture-Tape Augmentation for Traumatic Elbow Instability.

PURPOSE: Ligament repair with suture-tape augmentation has been used in the operative treatment of joint instability and may have advantages with respect to early motion and stability. The purpose of this investigation was to describe the clinical results of traumatic elbow instability treated with lateral ulnar collateral ligament repair with suture-tape augmentation. METHODS: All cases of acute and chronic elbow instability treated surgically between 2018 and 2020 were included if they underwent ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament as part of the procedure. Cases with <6 months of follow-up were excluded. A manual chart review was performed to record patient demographics as well as injury and surgery characteristics. Radiographic outcomes, range of motion, and patient-reported outcome measures, including the visual analog pain scale and Disabilities of the Arm, Shoulder, and Hand, were recorded. Range of motion measurements were recorded at the end of the clinical follow-up, as were surgical complications. RESULTS: Eighteen cases were included with a mean follow-up of 20 months. Five (28%) cases involved a high-energy mechanism, and 11 (62%) cases involved terrible triad fracture dislocations. The mean Disabilities of the Arm, Shoulder, and Hand questionnaire and visual analog pain scale scores were 17 and 2, respectively. The mean flexion-extension arc was 124°, and 2 (11%) cases had <100° flexion-extension arc. There were 2 (11%) postoperative complications, and both cases had postoperative instability requiring reoperation. We observed no cases of capitellar erosion from the suture-tape material. CONCLUSIONS: For complex elbow instability, ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament results in acceptable functional outcomes and a reoperation rate comparable with other joint stabilization procedures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The Impact of Smoking on Delayed Osseous Union After Arthrodesis Procedures in the Hand and Wrist.

PURPOSE: The purpose of this study was to evaluate the relationship between smoking and delayed radiographic union after hand and wrist arthrodesis procedures. We hypothesized that smoking would be associated with a higher rate of delayed union. METHODS: All cases of hand or wrist arthrodesis procedures in patients aged ≥18 years from 2006 to 2020 were identified. Cases were included if they had >90 days of radiographic follow-up or evidence of union before 90 days. Baseline demographics were recorded for each case including smoking status at the time of surgery. Complications were recorded and all postoperative radiographs were reviewed to assess for evidence of delayed union (defined as lack of osseous union by 90 days after surgery). We compared active smokers and nonsmokers and performed a logistic regression analysis to estimate the odds of experiencing a delayed radiographic union. RESULTS: A total of 309 arthrodesis cases were included and 24% were active smokers. Overall, radiographic evidence of a delayed union was found in 17% of cases. Smokers were significantly more likely to have a delayed union compared with nonsmokers (27% vs 14%). Results of the adjusted logistic regression analysis demonstrated that there was a significantly increased odds of experiencing a delayed union for patients who were active smokers compared with nonsmokers (odds ratio, 2.20; 95% confidence interval, 1.09-4.43). In addition, the rate of symptomatic nonunion requiring reoperation was higher in smokers (15%) compared with nonsmokers (6%). CONCLUSIONS: Smoking was associated with increased odds of delayed radiographic union in patients undergoing hand and wrist arthrodesis procedures. Patients should be counseled appropriately on the risks of smoking on bone healing and encouraged to abstain from nicotine use in the perioperative period. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

The Effect of an Intraoperative Real-Time Counter on Radiation Exposure Events During Operative Treatment of Distal Radius Fractures.

PURPOSE: Occupational radiation exposure can have adverse health consequences for surgeons. The purpose of this study was to determine if utilization of an intraoperative, real-time radiograph counter results in decreased radiation exposure events (REEs) during open reduction and internal fixation (ORIF) of distal radius fractures (DRFs). METHODS: We reviewed all cases of isolated ORIF DRFs performed at a single center from January 2021 to February 2023. All cases performed on or after January 1, 2022 used an intraoperative radiograph counter, referred to as a "shot-clock" (SC) group. Cases prior to this date were performed without a SC and served as a control group (NoSC group). Baseline demographics, fracture, and surgical characteristics were recorded. Final intraoperative radiographs were reviewed to record reduction parameters (radial inclination, volar tilt, and ulnar variance). REEs, fluoroscopy exposure times, and total radiation doses milligray (mGy) were compared between groups. RESULTS: A total of 160 ORIF DRF cases were included in the NoSC group, and 135 were included in the SC group. The NoSC group had significantly more extra-articular fractures compared with the SC group. Reduction parameters after ORIF were similar between groups. The mean number of REEs decreased by 48% in the SC group. Cases performed with the SC group had significantly lower total radiation doses (0.8 vs 0.5 mGy) and radiation exposure times (41.9 vs 24.2 seconds). Mean operative times also decreased for the SC group (70 minutes) compared with that for the NoSC group (81 minutes). CONCLUSIONS: A real-time intraoperative radiograph counter was associated with decreased REEs, exposure times, and total radiation doses during ORIF DRFs. Cases performed with a SC had significantly shorter operative times without compromising reduction quality. Using an intraoperative SC counter during cases requiring fluoroscopy may aid in decreasing radiation exposure, which serves as an occupational hazard for hand and upper-extremity surgeons. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Evaluation of a Comprehensive Telemedicine Pathway for Carpal Tunnel Syndrome: A Comparison of Virtual and In-Person Assessments.

PURPOSE: We evaluated a comprehensive telemedicine pathway for carpal tunnel syndrome (CTS). Our primary aim was to compare telemedicine and in-person administration of the six item CTS-6 instrument (CTS-6) in patients undergoing carpal tunnel release (CTR) and to determine whether surgical plans determined via telemedicine were altered by in-person assessments. We additionally aimed to assess agreement between telemedicine and in-person examinations. METHODS: In this prospective investigation, patients referred to a hand surgeon for evaluation of CTS were offered a telemedicine pathway. A modified, virtual CTS-6 was administered during the telemedicine consultation and a virtual exam was performed. Patients indicated for CTR were evaluated in person on the day of surgery. Agreement between the telemedicine and in-person CTS-6 and exam findings was determined. Patients were evaluated via telemedicine postoperatively to determine satisfaction with the program and assess surgical complications. RESULTS: A total of 32 cases were included. The mean CTS-6 score administered via telemedicine was 17.7, compared with 16.8 in person; this difference was not statistically significant. There were no cases indicated for CTR during the telemedicine visit that had a subsequent change in management based on the in-person evaluation. Agreement was lowest for the sensory assessment (63%). The Phalen and Durkan compression tests demonstrated high levels of agreement (97% and 94%, respectively). Satisfaction was high for patients in the telemedicine CTS pathway. CONCLUSIONS: Overall agreement between telemedicine and in-person administration of the CTS-6 is high for patients with CTS. In patients indicated for CTR via telemedicine, an in-person examination does not appear to alter management. The telemedicine examination of hand sensation demonstrates lower levels of agreement with the in-person assessment. Telemedicine can serve as an alternative to conventional, in-person clinic visits for the diagnosis and postoperative management of uncomplicated, primary CTS. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

The Impact of Cement Mantle Characteristics on Early Loosening in Primary Total Elbow Arthroplasty.

PURPOSE: To assess the association between cement mantle characteristics and early radiographic loosening in total elbow arthroplasty (TEA). We aimed to determine whether shorter mantle heights (<20 mm) were associated with loosening. METHODS: We reviewed primary TEAs from a single healthcare system from 2006 to 2020. TEAs complicated by infection or performed for oncologic conditions were excluded. Initial postoperative radiographs were reviewed to determine cement mantle and component characteristics (mantle quality, mantle height, and component angulation). One-year postoperative radiographs were reviewed to assess for implant loosening, and we compared demographics and radiographic criteria for cases with and without early loosening. We noted whether cases underwent subsequent revision for aseptic osteolysis. RESULTS: A total of 54 TEA cases were included. Forty percent of ulnar and 24% of humeral mantles were classified as short (between 1 and 19 mm). According to the Morrey classification, 6 (11%) cases had an inadequate cement mantle Twenty-four (45%) cases had radiographic evidence of loosening at 1 year. Of the cases with early loosening, 6 (25%) had initial inadequate mantle quality. There were no inadequate mantles in the group without loosening. There were no statistically significant differences in mantle heights for cases with and without loosening at 1 year after surgery. Eight (33%) cases underwent revision in the group with early loosening compared with 1 (3%) case without early loosening. CONCLUSIONS: Inadequate cement mantle quality was associated with an increased risk of early aseptic loosening after primary TEA. Cement mantles that extended past the tip of the prosthesis were not associated with loosening. Considering the potential need for future revision and morbidity of cement removal, surgeons should focus on mantle quality and carefully plan mantle height because shorter heights may not be associated with early implant failure. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Telemedicine in Hand and Upper-Extremity Surgery.

Smartphones, computers, and Internet access continue to become more available to both patients and physicians. As these technologies develop with respect to health care, opportunities for telemedicine visits continue to emerge. The purpose of this review article was to analyze the current use and potential applications of telemedicine in hand and upper-extremity surgery. Although the literature pertaining to the use of telemedicine in hand surgery is limited, videoconferencing visits may provide benefits to patients. Particularly in rural and underserved regions, patients can decrease considerable travel burdens. Potential applications for this technology include remote inpatient and emergency room consultations, outpatient clinic visits, and postoperative care. There are unique considerations with respect to confidentiality and security. As with any new technology, it is important to analyze safety concerns. Future randomized, prospective investigations are necessary to define the economic implications of telemedicine programs more clearly within hand and upper-extremity surgery.

Orthopaedic Research Consortiums: A Review of Scope, Sex and Racial Representation.

Introduction The creation of research groups and consortiums has become more common in all medical and surgical specialities. The purpose of this investigation was to assess and describe collaborative research groups and consortiums within orthopaedic surgery. In addition, we aimed to define the demographics of the research consortium members with particular attention to female and minority members. Methods  Journals with a musculoskeletal/orthopaedic focus and a few medical journals were selected to identify articles published by research groups and consortiums. Articles published from 2020 to 2022 were manually reviewed. Bibliographic information, author information and level of evidence (LOE) were recorded. For identified consortium members, sex and race were defined in a binary manner. Results A total of 92 research consortiums were identified. A list of members was identified for 77 groups (83.7%), totalling 2,260 researchers. The remaining group members were not able to be identified due to the lack of information in the included publications, research group websites or after communicating with the corresponding author for respective articles. Most researchers were male (n=1,748, 77.3%) and white (n=1,694, 75%). Orthopaedic surgeons comprised 1,613 (71.4%) identified researchers. The most common fellowship training for orthopaedic surgeons was paediatrics (n=370, 16.4%), trauma (n=266, 11.8%) and sports medicine (n=229, 10.1%). The consortiums published 261 articles: women were lead (first) authors in 23% and senior (last) authors in 11.1%. Non-white researchers were lead authors in 24.5% (n=64) and senior authors in 17.2% (n=45). The most common level of evidence was level 3, accounting for 45.6% (n=119) of all publications. Level 1 evidence accounted for 12.6% (n=33) of published articles. Discussion Representation of women in orthopaedic research consortiums exceeds their representation in almost every orthopaedic professional society. There is less publicly available data to compare the involvement of under-represented minorities (URMs) in research consortiums to general practice. Further investigations should analyse possible avenues in which gender and racial disparity could be improved within orthopaedic surgery research.

Foregoing Preoperative Antibiotics in Clean, Implant-Based Hand Surgery Does Not Increase Postoperative Infectious Risks.

Purpose: Although data support foregoing preoperative antibiotics for outpatient, soft-tissue procedures, there is a paucity of evidence regarding antibiotics for implant-based hand procedures. The purpose of this investigation was to assess early postoperative infectious concerns for patients undergoing implant-based hand surgery, regardless of preoperative antibiotic use. Methods: A retrospective cohort analysis was performed consisting of all patients undergoing implant-based hand procedures between January 2015 and October 2021. Primary outcomes included antibiotic prescription or reoperation for infection within 90 days of surgery. Demographics (age, gender, body mass index, diabetes, and smoking status) and hand surgery procedure type were recorded. To account for differences in baseline characteristics between patients who did and did not receive preoperative antibiotics, covariate balancing was performed with subsequent weighted logistic regression models constructed to estimate the effect of no receipt of preoperative antibiotics on the need for postoperative antibiotics. In a separate logistic regression analysis, patients' baseline characteristics were evaluated together as predictors of postoperative antibiotic prescription. Results: One thousand eight hundred sixty-two unique procedures were reviewed with 1,394 meeting criteria. Two hundred thirty-six patients (16.9%) were not prescribed preoperative antibiotics. Overall, 54 (3.87%) and 69 (4.95%) patients received antibiotics within 30 and 90 days of surgery, respectively. One patient (0.07%) underwent reoperation. There were no differences in the rates of 30- and 90-day postoperative antibiotic prescriptions between the two groups. After covariant balancing of risk factors, patients not prescribed preoperative antibiotics did not display significantly higher odds of requiring postoperative antibiotics at 30 or 90 days. Logistic regression models showed male gender, temporary Kirschner wire fixation, and elevated body mass index were associated with increased postoperative antibiotics at 30 and 90 days. Conclusions: For implant-based hand procedures, there was no increased risk in postoperative antibiotic prescription or reoperation for patients who did not receive preoperative antibiotics. Type of study/level of evidence: Therapeutic III.

Comparison of Artificial Intelligence to Resident Performance on Upper-Extremity Orthopaedic In-Training Examination Questions.

Purpose: Currently, there is a paucity of prior investigations and studies examining applications for artificial intelligence (AI) in upper-extremity (UE) surgical education. The purpose of this investigation was to assess the performance of a novel AI tool (ChatGPT) on UE questions on the Orthopaedic In-Training Examination (OITE). We aimed to compare the performance of ChatGPT to the examination performance of hand surgery residents. Methods: We selected questions from the 2020-2022 OITEs that focused on both the hand and UE as well as the shoulder and elbow content domains. These questions were divided into two categories: those with text-only prompts (text-only questions) and those that included supplementary images or videos (media questions). Two authors (B.K.F. and G.S.M.) converted the accompanying media into text-based descriptions. Included questions were inputted into ChatGPT (version 3.5) to generate responses. Each OITE question was entered into ChatGPT three times: (1) open-ended response, which requested a free-text response; (2) multiple-choice responses without asking for justification; and (3) multiple-choice response with justification. We referred to the OITE scoring guide for each year in order to compare the percentage of correct AI responses to correct resident responses. Results: A total of 102 UE OITE questions were included; 59 were text-only questions, and 43 were media-based. ChatGPT correctly answered 46 (45%) of 102 questions using the Multiple Choice No Justification prompt requirement (42% for text-based and 44% for media questions). Compared to ChatGPT, postgraduate year 1 orthopaedic residents achieved an average score of 51% correct. Postgraduate year 5 residents answered 76% of the same questions correctly. Conclusions: ChatGPT answered fewer UE OITE questions correctly compared to hand surgery residents of all training levels. Clinical relevance: Further development of novel AI tools may be necessary if this technology is going to have a role in UE education.

Readability of Online Hand and Upper Extremity Patient Resources.

Background Online patient resources regarding hand and upper extremity topics published by professional societies are written at a level that exceeds that of the average reader. Methodology Online patient resources focused on hand and upper extremity topics published by the American Society for Surgery of the Hand (ASSH), the American Association for Hand Surgery (AAHS), and the American Academy of Orthopaedic Surgeons (AAOS) were reviewed. The reading material from each topic page was analyzed using the Flesch-Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE) formulas. The reading level (FKGL) of each topic page was compared against an eighth-grade reading level, which corresponds to the average US reading level. Results A total of 170 online patient resources were reviewed, including 84 from the ASSH, 74 from the AAOS, and 12 from the AAHS. Overall, the mean FKGL was 9.1, and the mean FRE was 57.3. Overall, 50% of all hand and upper extremity online resources were written at or below an eighth-grade reading level. Pairwise testing revealed topic pages written by the ASSH had lower FKGL compared to those written by the AAHS (p = 0.046). Conclusions Online patient resources focused on hand and upper extremity topics are, on average, written at a level that exceeds the ability of the average reader. Comparisons between organizations showed a statistical, but not clinical, difference in readability measures. An emphasis on improving readability should be maintained as professional organizations continue to develop their online patient resources.

Publicly Disclosed Pricing for Common Upper-Extremity Procedures: An Analysis of Hospital Chargemasters.

BACKGROUND: American hospitals are required to provide price transparency data (known as a chargemaster) for medical services, which is intended to allow consumers to accurately estimate the cost of medical services. Our purpose was to identify hospital compliance in publishing chargemaster documents and to assess the price information published for common upper-extremity services and procedures. METHODS: We performed a cross-sectional analysis of publicly available chargemaster data from 122 hospitals, which included the top-20-ranked Honor Roll hospitals from US News and World Report and 2 top-ranked hospitals from each state. Chargemaster files were accessed for each hospital, and price information was recorded for 10 common upper-extremity procedures including radiographs, injections, and surgeries. Mean procedural prices were compared between academic and nonacademic hospitals. RESULTS: Chargemaster files were able to be accessed for 107 (88%) of 122 institutions. Price estimates for imaging studies were more frequently reported (73%) than those of procedures (23%-41%). With 50 hospitals reporting a price estimate, carpal tunnel injection was the most frequently reported procedure, whereas trigger finger release was the least frequently reported (41% and 23%, respectively). Wide price ranges were noted, with mean charges for a total shoulder arthroplasty listed as US $51 723 (range, US $247-US $364 024). Mean prices between academic and nonacademic hospital systems were similar. CONCLUSIONS: While most (88%) of the included hospitals have been compliant with publishing their price transparency files, price estimates for common upper-extremity procedures and imaging studies are inconsistently reported and, when present, demonstrate high levels of price variability between and within hospital systems.

Warm Saline Irrigation Protocol Decreases Cement Curing Time in Hip Arthroplasty.

Cementation in hip arthroplasty is a common and reliable technique for achieving a stable bone-component interface. However, there are significant costs to the patient, surgeon, and hospital related to the use of cement. It has been previously demonstrated that increasing ambient room temperature and femoral component temperature decreases cement curing time. A protocol utilizing warmed saline irrigation within the surgical field and a warm saline bath for the femoral component was developed. We performed a comparative cohort study to investigate if this protocol reduced time to cement curing in an in vivo setting. Ten patients were enrolled in the experimental group and 11 patients in the control group. Time to cement curing was significantly lower in the experimental group (7.5 minutes vs. 11.1 minutes, p < 0.0001). The use of a simple and inexpensive warmed saline irrigation protocol during cemented hip arthroplasty decreases time to cement curing.

Online Information Related to Symptoms of Carpal Tunnel Syndrome: A Google Search Analysis.

Introduction While Google is frequently used to access internet-based health resources, the quality of online health information remains variable. Our purpose was to assess suggested resources identified through Google search features for common symptoms related to carpal tunnel syndrome (CTS). Methods Two searches were performed. The first, labeled "symptom-related," included the terms "hand numbness," "hand tingling," and "hand falling asleep." The second, labeled "CTS-specific," included "carpal tunnel syndrome," "carpal tunnel surgery," and "carpal tunnel release." A novel feature of Google's search engine is to display similar searches made by other users ("People Also Ask" snippet). For each search, the first 100 results snippets and the associated website links were recorded. A list of unique questions was compiled and classified into 1 of 3 categories using the Rothwell classification: fact, policy, or value. Questions were also classified based on the diagnoses suggested by the query. Website authorship was determined, and the corresponding links were categorized by two independent reviewers. Results The "symptom-related" searches yielded 175 unique questions and 130 unique website links, and the "CTS-specific" searches yielded a total of 243 questions and 179 unique links. For "symptom-related" searches, 65% of questions suggested a diagnosis, with CTS being suggested as a diagnosis for only 3% of questions. In contrast, CTS was suggested by 92% of questions in "CTS-specific" searches. In both searches, nearly 75% of questions were classified as "facts." Commercial websites were the most common in both searches. Conclusion Google searches for common symptoms of median nerve compression rarely yield information related to CTS.

Fifty Most-Cited Research Articles in Elbow Surgery: A Modern Reading List.

Purpose: Bibliometric analysis is a common method for evaluating current trends within a scientific field. The primary aim of this study was to define and analyze the 50 most frequently cited articles in the field of elbow surgery, both of all time and those published during the 21st century. Methods: We searched the Journal Citation Report to identify articles related to elbow surgery within academic journals. Articles were sorted by total citations. The overall top 50 articles and those published since 2000 were identified, and data were collected, including title, journal of publication, publication year, country of publication, citation density, level of evidence, article type, institution, and sex of the lead and senior authors, and inclusion on the reference list for the Orthopaedic In-Training Examination within the last 5 years. Descriptive statistics were reported, and correlation analysis was performed using Spearman test. Results: For the most-cited elbow surgery articles, "fracture" was overall the most reported topic, whereas "lateral epicondylosis" and "fracture" were equal for those published since 2000. The United States was the most represented overall and for articles published since 2000. Women comprised 1/50 (2%) of lead authors overall, increasing to 8/50 (16%) for articles published during the 21st century. Most articles in during both periods contained level IV evidence, with level I evidence appearing infrequently (4%). Six percent of the most-cited articles of all time had appeared on the reference list of the Orthopaedic In-Training Examination within the past 5 years. Conclusions: The top 50 most-cited elbow surgery articles often assess fracture and lateral epicondylosis, most commonly originating from the United States. Level IV retrospective series comprises over half of the articles on this list. Women remain underrepresented as authors. Clinical Relevance: This study provides a modern reading list for upper-extremity surgeons about impactful elbow surgery articles.

Analysis of Terminated Hand and Wrist-Related Clinical Trials.

Purpose: While clinical trials provide high-quality evidence guiding medical decision-making, early trial termination can result in both lost time and resources. Our purpose was to investigate the rate of and reasons for clinical trial termination for hand and wrist-related conditions and identify study characteristics associated with early trial termination. Methods: The ClinicalTrials.gov database was queried for all hand and wrist-related clinical trials. All terminated and completed trials were reviewed, with characteristics and reasons for termination recorded. Study characteristics included type, purpose, intervention assessed, enrollment, group allocation, blinding, trial phase, sponsor type, and geographic region. Chi-square test was used to identify associations between trial characteristics and terminated versus completed status. Results: A total of 793 hand and wrist-related clinical trials were identified, with 77 trials (10%) terminated prior to completion. The most common reason for termination was "recruitment/retention difficulty," reported in 37 (48%) terminated trials. In comparing competed versus terminated trials, primary purpose (nonobservational studies), enrollment (<50 patients), and geographic region (North America) were all significantly more likely to be terminated. Terminated trials were more likely to have an intervention type investigating a specific device or drug. Conclusions: Early trial termination for hand and wrist-related conditions is common (10%), with patient recruitment and retention identified as the leading cause of termination. Trials involving potential commercial incentives (those investigating a device or drug) were associated with an increased rate of trial termination. Clinical relevance: An emphasis on patient enrollment during study design may aid in mitigating the most common cause of early clinical trial termination.

Trends in the Utilization of Computed Tomography in Operative Treatment of Distal Radius Fractures.

Purpose: To identify patient, surgeon, and injury characteristics associated with preoperative computed tomography (CT) scan utilization for operative distal radius fractures (DRF). In addition, we aimed to determine if preoperative CT was associated with treatment methods other than isolated volar-locked plating (VLP). Methods: We retrospectively reviewed all operatively treated adult DRFs within our health care system from 2016 to 2020. Baseline demographics, injury, treatment characteristics, and the fellowship training of the 44 included surgeons were recorded. We compared cases with and without a preoperative CT, and an adjusted logistic regression model was generated to determine the odds of having a preoperative CT. Results: A total of 1,204 operatively treated DRFs performed by 44 surgeons were included. CT utilization increased during the study period. Intra-articular fractures accounted for 76% of cases, and preoperative CT scans were ordered in 243 of 1240 cases (20%). Overall, isolated VLP was used in 83% of cases. Cases with a preoperative CT were more likely to be treated with an alternative method of fixation (such as dorsal plating). The adjusted logistic regression model demonstrated that male sex (OR 1.62; 95% CI: 1.16, 2.26), intra-articular fractures (OR 3.11; 95% CI: 1.87, 5.81), and associated fractures (OR 2.69; 95% CI: 1.82, 3.98) had a significantly increased odds of having a preoperative CT. Fellowship training was not associated with increased CT utilization overall, but hand surgeons were more likely to use a CT in Orthopaedic Trauma Association-C3 fractures. Conclusions: Patient and injury characteristics are associated with CT utilization in operative DRFs. Preoperative CTs are associated with alternative fixation approaches, as cases with a CT were more likely to use fixation methods other than isolated VLP. The costs and benefits of CT scans must be carefully weighed against whether this modality adds value or improves outcomes in treating DRFs. Level of evidence: Prognostic II.

Adherence to Complication Reporting for Randomized Controlled Trials Contained in Clinical Practice Guidelines for the Management of Carpal Tunnel Syndrome.

Purpose: Randomized controlled trials (RCTs) are frequently used in creating recommendations contained within clinical practice guidelines (CPGs). However, investigations outside of hand surgery have reported that RCTs within CPGs infrequently report complications and harms-related data. Our purpose was to assess adherence to complication reporting and harms-related outcomes contained in the Consolidated Standards for Reporting (CONSORT) Extension of Harms and Standards for Reporting of Diagnostic Accuracy Studies (STARD) reporting checklists for RCTs within the American Academy of Orthopaedic Surgery (AAOS) CPGs for carpal tunnel syndrome (CTS). Methods: We identified all RCTs within the AAOS CTS CPGs. All therapeutic RCTs and diagnostic studies were included. We used the CONSORT Harms Checklist criteria to assess adherence to the reporting of adverse events for therapeutic RCTs and the STARD criteria to assess the diagnostic accuracy of the articles. We defined adequate compliance as adherence to ≥50% of the checklist items. Results: We identified 82 therapeutic RCTs and 90 diagnostic accuracy articles within the AAOS CTS CPG. For therapeutic RCTs, we found that the average compliance with the published checklists was 19%. For diagnostic studies, the average compliance with checklists was found to be 55%. Eleven therapeutic RCTs (13%) and 60 diagnostic studies (67%) were determined to have adequate compliance for the CONSORT and STARD checklists, respectively. Conclusions: Randomized controlled trials in the AAOS CPGs for CTS have low compliance with the CONSORT Extension for Harms Checklist. Although the overall adherence to the items published in the STARD statement for diagnostic accuracy evaluation remains higher, future efforts should be made to improve the adherence rates to both checklists. Clinical relevance: Improved standardization of complication reporting may aid in comparing outcomes across multiple clinical investigations of upper-extremity procedures.

Readability of Online Spine Patient Education Resources.

OBJECTIVE: We assessed the readability of spine-related patient education materials on professional society websites to determine whether this had improved since last studied. We also compared the readability of these materials to a more patient-centered source, such as WebMD. METHODS: Patient education pages from the American Association of Neurologic Surgeons (AANS), North American Spine Society (NASS), and spine-related pages from the American Academy of Orthopaedic Surgeons (AAOS), and WebMD were reviewed. Readability was evaluated using the Flesch Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE) formulas. The mean FKGL and FRE scores of the societies were compared using one-way analysis of variance. The rate of a reading level at or below an eighth grade level was compared using the χ2 test. RESULTS: We analyzed a total of 156 sites. The mean FKGL score for the professional society sites was 11.4. The mean FRE score for the professional societies was 45.8, with 14.4% written at or below an eighth grade reading level. We found a significant difference in the FKGL scores and materials at or below the eighth grade level between the AAOS and AANS and AAOS and NASS. The mean FKGL and FRE scores for WebMD were 7.57 and 68.1, respectively, with a significant difference compared with the scores for the AAOS, NASS, and AANS. In addition, 80% of the WebMD materials had been written at or below the eighth grade reading level. A significant difference compared with the AANS and NASS (P < 0.0001) but not for the AAOS (P = 0.059). CONCLUSIONS: The average readability of spine-related topics exceeded the eighth grade reading level. The AAOS resources had better readability compared with the NASS and AANS. We found no improvement in readability since last studied. The readability of professional societies' materials was significantly worse than those from WebMD.