Does Surgery Improve Healing After Isolated Diaphyseal Ulna Fractures?

PURPOSE: Isolated diaphyseal ulna fractures can be treated nonsurgically or with open reduction and internal fixation (ORIF). It is unclear whether ORIF provides quicker and/or more predictable healing. The purpose of this study was to compare the healing characteristics of isolated diaphyseal ulna fractures after surgical and nonsurgical treatment. METHODS: All patients treated for an isolated diaphyseal (distal- or middle-third) ulna fracture between 2010 and 2018, with a minimum of 3 months of follow-up, were identified. Electronic medical records were reviewed to record patient demographics, assess the treatments used, and compare outcomes. We determined healing and nonunion rates, complications, reoperations, and final radiographic fracture alignment. RESULTS: Ninety-five patients were included with a median follow-up of 20 weeks. Of these, 56 patients were treated nonsurgically and 39 patients were treated with ORIF. At the time of the final follow-up, 51 of the 56 (91.1%) nonsurgically treated fractures had healed and 38 of the 39 (97.4%) surgically managed fractures had healed. There were 5 nonunions after nonsurgical treatment (8.9%) and 1 nonunion after ORIF (2.6%). Eleven patients (19.6%) treated nonsurgically required conversion to ORIF, whereas 4 patients (10.3%) treated with ORIF required reoperation. Middle-third fractures treated nonsurgically had a higher rate of nonunion (30.8%) compared with distal-third fractures treated nonsurgically (2.3%). CONCLUSIONS: The healing characteristics of isolated ulnar shaft fractures do not appear to differ substantially between surgical and nonsurgical treatment. However, nearly 20% of the patients treated nonsurgically may require eventual ORIF. Distal-third fractures may be at a higher risk of conversion to ORIF, and middle-third fractures may be at a higher risk of nonunion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Wound Dehiscence Following Cubital Tunnel Surgery.

PURPOSE: Cubital tunnel syndrome is the second most common upper-extremity compressive neuropathy, and persistent symptoms can necessitate operative treatment. Surgical options include simple decompression and ulnar nerve transposition. The cause of wound dehiscence after surgery is not well known, and the factors leading to the development of these complications have not been previously described. METHODS: Patients undergoing ulnar nerve surgery from January 1, 2016, to December 31, 2019, were retrospectively evaluated for the development of wound dehiscence within 3 months of surgery. There were 295 patients identified who underwent transposition and 1,106 patients who underwent simple decompression. Patient demographics and past medical history were collected to evaluate the risk factors for the development of wound dehiscence. RESULTS: The overall rate of wound dehiscence following surgery was 2.5%. In the simple decompression group, the rate of wound dehiscence was 2.7% (30/1,106), which occurred a mean of 21 days (range, 2-57 days) following surgery. In the transposition group, the rate of wound dehiscence was 1.7% (5/295), which occurred a mean of 20 days (range, 12-32 days) following surgery. The difference in rates of dehiscence between the decompression and transposition groups was not significant. Five patients in the simple decompression group and 1 patient in the transposition group required a secondary surgery for closure of the wound. Age, body mass index, smoking status, and medical comorbidities were not found to contribute to the development of wound dehiscence. CONCLUSIONS: Wound dehiscence can occur following both simple decompression and transposition, even after postoperative evaluation demonstrates a healed wound. Surgeons should be aware of this possibility and specifically counsel patients about remaining cautious with, and protective of, their wound for several weeks after surgery. Dehiscence may be related to suboptimal vascularity in the soft tissue envelope in the posteromedial elbow. When it occurs, dehiscence can generally be treated by allowing healing by secondary intention. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A Rare Presentation of Extensor Pollicis Longus Tendon Rupture After Nondisplaced Scaphoid Fracture.

Extensor pollicis longus tendon rupture is a reported complication after nondisplaced distal radius fractures. These are thought to occur secondary to mechanical irritation or compromised blood supply. We present a case of extensor pollicis longus rupture after a healed nondisplaced scaphoid fracture, which may have involved a similar attritional process. We are unaware of any prior reports of extensor pollicis longus rupture after this type of injury.

Surgical Outcomes Following Fixation of Peri-Implant Distal Radius Fractures: A Case Series.

PURPOSE: The purpose of this study was to evaluate surgical outcomes following fixation of peri-implant distal radius fractures. METHODS: A retrospective chart review was conducted of peri-implant distal radius fractures treated surgically at a large academic practice over 18 years. Patients were included if they had previously undergone open reduction and internal fixation of a distal radius fracture; subsequently sustained a fracture at, or adjacent to, the existing hardware; and then undergone revision fixation with the removal of hardware. Fractures were categorized into 3 groups: type A (distal to the implant), type B (at the level of the implant), and type C (proximal to the implant). Outcomes, including range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire scores, and radiographic alignment, were recorded at the latest follow-up visit. RESULTS: Twelve peri-implant distal radius fractures that had undergone revision surgical fixation were identified. At the time of injury, the average patient age was 63 years. Ten occurred around a volar plate, 1 occurred around an intramedullary device, and 1 occurred around a dorsal plate. One fracture occurred proximal to previous hardware (type C), 9 fractures occurred at the level of previous hardware (type B), and 2 fractures occurred distal to previous hardware (type A). The median time from initial fixation to peri-implant fracture was 2.7 years. At a mean follow-up of 6 months after the removal of the hardware and revision fixation, radiographic alignment was within acceptable parameters for all injuries. At the final follow-up, the average wrist motion for flexion, extension, supination, and pronation were 66°, 66°, 83°, and 86°, respectively. The average DASH score was 6.7. Three patients experienced complications. CONCLUSIONS: Although peri-implant fractures are infrequent complications following distal radius fracture internal fixation, outcomes of surgically treated peri-implant distal radius fractures are satisfactory with respect to radiographic alignment, range of motion, and function. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Effectiveness of Corticosteroid Injections in Diabetic Patients With De Quervain Tenosynovitis.

PURPOSE: We sought to determine the effectiveness of corticosteroid injections (CSIs) for de Quervain tenosynovitis in patients with diabetes mellitus. METHODS: We retrospectively identified all patients with diabetes receiving a CSI for de Quervain tenosynovitis by 16 surgeons over a 2-year period. Data collected included demographic information, medical comorbidities, number and timing of CSIs, and first dorsal compartment release. Success was defined as not undergoing an additional CSI or surgical intervention. The mixture of a corticosteroid and local anesthetic provided in each injection was at the discretion of each individual surgeon. RESULTS: Corticosteroid injections were given to 169 wrists in 169 patients with diabetes. Out of 169 patients, 83 (49%) had success following the initial CSI, 44 (66%) following a second CSI, and 6 (67%) following a third CSI. A statistically significant difference was identified in the success rates between the first and second CSIs. Ultimately, 36 of 169 wrists (21%) underwent a first dorsal compartment release. CONCLUSIONS: Patients with diabetes mellitus have a decreased probability of success following a single CSI for de Quervain tenosynovitis in comparison to nondiabetic patients, as described in the literature. However, the effectiveness of each additional CSI does not appear to diminish. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Unplanned Return to the Operating Room in Upper-Extremity Surgery: Incidence and Reason for Return.

PURPOSE: Complications after upper-extremity surgery are generally infrequent. The purpose of this study was to assess the rate of early unplanned return to the operating room (URTO) within 3 months after surgery) in upper-extremity surgical procedures. Our hypotheses were that the rate of URTO in upper-extremity surgery would be low and that surgically treated fractures would be at greatest risk for complications. METHODS: We performed a retrospective review of all upper-extremity surgical procedures performed at a large academic practice of fellowship-trained hand surgeons over a 5-year period. A chart review was conducted of all patients who underwent a second surgery within 3 months of the initial surgery. The surgical billing database was queried to determine the incidence of URTO per Current Procedural Terminology code. RESULTS: There were 422 Current Procedural Terminology codes with URTO out of a total of 62,608, for an incidence of 0.6%. The most frequently performed procedures were carpal tunnel release (10,674; 0.1% URTO), trigger finger release (4,549; 0.5% URTO), and open reduction internal fixation (ORIF) for distal radius fracture (2,728; 1.2% URTO). Procedures with the highest incidences of URTO were open reduction and internal fixation of the ulna (4.9%) and excision of the olecranon bursa (4.1%). Traumatic injuries were more commonly associated with URTO compared with elective procedures. Bony trauma and soft tissue trauma had URTO incidences of 1.4% and 1.1%, respectively, whereas bony elective and soft tissue elective cases were 0.6% and 0.4%, respectively. CONCLUSIONS: The 90-day URTO rate after upper-extremity surgery was low but higher than previously reported 30-day reoperation rates. Elbow procedures were most likely to result in URTO, as were procedures relating to bony and soft tissue trauma. Based on these results, we are able to counsel patients that the most common procedures we perform have low URTO rates, but surgically treated fractures are at greatest risk. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Reliability of Radiographs and Computed Tomography in Diagnosing Scaphoid Union After Internal Fixation.

PURPOSE: To evaluate the reliability of radiographs (XR) alone versus the combination of XR and computed tomography (CT) in determining scaphoid union following open reduction internal fixation (ORIF) with a headless compression screw. METHODS: We used our imaging database to identify 32 XR and corresponding CTs over a 6-year period (from 2012 to 2018) that were performed to evaluate scaphoid healing following ORIF. Three hand surgeons evaluated the studies to assess (1) healing, (2) if partially healed, the percentage of healing, and (3) the certainty of healing. Initially, XR were reviewed alone. Three weeks later, the same XR were reviewed with the corresponding CTs. Each reviewer performed a similar 2-stage evaluation 4 weeks later. We measured interobserver and intraobserver reliabilities using linearly weighted kappa (κ) coefficients for healing status and the percentage of healing. RESULTS: The interobserver reliability for healing (healed vs partially healed vs not healed) was moderate both with XR alone and with the combination of XR and CT. The intraobserver reliability for healing was substantial with XR alone compared to moderate with the combination of XR and CT. For the percentage of healing, both interobserver and intraobserver reliabilities were fair with XR alone or with the combination of XR and CT. Reviewers reported significantly greater certainty with the combination of XR and CT compared with XR alone. CONCLUSIONS: Following ORIF, surgeons are more certain in their evaluation of scaphoid healing with the combination of CT and XR. However, the reliability of assessing scaphoid union may not be improved by the addition of CT to XR. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

Comparison of the Costs of Reusable Versus Disposable Equipment for Endoscopic Carpal Tunnel Release Procedures Using Activity-Based Costing Analysis.

PURPOSE: Guidelines for sterilization of reusable equipment (eg, arthroscopes, surgical equipment) have recently been established. These guidelines are supported by the U.S. Food and Drug Administration and affect costs for sterilization. The current analysis was undertaken to understand if reusable or disposable endoscopic carpal tunnel release (ECTR) equipment is a less-expensive option. METHODS: An activity-based cost analysis was undertaken to determine the costs of reusable versus disposable equipment for ECTR. Costs of disposable equipment were obtained from manufacturers. Costs of processing reusable equipment including labor, time, cost of operating room time, and sterilization supplies and equipment were obtained from the literature and from recent reports identifying these costs. Infection rates and costs of infection were also factored in. Decision analysis software was used to determine the expected costs of each option (disposable vs reusable). A sensitivity analysis was undertaken on those variables that were determined to have the greatest effect on the overall costs of the procedure and sterilization. RESULTS: Costs for each option when totaled were $917 for disposable and $1,019 for reusable equipment, resulting in cost savings of $102 with disposable equipment. Reusable equipment was the least costly option when the following costs/events occurred: cost of a disposable arthroscope, >$452; cost of disposable ECTR, >$647; costs of operating room time, <$28.63/min; set up time, <6.8 minutes for reusable equipment; and cost of disposable ECTR blade used with reusable equipment, <$160. CONCLUSIONS: When considering the cost of operating room time, preparation, and processing of reusable equipment for ECTR, the disposable equipment for this procedure is less costly. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic Analysis II.

Distal Radius Malunion.

Malunion remains the most common complication of nonsurgical treatment of fractures of the distal radius and represents a common clinical entity. Symptomatic treatment often involves corrective osteotomy. Surgical correction is a challenging problem with unpredictable clinical outcomes. Prevention of malunion of a distal radius fracture is the best course of action. With maintenance of volar cortical contact and the use of volar fixed-angle devices, bone grafting may not be necessary in certain cases of malunion correction. New technologies such as 3-dimensional modeling and computer-generated osteotomy guides are likely to have a positive impact on the outcomes of surgical treatment.

The Reliability of Determining the Presence of Surgical Site Infection Based on Retrospective Chart Review.

PURPOSE: Surgical site infection (SSI) can be a challenging complication after hand surgery. Retrospective studies often rely on chart review to determine presence of an SSI. The purpose of this study was to assess reliability of Centers for Disease Control and Prevention (CDC) criteria for determining an SSI as applied to a chart review. We hypothesized that interobserver and intraobserver reliability for determining an SSI using these criteria while reviewing medical record documentation would be none to minimal (κ < 0.39) based on an interpretation of Cohen's κ statistics. METHODS: We created and used a database of 782 patients, 48 of whom received antibiotics within 3 months of a surgical procedure of the hand. Three fellowship-trained orthopedic hand surgeons then evaluated the charts of those 48 patients, in which each reviewer determined whether an SSI was present or absent based on CDC criteria provided to the reviewers. Patients' charts were then reassessed 1 month later by the same reviewers. Kappa statistics were calculated for each round of assessment and averaged to determine intraobserver and interobserver reliability. RESULTS: Overall κ values were 0.22 (standard error, 0.13), indicating fair reliability. Average κ value between reviewers was 0.26 (standard error, 0.13. On average, intrarater reliability was 68.7%. CONCLUSIONS: We found poor interobserver and intraobserver reliability when using CDC criteria to determine whether a patient had an SSI, based on chart review. CLINICAL RELEVANCE: Better criteria or documentation may be needed in patients with an infection after hand surgery. Retrospective chart reviews to assess infection may be unreliable.

Risk of Infection in Trigger Finger Release Surgery Following Corticosteroid Injection.

PURPOSE: To determine the risk for infection in trigger finger release surgery after preoperative corticosteroid injection. METHODS: We retrospectively evaluated all patients undergoing trigger finger release by 16 surgeons over a 2-year period. Data collected included demographic information, medical comorbidities, trigger finger(s) operated on, presence of a prior corticosteroid injection, date of most recent corticosteroid injection, postoperative signs of infection, and need for surgery owing to deep infection. Superficial infection was defined per Centers for Disease Control criteria. Deep infection was defined as the need for surgery related to a surgical site infection. RESULTS: In this cohort of 2,480 fingers in 1,857 patients undergoing trigger release surgery, 53 (2.1%) developed an infection (41 superficial [1.7%] and 12 deep [0.5%]). Before surgery, 1,137 fingers had no corticosteroid injection. These patients developed 1 deep (0.1%) and 17 superficial (1.5%) infections. In contrast, 1,343 fingers had been given a corticosteroid injection before surgery. These patients developed 11 deep (0.8%) and 24 superficial (1.8%) infections. Median time from corticosteroid injection to trigger release surgery was shorter for fingers that developed a deep infection (63 days) compared with those that developed no infection (183 days). The risk for developing a deep infection in patients who were operated on within 90 days of an injection (8 infections in 395 fingers) was increased compared with patients who were operated on greater than 90 days after an injection (3 infections in 948 fingers). CONCLUSIONS: Preoperative corticosteroid injections are associated with a small but statistically significantly increased rate of deep infection after trigger finger release surgery. The risk for postoperative deep infection seems to be time dependent and greater when injections are performed within 90 days of surgery, especially in the 31- to 90-day postinjection period. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The Optimal Position for Arthrodesis of the Proximal Interphalangeal Joints of the Border Digits.

PURPOSE: This study aimed to determine the functional characteristics of various arthrodesis angles of the proximal interphalangeal (PIP) joints of the border fingers. METHODS: The dominant hands of 48 volunteers were tested using custom orthoses to simulate PIP joint arthrodesis. For the index finger (IF), orthoses were made in 25°, 40°, and 55° of flexion (IF25, IF40, and IF55). For the little finger (LF), orthoses were made in 30°, 55°, and 70° of flexion (LF30, LF55, and LF70). Twenty-three volunteers performed grip and pinch (key, tripod, and pulp) strength testing with and without simulated arthrodeses and 25 volunteers performed the Jebsen Hand Function Test (JHFT) with and without simulated arthrodeses. Simulated conditions of arthrodesis were compared with the unrestricted state and with each other within the same finger. RESULTS: For grip and pinch strength, there were no significant differences between simulated arthrodesis angles. Compared with baseline, grip was significantly weaker for all 6 simulated arthrodesis angles. Pinch was tested with simulated IF arthrodesis only; key pinch was significantly weaker for all tested angles and tripod pinch for IF25 and IF40. For JHFT, the 3 experimental angles for the index or ring finger did not show any statistically significant differences for any subtest. Volunteers were slower at completion times for all simulated arthrodesis angles compared to baseline times. This was significant in 5 of 7 tasks for IF25, 3 of 7 tasks for IF40, and 4 of 7 tasks for IF55. Index finger angle of flexion of 40° was significantly faster than IF55 for writing and IF25 for lifting large, light objects. For the LF, LF30 was significantly slower than baseline for 6 of 7 tasks, LF55 for 3 of 7 tasks, and LF70 for 5 of 7 tasks. Index finger angle of flexion of 55° was significantly faster than LF70 for simulated feeding and IF30 for lifting large, heavy objects. CONCLUSIONS: No border digit PIP joint arthrodesis angle was superior for grip and pinch strength. Based on JHFT, IF40 and LF55 might be preferred arthrodesis angles. CLINICAL RELEVANCE: Intermediate arthrodesis angles may provide the best function for patients undergoing PIP joint arthrodesis of the IF and LF.

Preoperative Exposure to Benzodiazepines or Sedative/hypnotics Increases the Risk of Greater Filled Opioid Prescriptions After Surgery.

BACKGROUND: The effect of the preoperative exposure to controlled substances such as benzodiazepines and sedative/hypnotics on prolonged opioid consumption after hand surgery is not known. QUESTIONS/PURPOSES: (1) Is preoperative exposure to benzodiazepines and sedative/hypnotics associated with greater numbers of filled postoperative opioid prescriptions after hand surgery? (2) Is a positive history of the use of more than one controlled substance, a mood disorder, or smoking associated with greater numbers of filled opioid prescriptions after surgery? (3) Is preoperative exposure to opioids associated with greater numbers of filled postoperative opioid prescriptions after hand surgery? METHODS: Patients undergoing upper extremity surgery at one academic outpatient surgical center were prospectively enrolled. The Pennsylvania Drug Monitoring Program (PDMP) website was used to document prescriptions of opioids, benzodiazepines, and sedative/hypnotics filled 6 months before and after the procedure. Patients were grouped into exposed or naïve cohorts depending on whether a prescription was filled 6 months before surgery. Smoking history (current or previous smoking was considered positive) and a history of mood and pain disorders (as noted in the medical history), were collected from the outpatient and the operating room electronic medical record. RESULTS: After controlling for age, gender, and other confounding variables, we found that a history of exposure to benzodiazepines is associated with a greater number of filled postoperative opioid prescriptions (not-exposed, 1.2 ± 1.3; exposed, 2.2 ± 2.5; mean difference, 1.0; 95% confidence interval [CI], 0.5-1.5; p < 0.001); likewise, exposure to sedative/hypnotics is associated with greater opioid prescription fills (not-exposed, 1.2 ± 1.4; exposed, 2.3 ± 2.9; mean difference, 1.1; 95% CI, 0.3-1.9; p = 0.006). Patients who had used more than one controlled substance had more filled opioid prescriptions when compared with those not using more than one controlled substance (3.9 ± 3.5 versus 2.1 ± 1.2; mean difference, 1.8; 95% CI, 0.8-2.8; p = 0.002); patients with mood disorders also had more filled prescriptions when compared with those without mood disorders (2.0 ± 2.5 versus 0.9 ± .8; mean difference, 1.1; 95% CI, 0.7-1.5; p < 0.001); and finally, smoking history is associated with more filled prescriptions (1.9 ± 2.3 versus 1.2 ± 1.5, mean difference, 0.8; 95% CI, 0-1.4; p = 0.040). CONCLUSIONS: Patients exposed to benzodiazepines and sedative/hypnotics have prolonged use of opioids after surgery. Undergoing outpatient upper extremity surgery and being prescribed an opioid did not change the patterns of controlled substance use. Based on the results of this study, we are now more aware of the potential problems of patients with exposure to controlled substances, and are more attentive about reviewing their history of substance use in the PDMP website, an important resource. In addition, we now provide much more detailed preoperative counseling regarding the use and abuse of opioid medication in patients with exposure to benzodiazepines, sedatives, and those with a smoking history and mood disorders.Level of Evidence Level II, therapeutic study.

The Effect of Intraoperative Corticosteroid Injections on the Risk of Surgical Site Infections for Hand Procedures.

PURPOSE: The aim of the study was to assess the risk of surgical site infection (SSI) in patients who received an intraoperative injection (IOI) with a corticosteroid at the same time as hand surgery for a different condition. METHODS: This was a retrospective chart review of all patients who underwent hand surgery and corticosteroid injections concurrently over an 8-year period. Comparison of the rates of SSI was made of patients who had received an IOI and a matched control cohort of patients with no intraoperative injection (nIOI). There were 391 patients in each group. RESULTS: There were 8 SSIs in the IOI group compared with 2 in the nIOI group. One patient in the IOI group had a deep infection whereas all other infections were superficial. In the IOI group, 206 patients had injections on the side ipsilateral to their surgical procedure. Six of these patients had SSIs, a significant difference compared with the control group. There were 185 patients who had contralateral injections. Two of these patients had SSIs. Compared with the control group, this difference was not significant. CONCLUSIONS: Concomitant injection of steroid into the same side as the surgical site increases the risk of postoperative infection. We do not recommend administering a corticosteroid injection at the time of hand surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Delayed, Atraumatic Index Metacarpal Fracture After Trapeziectomy and Suture-Button Suspensionplasty for Thumb Carpometacarpal Osteoarthritis: A Report of Three Cases.

Trapeziectomy with suture-button suspensionplasty is a surgical treatment option for thumb carpometacarpal osteoarthritis refractory to nonsurgical management. We describe the cases of 3 patients who presented with index metacarpal fracture, in the absence of traumatic injury, over 4 months after trapeziectomy with suture-button suspensionplasty. All 3 fractures demonstrated the same pattern: short oblique/spiral, oriented proximal radial to distal ulnar with the distal end in the vicinity of the index metacarpal button, presumably after the orientation of the metacarpal drill hole. Two of the fractures were treated with surgical fixation. Fracture healing was obtained in all cases. Two of the 3 patients remained symptomatic with thumb pain, but decided against revision treatment for the carpometacarpal osteoarthritis. The third underwent restabilization of the suture button at the time of fracture fixation. Although uncommon, index metacarpal fracture after trapeziectomy with suture-button suspensionplasty can present without trauma several months after surgery.

Evaluation of the PROMIS Upper Extremity Computer Adaptive Test Against Validated Patient-Reported Outcomes in Patients With Basilar Thumb Arthritis.

PURPOSE: The Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) computer adaptive test was developed to reduce test burden and improve precision. We hypothesized that, in patients with thumb basilar joint arthritis (BJA), (1) PROMIS UE would correlate with established patient-outcomes (PROs), (2) PROMIS UE would require less time and fewer questions than current metrics, (3) there would be no floor or ceiling effects, and (4) PROMIS UE would not correlate with radiographic disease severity. METHODS: Patients presenting with a primary diagnosis of thumb BJA completed the Quick Disabilities of the Arm Shoulder and Hand (QuickDASH), Thumb Disability Examination (TDX), Patient-Rated Wrist Hand Evaluation (PRWHE), and PROMIS UE. Radiographic disease severity as described by the Eaton scoring system was recorded. The relationships among PROs were described with Spearman correlation coefficients. The presence of a floor or ceiling effect was confirmed if greater than 15% of patients achieved the lowest or the highest possible score, respectively. RESULTS: One hundred patients with thumb BJA formed the sample for this study. A good to excellent correlation was identified between PROMIS UE and QuickDASH. There were good correlations between PROMIS UE and TDX as well as PRWHE. The PROMIS UE was significantly less time consuming (average: 58.5 seconds vs QuickDASH, 92.2; TDX, 62.6; and PRWHE, 144.7), and required fewer questions than current metrics (average: 4.9 questions vs QuickDASH, 11; TDX, 20; and, 15). In addition, there were no appreciable floor or ceiling effects. Radiographic disease severity did not correlate with PROMIS UE. CONCLUSIONS: The PROMIS UE has a good to excellent correlation with QuickDASH and good correlations with PRWHE and TDX. In addition, PROMIS UE required less time and fewer questions than established PROs. There were no floor or ceiling effects. Used as a single PRO, PROMIS UE may be a practical alternative to legacy scales in patients with thumb BJA. CLINICAL RELEVANCE: The PROMIS UE PRO instrument may be a valuable addition in the assessment of patients with basilar thumb arthritis.

A Prospective Evaluation of Early Postoperative Complications After Distal Biceps Tendon Repairs.

PURPOSE: The reported incidence of postoperative complications after distal biceps tendon repairs (DBTRs) has been determined largely by retrospective studies. We hypothesized that a large prospective cohort study of DBTRs would demonstrate increased complication rates relative to existing literature values. Secondarily, we hypothesized that most complications would be transient and self-limiting, regardless of the surgical technique employed for the repair. METHODS: Consecutive patients undergoing acute, primary DBTR from July 2016 to December 2017 were enrolled. The repair technique, postoperative protocol, and follow-up intervals were determined by the individual surgeons' protocols. Demographic information, surgical data, and complications were tabulated prospectively. Exclusion criteria included chronic DBTRs, secondary DBTRs requiring allograft, DBTRs of partial tears, and postoperative follow-up of less than 12 weeks. We included 212 repairs performed by 37 orthopedic surgeons in 3 different subspecialties. RESULTS: Sixty-five patients (30.7%) had 73 complications. Fifty patients (44.6%) in the 1-incision group experienced complications compared with 15 (15.0%) in the 2-incision group. Sixty patients (28.3%) developed a minor complication. Fifty-seven patients (26.9%) had sensory neurapraxias, 47 after a 1-incision procedure and 10 after a 2-incision procedure, a statistically significant difference. Of the patients with neurapraxias, 94.7% were resolved or improving at the time of the latest follow-up. Five patients (2.4%) developed a major complication, defined as a return to the operating room in the postoperative period due to deep infection or rerupture. CONCLUSIONS: The complication rate after DBTR appears to be higher than 2 other retrospective studies and is predominantly in the form of transient neurapraxias. This study confirms that there is a higher complication rate in 1-incision techniques as compared with 2-incision techniques. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Geographic Distribution of Hand Surgeons Throughout the United States.

The purpose of this study was to evaluate the geographic distribution of hand surgeons in the United States. We assessed the states and congressional districts (CDs) for optimal numbers of surgeons, determined whether there is an even distribution, and identified factors influencing practice location. Hand surgeon practice location data from the American Association for Hand Surgery and American Society for Surgery of the Hand (2015) and both state and CD population data from the US Census (2014) were assessed. CDs each contain approximately the same population. Furthermore, select hand surgeons were asked to fill out a survey to identify how 6 factors influence practice location. A total of 2,707 American Association for Hand Surgery active and American Society for Surgery of the Hand active and candidate US members were included. The mean number of hand surgeons per state was 53 (range: 3-298). The most hand surgeons were in California, Texas, New York, and Florida and least were in Wyoming and Alaska. There were 16, 11, and 24 states with suboptimal, optimal, and greater-than-optimal density, respectively. There were 436 CDs. We found 231, 30, and 175 CDs with suboptimal, optimal, and greater-than-optimal density, respectively. There were weak correlations between hand surgeons and CD populations and between CD population densities and CD hand surgeons per capita. Twenty hand surgeons were included in the survey resulting in no difference of any 1 factor compared with the other 5 factors. There was a difference in the factor "population size" between hand surgeons from greater-than-optimal and suboptimal CDs. The findings of our study indicate that hand surgeon proportions do not correlate with population proportions, and distribution is not skewed toward areas of higher population density. Many areas are not optimally served, and hand surgeons may be choosing where to practice based on a combination of factors beyond population need.

An Evaluation of the Reliability of Wrist Arthroscopy in the Assessment of Tears of the Triangular Fibrocartilage Complex.

PURPOSE: Wrist arthroscopy is generally considered the reference standard in the diagnosis of triangular fibrocartilage complex (TFCC) injuries. There is a paucity of data examining the reliability of wrist arthroscopy as a diagnostic modality for TFCC injuries. The goal of this study was to evaluate the interobserver and intraobserver reliability of the diagnosis of TFCC pathology during wrist arthroscopy. METHODS: Twenty-five intraoperative digital videos were captured by the senior author during diagnostic and surgical arthroscopy of the wrist joint for known or suspected articular pathology. The senior author (P.K.B.) confirmed TFCC resilience on visual inspection and ballottement (trampoline effect) to make the diagnosis. Two videos were excluded for poor quality and inadequate visualization. Three hand surgeons subsequently reviewed the remaining 23 videos in a blinded fashion at 2 time points separated by 4 weeks. The reviewers determined if the trampoline test was positive and if a TFCC tear was present. Tears were classified using a morphologic classification. Statistical measures of reliability including percentage agreement and κ coefficients were calculated. RESULTS: Agreement between observers for the presence or absence of a tear was 66.7%. The average intraobserver agreement regarding the presence or absence of a tear was 67.4% The kappa value for interobserver agreement was 0.33, whereas the intrarater agreement was 0.88. The 3 reviewers identified an average of 11.3 positive trampoline tests. Agreement between observers for a positive trampoline test was 65.2%. The average percentage of intraobserver agreement regarding a positive trampoline test was 49.3%. In cases where all 3 reviewers agreed on the presence of a TFCC tear, the agreement regarding tear location was 76.6%. CONCLUSIONS: Wrist arthroscopy remains instrumental in the treatment of TFCC tears. However, given that inter-rater reliability in the assessment of these tears is probably too low, reconsideration should be given to arthroscopy as the reference standard in the diagnosis of these tears. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

The Accuracy of the Scratch Collapse Test Performed by Blinded Examiners on Patients With Suspected Carpal Tunnel Syndrome Assessed by Electrodiagnostic Studies.

PURPOSE: A diagnostic maneuver known as the "scratch-collapse test" (SCT), to aid in the diagnosis of compressive upper limb neuropathies such as carpal tunnel syndrome (CTS), has been described. There is a wide variability in the sensitivity and specificity values reported to date, and the reason for this discrepancy is unclear. The purpose of this study was to evaluate the utility of the SCT performed by examiners blinded to the meaning of the examination. METHODS: Forty consecutive patients referred to a single physiatrist for electrodiagnostic testing for the evaluation of suspected CTS were included in the study. The patients were evaluated by blinded physician examiners with no knowledge of the SCT. The examiners were instructed on the maneuver but were not told the purpose of the test or the significance of a "positive" or "negative" response. Routine electrodiagnostic testing including nerve conduction studies and electromyography were also performed. RESULTS: For the blinded examiners, the SCT had a sensitivity of 0.24, a specificity of 0.6, a positive predictive value of 0.73, a negative predictive value of 0.15, and the accuracy was 31%. The SCT performed by the attending physician demonstrated a sensitivity of 0.28, a specificity of 0.75, a positive predictive value of 0.81, a negative predictive value of 0.2, and the accuracy was 37%. All of the previous values are presented with electrodiagnostic studies as the reference standard for CTS. There was disagreement between the blinded, inexperienced examiners and the attending physician in only 3 of the 40 patients evaluated with the SCT. CONCLUSIONS: The SCT appears to have low sensitivity and specificity values relative to electromyography findings in patients with CTS when performed by examiners blinded to the meaning of the patients' response. Further study of this maneuver is necessary to fully assess its performance. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.