Evaluating Male Patients' Understanding of Osteoporosis Evaluation and Treatment Following a Distal Radius Fracture.

PURPOSE: Current estimates suggest that 1-2 million men in the United States have osteoporosis, yet the majority of osteoporosis literature focuses on postmenopausal women. Our aim was to understand men's awareness and knowledge of osteoporosis and its treatment. METHODS: Semistructured interviews were conducted with 20 male patients >50 years old who sustained a low-energy distal radius fracture. The goal was to ascertain patients' knowledge of osteoporosis, its management, and experience discussing osteoporosis with their primary care physicians (PCP). RESULTS: Participants had little knowledge of osteoporosis or its treatment. Many participants regarded osteoporosis as a women's disease. Most participants expressed concern regarding receiving a diagnosis of osteoporosis. Several patients stated that they believe osteoporosis may have contributed to their fracture. Families, friends, or mass media served as the primary information source for participants, but few had good self-reported understanding of the disease itself. The majority of participants reported never having discussed osteoporosis with their PCPs although almost half had received a dual x-ray absorptiometry scan. Participants expressed general interest in being tested/screened and generally were willing to undergo treatment despite the perception that medication has serious side effects. One patient expressed concern that treatment side effects could be worse than having osteoporosis. CONCLUSION: Critical knowledge gaps exist regarding osteoporosis diagnosis and treatment in at-risk male patients. Specifically, most patients were unaware they could be osteoporotic because of the perception of osteoporosis as a women's disease. Most patients had never discussed osteoporosis with their PCP. CLINICAL RELEVANCE: Male patients remain relatively unaware of osteoporosis as a disease entity. Opportunity exists for prevention of future fragility fractures by improving communication between patients and physicians regarding osteoporosis screening in men following low-energy distal radius fractures.

Hand Surgery Fellowship Case Minimums: History and Design.

In the 1960s, the American Society for Surgery of the Hand embarked on an endeavor to improve and standardize the educational experience in hand surgery. By the 1980s, numerous programs existed across the country with the Accreditation Council for Graduate Medical Education formally recognizing orthopedic surgery-based fellowships in 1985 and plastic surgery-based fellowships in 1986. In order to sit for what was then termed the Certificate of Additional Qualification examination, applicants had to demonstrate performance of a specific number of procedures while in practice. Borrowing from this theme, the Accreditation Council for Graduate Medical Education began to analyze programs according to the relative proportion of cases done by fellows at individual institutions compared to national trends. Beginning in 2019 and working collaboratively with the Accreditation Council for Graduate Medical Education, the Hand Fellowship Director's Association has since modified the methods by which programs are evaluated, pivoting away from comparative percentages to the establishment of case minimums. The development of this process has been iterative with the resultant outcome being an evaluation system that focuses on educational quality and technical proficiency over sheer numerical volume.

Development of a Survey for the Assessment of Prospective Hand Surgery Fellows' Goals and Interests.

Through an accepted seven-step process outlined by the International Association for Medical Education, we created a high-quality questionnaire that will provide objective evaluation of prospective hand surgery fellows' goals and desires. Utilizing qualitative methodology via semistructured interviews with prospective and current hand surgery fellows from across the United States, we developed a codebook that represented desired themes within a one-year hand surgery fellowship, focusing on numerous topics including the importance of exposure to a specific pathology, curriculum, fellowship size, and location, etc. We then generated a survey, validated it among experts including current program directors, and performed cognitive interviews with the same prospective and current fellows to ensure content validity. The result was the creation of a survey, which can be employed to monitor trends in the goals and desires of prospective hand surgery applicants to ensure that fellowships remain adaptable and current.

Do Surgeons Accurately Predict Level of Activity in Patients With Distal Radius Fractures?

PURPOSE: One factor influencing the management of distal radius fractures is the functional status of the patient. The purpose of this study was to assess the agreement between patient and surgeon assessments of patient activity level in patients sustaining a distal radius fracture. METHODS: Ninety-seven patients were included, with a mean age of 58.5 years (range, 18-92 years). Patients completed the International Physical Activity Questionnaire, a validated survey that provides a score of low, moderate, or high activity levels. Treating surgeons provided an independent assessment using the same scale. Agreement between patient and surgeon assessments was evaluated using a weighted kappa-statistic, with a secondary analysis using logistic regression models to assess odds of surgical treatment. RESULTS: Interrater agreement between surgeons and patients demonstrated only "fair" agreement, with a kappa-statistic of 0.33. Predictive models showed that surgeons accurately identified 73% of "high activity" patients but failed to correctly identify more than 41% of patients rated as "moderate activity" or "low activity." There was a correlation between surgical intervention and increasing physical activity status as assessed by the surgeon; however, the magnitude of this effect was unclear (odds ratio, 2.14; 95% confidence interval, 1.07-4.30). This relationship was no longer significant after adjusting for age, Charlson comorbidity index, and fracture class. There was no association between surgical intervention and physical activity status when using the status provided by the patient. CONCLUSIONS: Surgeon assessment of patient activity level does not have strong agreement with patients' independent assessment. Surgeons are most accurate at identifying "high activity level" patients but lack the ability to identify "moderate activity level" or "low activity level" patients. CLINICAL RELEVANCE: Recognition of surgeon assessment of patient activity level as flawed can stimulate improved dialog between patients and physicians, ultimately improving the shared decision-making process.

Self-Reported Physical Function and Grit Are Not Correlated in Patients Who Undergo Open Reduction Internal Fixation for Distal Radius Fractures.

PURPOSE: "Grit" is defined as the perseverance and passion for long-term goals. Thus, grittier patients may have a better function after common hand procedures; however, this is not well-documented in the literature. Our purpose was to assess the correlation between grit and self-reported physical function among patients undergoing open reduction internal fixation (ORIF) for distal radius fractures (DRFs). METHODS: Between 2017 and 2020, patients undergoing ORIF for DRFs were identified. They were asked to complete the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire before surgery and at 6 weeks, 3 months, and 1 year after surgery. The first 100 patients with at least 1-year follow-up also completed the 8-question GRIT Scale, a validated measure of passion and perseverance for long-term goals measured on a scale of 0 (least grit) to 5 (most grit). The correlation between the QuickDASH and GRIT Scale scores was calculated using Spearman rho (ρ). RESULTS: The average GRIT Scale score was 4.0 (SD, 0.7), with a median of 4.1 (range, 1.6-5.0). The median QuickDASH scores at the preoperative, 6-week postoperative, 6-month postoperative, and 1-year postoperative time points were 80 (range, 7-100), 43 (range, 2-100), 20 (range, 0-100), and 5 (range, 0-89), respectively. No significant correlation was found between the GRIT Scale and QuickDASH scores at any time. CONCLUSIONS: We found no correlation between self-reported physical function and GRIT levels in patients undergoing ORIF for DRFs, suggesting no correlation between grit and patient-reported outcomes in this context. Future studies are needed to investigate the influence of individual differences in character traits other than grit on patient outcomes, which may help better align resources where needed and further the ability to deliver individualized, quality health care. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Prospective Fellows' Appraisal of Hand Surgery Fellowships.

PURPOSE: The nature and focus of hand surgery fellowships has been shown to vary. Compounding this issue is a paucity of information regarding the educational goals and desires of prospective fellows. The purpose of this study was to understand applicant motivation for pursuing a fellowship and the most important components of these fellowships. METHODS: We performed an anonymous survey of all the candidates who applied for a hand surgery fellowship during the 2019-2020 academic year to establish general demographic information, preferences regarding fellowship size, and the importance of various educational and logistical components. We also recorded self-reported comfort level in treating pathologies encountered during a hand-focused subspecialty practice. RESULTS: The most important motivation cited for pursuing a fellowship in hand surgery was the "complexity and variety of cases" (n = 55, 90%). The 5 most important desired components of a fellowship were the exposure to "bread and butter" hand surgery (n = 35, 57%), ability to take level 1 hand call (n = 26, 43%), exposure to complex wrist reconstruction (n = 26, 43%) or peripheral nerve surgery/transfers (n = 23, 38%), and soft tissue coverage including free flaps (n = 19, 31%). Further analysis revealed that the orthopedic surgery residents frequently rated exposure to level 1 call (n = 20, 45%) as 1 of their 3 most important characteristics, whereas the plastic/general surgery residents frequently ranked exposure to complex wrist reconstruction (n = 16, 38%) as 1 of their 3 most important characteristics. The components of a fellowship that received the fewest selections into an applicant's top 3 components were exposure to shoulder surgery (n = 1, 1.64%), education regarding practice building/billing (n = 2, 3.2%), and the ability to conduct research (n = 4, 6.5%). CONCLUSIONS: Most applicants pursue a subspecialty training in hand surgery because of the field's variety and breadth of cases. The applicants prioritize exposure to "bread and butter" cases in conjunction with both complex soft tissue and microsurgical reconstruction. CLINICAL RELEVANCE: Assisting hand fellowships in understanding what is most important to prospective fellows will allow for appropriate recruitment and development of the field of hand surgery in general.

Outcomes of Radial Head Fractures Treated With the "Tripod Technique".

PURPOSE: For fractures requiring operative fixation, the "tripod technique" using headless compression screws has recently been described as a less invasive alternative to open reduction and internal fixation with plate and screws. The purpose of this study was to evaluate the clinical and radiographic outcomes of the tripod technique for the treatment of radial head and neck fractures. METHODS: We performed a retrospective chart review of all radial head and neck fractures treated with the tripod technique at our institution over a 10-year period. Patients with less than 6 months of follow-up were excluded. Outcomes were evaluated at the latest follow-up using range of motion measurements and the Quick Disabilities of the Arm, Shoulder and Hand questionnaire. RESULTS: We evaluated 13 patients with a mean age of 48 years and average follow-up of 72 months (range, 21-153 months). All the patients achieved union by 12 weeks after surgery. The average postoperative Quick Disabilities of the Arm, Shoulder and Hand score was 5.9 (range, 0-23). The mean flexion was 139°, and the mean extension was -8°. There were no major postoperative complications. Five patients had minor complications. No patients required a reoperation. CONCLUSIONS: The tripod technique is a useful alternative to the traditional method of plate and screw fixation for unstable radial head and neck fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The Association Between Depression and Antidepressant Use and Outcomes After Operative Treatment of Distal Radius Fractures at 1 Year.

PURPOSE: Depression has been linked to inferior clinical outcomes among upper extremity patients. It often is challenging to distinguish the symptoms of depression, symptoms of injury, and the interaction between these 2 entities after a patient has been injured. We aimed to study the differences in clinical outcomes after surgical fixation of distal radius fractures between patients with and without a documented history and treatment for depression. METHODS: All subjects with an isolated, acute distal radius fracture undergoing operative fixation in a 10-year period at a level 1 academic trauma center were screened. Baseline demographic data were collected, and psychiatric history and antidepressant use were recorded and verified with a pharmacy database. Quick Disability of the Arm, Shoulder and Hand (QuickDASH), range of motion, and grip strength were assessed at 12 months after surgery. Multivariable linear regression analysis was used to assess the association of depression with QuickDASH scores at 1 year after surgery. RESULTS: A total of 211 patients were available for 1-year follow-up, 50 of whom were being treated actively for depression with medication at the time of injury and 161 were without a known diagnosis of, or treatment for, depression. Demographic and injury characteristics were similar between both groups. In a multivariable linear regression model controlling for age, sex, and a history of osteoporosis, active treatment for depression was associated with a slight mean increase in QuickDASH scores, 6.5 (1.3-11.8), 1 year after surgery. CONCLUSIONS: This study demonstrates a small increase in QuickDASH scores between subjects with a confirmed diagnoses of depression compared with all others after surgical fixation of distal radius fracture at 1-year follow-up. We suggest that a history of depression may portend worse clinical outcomes, although other factors, such as underreporting of depression may influence results. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

What Factors Are Associated with Increased Financial Burden and High Financial Worry For Patients Undergoing Common Hand Procedures?

BACKGROUND: Few studies have examined whether orthopaedic surgery, including hand surgery, is associated with patients' financial health. We sought to understand the level of financial burden and worry for patients undergoing two common hand procedures-carpal tunnel release and open reduction and internal fixation for a distal radius fracture-as well as to determine factors associated with a higher financial burden and worry. QUESTIONS/PURPOSES: In patients undergoing operative treatment for isolated carpal tunnel syndrome with carpal tunnel release or open reduction and internal fixation for a distal radius fracture, we used validated financial burden and worry questionnaires to ask: (1) What percentage of patients report some level of financial burden, and what is the median financial burden composite score? (2) What percentage of patients report some level of financial worry, and what percentage of patients report a high level of financial worry? (3) When accounting for other assessed factors, what patient- and condition-related factors are associated with financial burden? (4) When accounting for other assessed factors, what patient- and condition-related factors are associated with high financial worry? METHODS: In this cross-sectional survey study, a hand and upper extremity database at a single tertiary academic medical center was reviewed for patients 18 years or older undergoing operative treatment in our hand and upper extremity division for an isolated distal radius fracture between October 2017 and October 2019. We then selected all patients undergoing carpal tunnel release during the first half of that time period (given the frequency of carpal tunnel syndrome, a 1-year period was sufficient to ensure comparable patient groups). A total of 645 patients were identified (carpal tunnel release: 60% [384 of 645 patients]; open reduction and internal fixation for a distal radius fracture: 40% [261 of 645 patients). Of the patients who underwent carpal tunnel release, 6% (24 of 384) were excluded because of associated injuries. Of the patients undergoing open reduction and internal fixation for a distal radius fracture, 4% (10 of 261) were excluded because of associated injuries. All remaining 611 patients were approached. Thirty-six percent (223 of 611; carpal tunnel release: 36% [128 of 360]; open reduction and internal fixation: 38% [95 of 251]) of patients ultimately completed two validated financial health surveys: the financial burden composite and financial worry questionnaires. Descriptive statistics were calculated to report the percentage of patients who had some level of financial burden and worry. Further, the median financial burden composite score was determined. The percentage of patients who reported a high level of financial worry was calculated. A forward stepwise regression model approach was used; thus, variables with p values < 0.10 in bivariate analysis were included in the final regression analyses to determine which patient- and condition-related factors were associated with financial burden or high financial worry, accounting for all other measured variables. RESULTS: The median financial burden composite score was 0 (range 0 [lowest possible financial burden] to 6 [highest possible financial burden]), and 13% of patients (30 of 223) reported a high level of financial worry. After controlling for potentially confounding variables like age, insurance type, and self-reported race, the number of dependents (regression coefficient 0.15 [95% CI 0.008 to 0.29]; p = 0.04) was associated with higher levels of financial burden, while retired employment status (regression coefficient -1.24 [95% CI -1.88 to -0.60]; p < 0.001) was associated with lower levels of financial burden. In addition, the number of dependents (odds ratio 1.77 [95% CI 1.21 to 2.61]; p = 0.004) and unable to work or disabled employment status (OR 3.76 [95% CI 1.25 to 11.28]; p = 0.02) were associated with increased odds of high financial worry. CONCLUSION: A notable number of patients undergoing operative hand care for two common conditions reported some degree of financial burden and worry. Patients at higher risk of financial burden and/or worry may benefit from increased resources during their hand care journey, including social work consultation and financial counselors. This is especially true given the association between number of dependents and work status on financial burden and high financial worry. However, future research is needed to determine the return on investment of this resource utilization on patient clinical outcomes, overall quality of life, and well-being. LEVEL OF EVIDENCE: Level III, therapeutic study.

Orthopaedic Disaster Course: Preparing for the Worst/Best Moment in the Operating Room.

Orthopaedic surgeons perform a variety of procedures where life-threatening or limb-threatening clinical scenarios or complications are relatively rare. Because these devastating complications and disaster presentations are infrequent, the occurrence can lead to concerns regarding training and preparedness. This chapter will provide a general knowledge base of common intraoperative disasters as well as life-threatening and/or limb-threatening conditions related to the upper extremity, pelvis, and lower extremity. Fundamental clinical and surgical management strategies are explored with respect to these conditions to provide a level of preparedness to help any orthopaedic surgeon control a potentially devastating complication or emergency.

Hedgehog-Transmitted Trichophyton erinaceid Causing Painful Bullous Tinea Manuum.

Trichophyton is a species of fungus that commonly infects hedgehogs. As the popularity of keeping hedgehogs as pets increases, there have been reports of Trichophyton species infection in humans. Diagnosis and appropriate treatment of Trichophyton infection can be delayed owing to physicians' low index of suspicion and unfamiliarity with the physical manifestations. We describe a case of a 27-year-old healthy man who developed tinea manuum after handling a pet hedgehog. Presenting symptoms included a worsening bullous eruption and severe pain. Both fungal and histopathological study confirmed Trichophyton infection. He was treated with oral and topical antifungal medication. All symptoms resolved 2 weeks after initiation of treatment.

Evaluating Outcomes Following Open Fractures of the Distal Radius.

PURPOSE: A paucity of evidence exists regarding the optimal treatment of open fractures of the distal radius. The purpose of this study was to compare short-term complication rates between various treatment options following open fractures of the distal radius. METHODS: We performed a retrospective review of all open fractures of the distal radius at a single level 1 trauma center over a 10-year period. The primary outcome measure was the number of minor and major complications. Demographic and clinical characteristics of patients across treatment and outcome groups were compared and models were used to describe the relationships between outcome and treatment. RESULTS: Ninety patients met the inclusion criteria for evaluation. An even distribution between high-energy (n = 45) and low-energy (n = 45) injuries was seen with 61 fractures Gustilo I (67%), 19 Gustilo II (22%), and 10 Gustilo III (11%). The majority of fractures were intra-articular (n = 48 AO type C vs n = 42 AO type A/B). Fractures were treated with immediate open reduction internal fixation (ORIF) in 67 cases (74%), external fixation in 12 (13%), initial external fixation followed by ORIF at a later time in 8 (9%), or closed reduction and percutaneous pinning in 3 (4%). We observed 33 complications (37%) of which 24 were major and 9 minor. Mechanism of injury and type of treatment were the only variables shown to correlate with an increased rate of complications. CONCLUSIONS: We conclude that open fractures of the distal radius treated by immediate ORIF at the time of index debridement can result in satisfactory outcomes compared with other forms of treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Thumb Carpometacarpal Arthritis: Prognostic Indicators and Timing of Further Intervention Following Corticosteroid Injection.

PURPOSE: Corticosteroid injections are commonly used to treat thumb carpometacarpal arthritis in adults. We aimed to define the timing of surgery following an initial corticosteroid injection and identify patient-specific factors that influence the likelihood of repeat injection or surgery. METHODS: We performed a retrospective analysis of all patients who underwent a first-time corticosteroid injection for carpometacarpal arthritis between 2009 and 2017. Demographic information, radiographic classification, additional nonsurgical therapies, complications, and outcomes were collected. Primary outcomes were repeat injection and surgical reconstruction. Kaplan-Meier survival analysis was used to characterize the timing of surgical intervention and Cox regression modeling was used to identify predictors of subsequent intervention. RESULTS: Two-hundred thirty-nine patients (average age, 62.9 years) were identified, of which 141 (59.0%) had a repeat injection and 90 (37.6%) underwent surgery. There were no patient-specific characteristics associated with repeat injection. Eaton stage III/IV arthritis at initial presentation, current smoking status, and prior ipsilateral hand surgery were associated with an increased likelihood of surgery. By Kaplan-Meier analyses, 87.7% of patients who presented with Eaton III/IV arthritis did not have surgery within a year and 66.7% of these patients did not have surgery within 5 years. CONCLUSIONS: In this retrospective observational cohort study with 10-year follow-up from a 4-surgeon practice, advanced radiographic arthritis, current smoking status, and a history of ipsilateral hand surgery were patient-specific factors that predicted progression to surgery following injection. Of patients who presented with advanced radiographic arthritis, one-third underwent surgery within 5 years of initial injection. Although injection efficacy and causality cannot be inferred based on an observational longitudinal analysis, these data identify patient-specific factors that may have an impact on surgical decision-making and a potential timeframe for future intervention. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Outcomes and Complications Following Volar and Dorsal Osteotomy for Symptomatic Distal Radius Malunions: A Comparative Study.

PURPOSE: To compare patient-reported outcomes, functional outcomes, radiographic alignment, and complications of volar versus dorsal corrective osteotomies as the treatment for symptomatic distal radius malunions. METHODS: We performed a retrospective review of all patients who underwent a distal radius corrective osteotomy with either a volar or dorsal approach and plating at 1 of 3 institutions between 2005 and 2017. Demographic data, type of surgical treatment, and radiographs were examined. Outcomes were Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) function scores and radius union scoring system as well as major and minor complications. RESULTS: We included 53 cases (37 volar osteotomies and 16 dorsal osteotomies). Postoperative follow-up from the time of surgery to last QuickDASH score was 84.6 months (range, 12-169.4 months). Compared with the dorsal osteotomy group, the volar osteotomy group demonstrated a better postoperative flexion-extension arc (94.9° vs 72.9°, respectively), pronation-supination arc (146.2° vs 124.9°, respectively), and last QuickDASH scores (6.65 vs 12.87), respectively. Radiographically, there was no difference noted in radial height, radial inclination, or volar tilt in the immediate postoperative and last radiographs. There was a higher rate of complications in the dorsal osteotomy group (8 cases [50% of patients]) compared with the volar osteotomy group (7 cases [18.9% of patients]), including a higher rate of hardware removal. CONCLUSIONS: For patients with symptomatic malunions of the distal radius, the volar and dorsal approaches both resulted in improvement in QuickDASH scores and range of motion. Volar plating resulted in slightly better QuickDASH scores and fewer complications compared with dorsal plating. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Functional Outcomes After Sauve-Kapandji Arthrodesis.

PURPOSE: The Sauve-Kapandji procedure (SK) combines a distal radioulnar joint (DRUJ) arthrodesis with the creation of an ulnar pseudarthrosis for the salvage of DRUJ instability or arthritis. Despite several published case series, there are limited data on postoperative functional outcomes. This study evaluates patient-reported outcomes of SK using a validated functional outcomes scale. METHODS: We performed a retrospective review of patients who underwent SK in 2 health care systems over 10 years (2008-2018). Preoperative and postoperative range of motion, Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, and wrist plain film radiographic measurements were recorded. Preoperative and postoperative outcomes analyses and subgroup comparisons were performed. RESULTS: We included 57 patients in the study. Surgical indications included posttraumatic DRUJ arthritis (n = 35), rheumatoid arthritis (n = 10), degenerative DRUJ arthritis (n = 7), Madelung deformity (n = 3), psoriatic arthritis (n = 1), and giant cell tumor of bone (n = 1). During the first postoperative year, QuickDASH scores decreased from a mean of 52 before surgery to 28 at 12 months. The QuickDASH scores at final follow-up demonstrated significant improvement in patients with osteoarthritis and inflammatory arthritis. Supination significantly improved after surgery, from 48° to 74°, whereas wrist flexion, wrist extension, and pronation remained unchanged. Radiographically, significant postoperative decreases were seen in ulnar variance and McMurtry's translation index. The postoperative complication rate was 21%, including revision osteotomy in 4 patients (7.0%) and hardware removal in 4 patients (7.0%). No DRUJ nonunions were seen. CONCLUSIONS: The Sauve-Kapandji procedure for DRUJ salvage significantly improved patient-reported outcomes after 1 year and significantly improved supination. Similar functional improvements after SK were seen in both osteoarthritis and inflammatory arthritis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Trapeziometacarpal Joint Arthritis: Is Duration of Symptoms a Predictor of Surgical Outcomes?

PURPOSE: Great effort has been placed on determining the optimal surgical treatment for trapeziometacarpal joint arthritis (TMA). However, a paucity of literature exists concerning the optimal timing of surgical intervention. We hypothesized that an increased duration of TMA symptoms before operative intervention would negatively affect surgical outcomes. METHODS: We performed a retrospective review on 109 adult patients with 121 joints with symptomatic TMA treated with trapeziectomy and ligament reconstruction with tendon interposition (LRTI) from 2006 to 2017. Outcome measures included Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, complication rates, and surgical revision rates. RESULTS: Among 109 patients, average QuickDASH score at initial presentation was 41.1 ± 17.9. Patients had symptoms of TMA for an average of 3.2 years (median, 2.1 years) before undergoing operative intervention. Patients were divided into 2 groups: those with symptoms less than 2 years and those with symptoms greater than 2 years. Patients who underwent LRTI after less than 2 years of symptoms achieved a significantly greater degree of improvement in the QuickDASH score compared with patients with symptoms greater than 2 years (26.2 vs 5.3). CONCLUSIONS: Patients with less than 2 years of symptomatic TMA before LRTI can expect the greatest improvement in patient-reported disability impairment compared with those with more than 2 years of symptoms. This can be used to counsel patients regarding the optimal timing of surgery if nonsurgical treatment has failed to provide durable symptomatic relief. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The Impact of Obesity and Smoking on Outcomes After Volar Plate Fixation of Distal Radius Fractures.

PURPOSE: Distal radius fractures are common fractures of the upper extremity. Whereas surgical outcomes have been extensively investigated, the impact of risk factors such as body mass index (BMI) and smoking on patient outcomes has not been explored. We hypothesized that obesity and smoking would have a negative impact on the functional and radiographic outcomes of surgically treated patients with distal radius fractures. METHODS: We performed a retrospective analysis of patients surgically treated for a distal radius fracture between 2006 and 2017 at 2 level 1 trauma centers. Patients were divided into obese (BMI ≥ 30) and nonobese (BMI < 30) groups according to the World Health Organization BMI Classification. Patients were also divided into current, former, and never smokers based on reported cigarette use. Primary outcomes included patient-reported outcome measures (Quick Disabilities of the Arm, Shoulder, and Hand [QuickDASH]), range of motion (ROM) arc (flexion-extension, pronation-supination), radiographic union (Radiographic Union Scoring System [RUSS] score), and change in radiographic alignment (radial height, radial inclination, volar tilt) between first and last follow-up. Multivariable models corrected for age, sex, comorbidities, fracture complexity, osteoporosis, and time to surgery. RESULTS: Two hundred patients were identified, 39 with BMI of 30 or greater and 161 with BMI less than 30. Obese patients had more comorbidities but similar fracture types. At 3-month and 1-year follow-up, both groups achieved acceptable QuickDASH scores, close to those of the general population (21 vs 18, 14 vs 2, respectively). The 2 groups were similar in regard to motion, RUSS score, and alignment. There were 148 never smokers, 32 former smokers, and 20 current smokers. At 3 months, smokers demonstrated higher QuickDASH scores (42 vs 21-24) and a lower percentage of radiographically healed fractures (40% vs 69%-82%). At final follow-up, smokers reported small differences in patient-reported outcomes (QuickDASH 18 vs 9-13) whereas ROM, fracture healing, and complication rates were similar. CONCLUSIONS: Both obese and nonobese patients can achieve excellent outcomes following surgical treatment of distal radius fracture with similar self-reported outcomes, motion, RUSS score, and alignment. Despite slower healing in the early postoperative period, smokers had similar QuickDASH scores, ROM, and union rates to past smokers and never smokers at final follow-up, with a similar complication profile. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Reversed Palmaris Longus Muscle Causing Volar Forearm Pain and Ulnar Nerve Paresthesia.

A case of volar forearm pain associated with ulnar nerve paresthesia caused by a reversed palmaris longus muscle is described. The patient, an otherwise healthy 46-year-old male laborer, presented after a previous unsuccessful forearm fasciotomy for complaints of exercise exacerbated pain affecting the volar forearm associated with paresthesia in the ulnar nerve distribution. A second decompressive fasciotomy was performed revealing an anomalous "reversed" palmaris longus, with the muscle belly located distally. Resection of the anomalous muscle was performed with full relief of pain and sensory symptoms.

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.

Can therapy dogs improve pain and satisfaction after total joint arthroplasty? A randomized controlled trial.

BACKGROUND: The use of animals to augment traditional medical therapies was reported as early as the 9th century but to our knowledge has not been studied in an orthopaedic patient population. The purpose of this study was to evaluate the role of animal-assisted therapy using therapy dogs in the postoperative recovery of patients after THA and TKA. QUESTIONS/PURPOSES: We asked: (1) Do therapy dogs have an effect on patients' perception of pain after total joint arthroplasty as measured by the VAS? (3) Do therapy dogs have an effect on patients' satisfaction with their hospital stay after total joint arthroplasty as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)? METHODS: A randomized controlled trial of 72 patients undergoing primary unilateral THA or TKA was conducted. Patients were randomized to a 15-minute visitation with a therapy dog before physical therapy or standard postoperative physical therapy regimens. Both groups had similar demographic characteristics. Reduction in pain was assessed using the VAS after each physical therapy session, beginning on postoperative Day 1 and continuing for three consecutive sessions. To ascertain patient satisfaction, the proportion of patients selecting top-category ratings in each subsection of the HCAHPS was compared. RESULTS: Patients in the treatment group had lower VAS scores after each physical therapy session with a final VAS score difference of 2.4 units (animal-assisted therapy VAS, 1.7; SD, 0.97 [95% CI, 1.4-2.0] versus control VAS, 4.1; SD, 0.97 [95% CI, 3.8-4.4], p<0.001) after the third physical therapy session. Patients in the treatment group had a higher proportion of top-box HCAHPS scores in the following fields: nursing communication (33 of 36, 92% [95% CI, 78%-98%] versus 69%, 25 of 36 [95% CI, 52%-84%], p=0.035; risk ratio, 1.3 [95% CI of risk ratio, 1.0-1.7]; risk difference, 23% [95% CI of risk difference, 5%-40%]), pain management (34 of 36, 94% [95% CI, 81%-99%], versus 26 of 36, 72% [95% CI, 55%-86%], p=0.024; risk ratio, 1.3 [95% CI of risk ratio, 1.1-1.6]; risk difference, 18% [95% CI of risk difference, 5%-39%]). The overall hospital rating also was greater in the treatment group (0-10 scale) (9.6; SD, 0.7 [95% CI, 9.3-9.8] versus 8.6, SD, 0.9 [95% CI, 8.3-8.9], p<0.001). CONCLUSIONS: The use of therapy dogs has a positive effect on patients' pain level and satisfaction with hospital stay after total joint replacement. Surgeons are encouraged to inquire about the status of volunteer-based animal-assisted therapy programs in their hospital as this may provide a means to improve the immediate postoperative recovery for a select group of patients having total joint arthroplasty. LEVEL OF EVIDENCE: Level II, randomized controlled study. See Instructions for Authors for a complete description of levels of evidence.