Bone Health Screening Prior to Medicare Eligibility-Osteoporosis Screening and Fracture Prevention After Distal Radius Fractures in Patients Aged 50-59.

PURPOSE: Current guidelines recommend bone mineral density (BMD) testing after fragility fractures in patients aged 50 years or older. This study aimed to assess BMD testing and subsequent fragility fractures after low-energy distal radius fractures (DRFs) among patients aged 50-59 years. METHODS: We used the 2010-2020 MarketScan dataset to identify patients with initial DRFs with ages ranging between 50 and 59 years. We assessed the 1-year BMD testing rate and 3-year non-DRF fragility fracture rate. We created Kaplan-Meier plots to depict fragility fracture-free probabilities over time and used log-rank tests to compare the Kaplan-Meier curves. RESULTS: Among 78,389 patients aged 50-59 years with DRFs, 24,589 patients met our inclusion criteria, and most patients were women (N = 17,580, 71.5%). The BMD testing rate within 1 year after the initial DRF was 12.7% (95% CI, 12.3% to 13.2%). In addition, 1-year BMD testing rates for the age groups of 50-54 and 55-59 years were 10.4% (95% CI, 9.9% to 11.0%) and 14.9% (95% CI, 14.2% to 15.6%), respectively. Only 1.8% (95% CI, 1.5% to 2.1%) of men, compared with 17.1% (95% CI, 16.5% to 17.7%) of women, underwent BMD testing within 1 year after the initial fracture. The overall 3-year fragility fracture rate was 6.0% (95% CI, 5.6% to 6.3%). The subsequent fragility fracture rate was lower for those with any BMD testing (4.4%; 95% CI, 3.7% to 5.2%), compared with those without BMD testing (6.2%; 95% CI, 5.9% to 6.6%; P < .05). CONCLUSIONS: We report a low BMD testing rate for patients aged between 50 and 59 years after initial isolated DRFs, especially for men and patients aged between 50 and 54 years. Patients who received BMD testing had a lower rate of subsequent fracture within 3 years. We recommend that providers follow published guidelines and initiate an osteoporosis work-up for patients with low-energy DRFs to ensure early diagnosis. This provides an opportunity to initiate treatment that may prevent subsequent fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis II.

Patient Perspectives on Cognitive Behavioral Therapy for Thumb, Hand, or Wrist Pain and Function: A Survey of 98 Patients.

PURPOSE: Cognitive behavioral therapy (CBT) is an established option to improve pain and function for many orthopedic conditions. Our purpose was to obtain patient perspectives regarding CBT for thumb, hand, or wrist pain and function. METHODS: Between March and April 2022, we distributed an electronic survey via email to patients in our institution's health system with a diagnosis of arthritic or non-specific thumb, hand, or wrist pain. The survey included the opening statement "Cognitive Behavioral Therapy (CBT) is a non-medication option to help manage pain and improve function" and up to 13 questions pertaining to patients' experiences and perceptions regarding CBT. The survey was anonymous and did not collect protected health information. We used descriptive statistics for the findings. RESULTS: We distributed the survey to 327 patients, yielding a 30% response rate (98/327). Of the respondents, 17 reported already using CBT to specifically help with pain/function. Of these, 15 felt it was helpful and agreed it could help others. Of the subset that used CBT for arthritis, all felt it was helpful. Of the 75 respondents with no CBT experience, 42 indicated "I've never heard of it," 28 responded "I never had it recommended as an option," and 16 marked "I don't know enough about it." Small subsets noted potential personal barriers to CBT implementation, such as cost, time involved, or perceived lack of potential efficacy for themselves. CONCLUSIONS: A small proportion of patients from our institution with thumb, hand, or wrist pain are utilizing CBT, and the majority finds it helpful. CLINICAL RELEVANCE: While some patients are already substantially benefiting from CBT to improve their thumb, hand, or wrist pain or function, there is a notable opportunity for providers to increase awareness and recommendations for this option.

Efficacy of Postoperative Opioid-Sparing Regimens for Hand Surgery: A Systematic Review of Randomized Controlled Trials.

PURPOSE: Multiple interventions have been implemented to reduce opioid prescribing in upper extremity surgery. However, few studies have evaluated pain relief and patient satisfaction as related to failure of these protocols. We sought to evaluate the efficacy of limited and nonopioid ("opioid-sparing") regimens for upper extremity surgery as it pertains to patient satisfaction, pain experienced, and need for additional refills/rescue analgesia. METHODS: We aimed to systematically review randomized controlled trials of opioid-sparing approaches in upper extremity surgery. An initial search of studies evaluating opioid-sparing regimens after upper extremity surgery from the elbow distal yielded 1,320 studies, with nine meeting inclusion criteria. Patient demographics, surgery type, postoperative pain regimen, satisfaction measurements, and number of patients inadequately treated within each study were recorded. Outcomes were assessed using descriptive statistics. RESULTS: Nine randomized controlled trials with 1,480 patients were included. Six of nine studies (67%) reported superiority or equivalence of pain relief with nonopioid or limited opioid regimens. However, across all studies, 4.2% to 25% of patients were not adequately treated by the opioid-sparing protocols. This includes four of seven studies (57%) assessing number of medication refills or rescue analgesia reporting increased pill consumption, refills, or rescue dosing with limited/nonopioid regimens. Five of six studies (83%) reporting satisfaction outcomes found no difference in satisfaction with pain control, medication strength, and overall surgical experience using opioid-sparing regimens. CONCLUSIONS: Opioid-sparing regimens provide adequate pain relief for most upper extremity surgery patients. However, a meaningful number of patients on opioid-sparing regimens required greater medication refills and increased use of rescue analgesia. These patients also reported no difference in satisfaction compared with limited/nonopioid regimens. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Medial Femoral Trochlea Osteochondral Flap Reconstruction of the Previously Unsalvageable Kienbock-Associated Lunate With a Coronal Split.

PURPOSE: Patients with Kienbock disease can present with coronal fracture and collapse of the proximal lunate (Unified B2/Bain grade 1, 2B). Traditionally, this was considered unsalvageable. However, medial femoral trochlea (MFT) osteochondral reconstruction, used to recreate the proximal lunate surface, can be paired with reduction and repair of the coronal plane fracture, thus restoring midcarpal congruity. The purpose of this study was to report radiographic and clinical outcomes following lunate coronal fracture fixation at the time of MFT osteochondral reconstruction. METHODS: This was a retrospective study performed at a single institution. We identified patients with Kienbock disease who underwent MFT osteochondral reconstruction from 2014 to 2023. Patients were included if they had a coronal fracture of the lunate distal articular surface fixed at the time of surgery. Radiographic and clinical parameters were evaluated, including carpal height ratio, union rate, presence of heterotopic ossification, need for revision surgery, and patient-reported outcome measures. RESULTS: Thirty-three patients were included, with a mean age of 27.5 years (range: 15-41); 19 (58%) were women. Mean radiographic follow-up time was 5.8 months, and mean clinical follow-up time was 22.6 months. Union was achieved in 30/33 patients (91%). Carpal height ratio improved from 1.32 to 1.4. Two patients (6%) required reoperation, one for removal of heterotopic ossification and another for conversion to proximal row carpectomy. Patients demonstrated meaningful improvement in brief Michigan Hand Questionnaire and Patient-Reported Outcomes Measurement Information Upper Extremity scores. Range of motion before and after surgery was similar. CONCLUSIONS: Lunate coronal fracture fixation with MFT osteochondral reconstruction represents an additional management option in select patients with Kienbock disease. This technique restores the midcarpal joint during lunate reconstruction and may allow patients to avoid salvage procedures. Early radiographic and clinical outcomes are promising. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Comparison of 3 Dynamic External Fixation Devices for Proximal Interphalangeal Joint Dorsal Fracture-Dislocations in a Cadaver Model.

PURPOSE: Several improvised dynamic external fixation devices are used for treating unstable dorsal proximal interphalangeal (PIP) joint fracture-dislocations. We compared the effectiveness of 3 constructs for simulated dorsal PIP joint fracture-dislocations in a cadaver model. METHODS: We tested 30 digits from 10 fresh-frozen, thawed cadaver hands. We aimed to remove the palmar 50% of the base of each digit's middle phalanx (P2), simulating an unstable dorsal PIP joint fracture-dislocation. Each PIP joint was then stabilized via external fixation with either a pins-and-rubber-bands construct, pins-only construct, or tuberculin syringe-pins construct. We allocated 10 digits per fixation group. The finger tendons were secured to a computer-controlled stepper motor-driven linear actuator. Via this mechanism, all PIP joints were taken through 1,400 cycles of flexion-extension. With the PIP joint in neutral extension, we measured the P2 dorsal translation at baseline, after fixator stabilization, and after the motion protocol. RESULTS: The actual mean P2 palmar defect created was 48% of the base. All PIP joints were unstable after creating the defect, with a mean initial P2 dorsal displacement of 3.7 mm. After application of the fixators, all PIP joint dislocations were reduced. The median residual P2 dorsal displacements were 0.0 mm for the pins-rubber bands group, 0.1 mm for the pins-only group, and 0.5 mm for the syringe-pins group. There were no cases of PIP joint redislocation after flexion-extension cycling, and the median dorsal P2 displacements were 0.0 mm for the pins-rubber bands group; 0.0 mm for the pins-only group; and 0.5 mm for the syringe-pins group. CONCLUSIONS: All 3 external fixators restored PIP joint stability following simulated dorsal fracture-dislocation, with all reductions maintained after motion testing. The syringe-pins construct had significantly greater median residual P2 dorsal displacement after the initial reduction and motion testing, which is of unclear clinical importance. CLINICAL RELEVANCE: This study informs surgeon decision-making when considering dynamic external fixator options for dorsal PIP joint fracture-dislocations.

All-Suture Anchor Repair of the Flexor Digitorum Profundus Insertion: A Biomechanical Comparison of 2 Suturing Techniques.

PURPOSE: We compared 2 suturing techniques for reattachment of the flexor digitorum profundus (FDP) via all-suture anchor. METHODS: We used fresh, matched-pair, cadaveric hands. We disarticulated the fingers at the proximal interphalangeal joints, preserving the proximal FDP. We released the FDPs at their distal insertion and placed an all-suture, 1.0-mm anchor at the center of each FDP footprint. Each anchor's sutures were used to reattach each FDP using 1 of 2 techniques: group H (n = 14) via horizontal mattress; group H + K (n = 12) via horizontal mattress with knots thrown and, with each suture tail, 3 proximal, running-locking, Krackow-type passes on the radial and ulnar FDP sides with the suture ends tied together. We excluded 2 specimens from the H + K group because of improper anchor placement. All other fingers in both groups were individually mounted in an MTS machine for FDP loading in the following sequence for 500 cycles each: (1) to 15 N to simulate passive motion forces; (2) to 19 N for short-arc active motion forces; and (3) to 28 N for full active motion forces. Specimens that had not failed during cyclic testing were then loaded to failure. We measured FDP-to-bone gapping via a digital transducer. We defined failure as >3-mm gapping. RESULTS: The H + K group had significantly less gapping during cyclic loading up to 19 N and significantly higher load to failure. The H + K group failed exclusively at the anchor-bone level; the H group failed mostly by suture-tendon pullout. CONCLUSIONS: The H + K group performed significantly better regarding cyclic and load-to-failure testing after FDP reattachment. CLINICAL RELEVANCE: The H + K technique combines the benefits of horizontal-mattress tendon-to-bone apposition and Krackow-tendon locking. It converts the point of failure to the bone level rather than the suture-tendon level.

Evaluating Language Characteristics and Related Gender Bias in Letters of Recommendation for Hand Surgery Fellowship.

PURPOSE: Letters of recommendation (LORs) function as an indicator of competence and future potential for a trainee. Our purpose was to evaluate gender bias in hand surgery fellowship applicant LORs. METHODS: This was a retrospective study of all LORs submitted to a hand surgery fellowship program between 2015 and 2020. Demographic data about applicants and letter writers were collected. Linguistic analysis was performed using a text analysis software, and results were evaluated with nonparametric tests, multiple linear regression models, and a mixed effects regression model. RESULTS: Letters of recommendation were analyzed; 720 letters for 188 (23.4%) female applicants and 2,337 letters for 616 (76.6%) male applicants. Compared with LORs written for men, those written for women had more references to categories of anxiety (eg, worried and fearful) and affiliation (eg, ally and friend). Letters for women had more "clout." In subgroup analysis, letters for female plastic surgery applicants had more words signaling power, whereas recommendations for female applicants from orthopedic residencies had more words related to anxiety, achievement, work, and leisure. CONCLUSIONS: Letters of recommendation written for female residents applying to hand fellowship had more references to anxiety but were written with higher clout and more words of affiliation. Subgroup analysis looking at orthopedic and plastic surgery applicants separately found a mixed picture. Overall, these LORs written for applicants to hand fellowship had no notable specific patterns of gender bias in our analyses. CLINICAL RELEVANCE: Because programs look to train the next generation of hand surgeons, alerting letter readers to trends in implicit bias may help in the selection of qualified applicants. Bringing topics of implicit bias forward may help writers think more critically about word choice and topics.

Performance of Near-Infrared Spectroscopy in Detecting Acute Tourniquet-Induced Upper-Extremity Ischemia Across Different Skin Phenotypes.

PURPOSE: Diagnosing acute tissue ischemia is challenging, particularly in patients with higher skin melanin content. We investigated whether near-infrared spectroscopy (NIRS) is effective and consistent in detecting upper extremity ischemia across various skin phenotypes. METHODS: Volunteers underwent tourniquet-induced upper extremity ischemia. Skin color was evaluated by the Fitzpatrick scale (FP, range: I-VI) and the Von Luschan scale (vL, range: 1-36). A NIRS probe was placed on one finger. The tourniquet was inflated to 250 mmHg and perfusion was restricted for 7 minutes, followed by a 10-minute monitored reperfusion period. The percent tissue oxygenation (StO2) was recorded. RESULTS: A total of 55 volunteers were enrolled (22 self-identified as Caucasian, 21 African American, 7 Asian, 2 Latinx, and 2 Biracial). Average starting and ending StO2 for the cohort was 72.2% and 45.9%, respectively. However, there was variability based on skin melanin content. Increasing vL correlated with lower starting StO2, smaller StO2 decrease, and shorter time to reach ischemic steady state. High skin melanin (FP scale IV-VI) was associated with significantly lower starting StO2 (-7.1%) and shorter time to reach ischemic steady state (-0.3 mins). African Americans had lower starting StO2 (-8.6%) and 7.8% lesser total StO2 decrease than other groups. CONCLUSIONS: NIRS can rapidly detect acute onset tissue ischemia in the upper extremity. However, given the lower starting StO2 and smaller total StO2 decrease after tourniquet-induced ischemia for patients with higher skin melanin, using NIRS for clinical detection of acute ischemia may be more challenging in these patients. These inconsistencies may limit use of NIRS clinically for spot identification of ischemia. CLINICAL RELEVANCE: Although NIRS has utility in tracking tissue oxygenation, variable performance with different skin melanin content raises concerns as to whether different cutoff/threshold levels are needed for different groups, and whether NIRS is reliable for spot checks in acute events.

Evaluating the Role of Mentorship in Career Advancement: A Survey of Women in Academic Hand Surgery.

PURPOSE: Despite the increasing percentage of women within the American Society for Surgery of the Hand, women remain underrepresented within leadership in academic hand surgery. Although this disparity in leadership representation may be improving, we aimed to investigate the role mentorship plays in advancing women in academic hand surgery. METHODS: This is a survey-based, mixed-methods study. A written survey assessing themes in personal and professional experiences with mentorship was sent to hand fellowship-trained women. Inclusion criteria were the completion of a hand fellowship and current affiliation with an academic institution. An evolved grounded theory framework was used to evaluate the responses. Themes were identified based on common responses. RESULTS: Of 186 eligible participants, 144 (85.2%) received the survey. The response rate was 48.6%. Respondents indicated that residency was the stage at which mentorship was most impactful (n = 25, 37%), and half of the respondents identified their desire to work in academic hand surgery during residency (n = 35, 50%). Obstacles to finding a mentor included lack of availability (n = 46, 67.7%), hesitance in searching for a mentor (n = 16, 23.5%), and searching for a mentor within an environment that was not conducive to success for trainees (n = 7, 10.3%). Most (84%) cited instances were the ones having the advice of a woman mentor was more impactful than that of a mentor who is a man. The reported need for same-sex mentorship fell into three categories: (1) insight into shared experiences, (2) assistance with conflict/bias management, and (3) support during career navigation. CONCLUSIONS: The findings of this study demonstrate the need for high-quality mentorship during the residency with a specific emphasis on same-sex mentorship. CLINICAL RELEVANCE: Our findings provide clear objectives related to improving access to and quality of mentorship. This foundational understanding will enrich mentor-mentee relationships, allowing for greater personal and professional success and satisfaction for both parties.

Passive Manipulation for Proximal Interphalangeal Joint Extension Contractures.

PURPOSE: We investigated closed passive manipulation as an alternative to surgery for certain proximal interphalangeal (PIP) joint extension contractures. METHODS: We retrospectively reviewed all patients with PIP joint extension contractures treated with passive manipulation at our institution between 2015 and 2019. The included patients were a minimum of 12 weeks from their initial injury/surgery (median 179 days; interquartile range: 130-228 days), had plateaued with therapy, and underwent a 1-time passive manipulation. All included fingers had congruent PIP joints and no indwelling hardware that could have had direct adhesions. Most (80%) patients had a direct injury to the finger ray(s) that led to the contractures. Most (75%) patients had the manipulation performed under local anesthesia in the office. Available measures of passive range of motion (PROM) and active range of motion (AROM) immediately, within 6 weeks, between 6 and 12 weeks, and at >12 weeks after the manipulation were recorded. RESULTS: Twenty-eight patients and 46 digits met the criteria. The median PIP joint PROM improved from 50° to 90° immediately following the manipulation. The median PROM values within 6 weeks, between 6 and 12 weeks, and at >12 weeks following manipulation were 80°, 85°, and 85°, respectively. The median AROM immediately after the manipulation improved from 40° to 90°, and the median AROM values within 6 weeks, between 6 and 12 weeks, and at >12 weeks were 70°, 50°, and 60°, respectively. None of the patients experienced worsening of PIP joint range of motion. One patient who had 4 fingers manipulated had a 45° distal interphalangeal joint extension lag for one of the fingers after the manipulation. Eight fingers underwent later flexor tenolysis or reconstruction to improve AROM after the gains in PROM via manipulation were maintained. CONCLUSIONS: Passive manipulation is an alternative to surgical release for select PIP joint extension contractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Video-Based Assessment of Microsurgical Trainees: An Evaluation of Gender Bias.

BACKGROUND: Gender bias in graduate medical evaluations remains a challenging issue. This study evaluates implicit gender bias in video-based evaluations of microsurgical technique, which has not previously been described in the literature. METHODS: Two videos were recorded of microsurgical anastomosis; the first was performed by a hand/microsurgery fellow and the second by an expert microsurgeon. A total of 150 surgeons with microsurgical experience were recruited to evaluate the videos; they were told these videos depicted a surgical trainee 1 month into fellowship followed by the same trainee 10 months later. The only variable was the name ("Rachel" or "David") that each participant was randomly assigned to evaluate. Participants were asked to score each video for quality, technique, efficiency, as well as overall progression and development after the second video compared with the initial video. To focus on bias, these outcome measures were selected to be purposefully subjective and all ratings were based on a subjective 1to 10 scale (10 = excellent). RESULTS: The analysis included 150 participants (75% male). There were no statistically significant differences in scores between the "female" and "male" trainee. The trainees received the same median initial (1-month video) and final (11th-month video) scores for all criteria except initial technique, in which the female trainee received a 7 and the male trainee received an 8. Notably, 11-month scores were consistently the same or lower than 1-month scores for both study groups (p < 0.001). There were also no differences within either study group based on participant sex. Microsurgery practitioners overall rated both groups lower than those who do not currently practice microsurgery. CONCLUSION: Our study did not identify a gender bias in this evaluation method. Further investigation into how we assess and grade trainees as well as the presence and impact of implicit biases on varying surgical assessment methods is warranted.

Patient-level barriers and facilitators to completion of patient-reported outcomes measures.

PURPOSE: To identify patient-level barriers and facilitators to completion of patient-reported outcomes measures (PROMs) in a hand and upper extremity clinic in Baltimore, Maryland. METHODS: We conducted 12 h of direct observation of PROM completion (October-November, 2020). Ethnographic observation memos were qualitatively analyzed for barriers and facilitators using rapid thematic analysis. Informed by observation findings, we conducted 17 semi-structured interviews with mixed-literacy patients, caregivers, and clinic staff to understand the patient experience when completing PROMs (November 2020-March 2021). We identified initial themes through inductive and deductive framework analysis and validated findings through subsequent interviews with member-checking. RESULTS: We identified nine patient-level factors that influence PROM completion: platform design, print literacy, health literacy, technology literacy, language proficiency, physical functioning, vision, cognitive functioning, and time. CONCLUSIONS: There are multiple distinct patient-level factors that affect PROM completion. Failure to consider these factors in PROM design and implementation may lower completion rates or prevent accurate completion, undermining PROM validity. Because certain factors affect minority populations at disproportionate rates, this may also contribute to existing health disparities.

Decreasing Medicare Utilization, Reimbursement, and Reimbursement-to-Charge Ratio of Reconstructive Plastic Surgery Procedures: 2010 to 2019.

BACKGROUND: This study aimed to evaluate recent trends in utilization, reimbursement, and charges for reconstructive plastic surgery procedures billed to Medicare. METHODS: We queried the Physician/Supplier Procedure Summary from the Centers for Medicare and Medicaid Services for procedures billed by plastic surgeons to Medicare Part B between 2010 and 2019. We collected service counts, charges, and reimbursements. We adjusted utilization by Medicare enrollment and adjusted monetary values for inflation. We calculated the weighted mean charge and reimbursement, which were used to calculate the reimbursement-to-charge ratio (RCR). We examined trends over time by calculating differences and performing correlation analyses of utilization, charges, reimbursement, and RCR for all procedures and for different procedural categories. RESULTS: From 2010 to 2019, the overall enrollment-adjusted utilization for 912 reconstructive procedures decreased by 6.6% (r2 = 0.46). Utilization increased in certain procedural categories such as skin debridement (+36.9%, r2 = 0.48) and procedures of the breast (+114.9%, r2 = 0.48). Charges increased by 32.9% (r2 = 0.99), reimbursement decreased by 5.3% (r2 = 0.84), and RCR decreased by 28.7% (r2 = 0.99). Skin replacement/flaps/grafts procedures underwent the greatest relative decrease in reimbursement (-26.8%, r2 = 0.87). Reimbursement-to-charge ratio decreased for all procedural categories except for procedures of the auditory system. CONCLUSIONS: In the past decade, Medicare utilization and reimbursement for reconstructive plastic surgery procedures decreased, whereas charges increased. This resulted in decreasing reimbursement relative to charged amounts. These findings raise concerns regarding the economic viability of providing plastic surgery services to an aging population and may impact patients' ability to access affordable plastic surgical care.

Responsiveness of the Brief Michigan Hand Outcomes Questionnaire and Patient-Reported Outcomes Measurement Information System Pain Interference in the Context of Patient Mental Health.

PURPOSE: A patient-reported outcomes measure (PROM) is responsive if it is sensitive to clinical status changes. The minimal clinically important difference (MCID) is used to indicate meaningful change, helpful in designing studies and adding context to some study results, and is related to instrument responsiveness. Our purpose was to provide MCID estimates for the brief Michigan Hand Outcomes Questionnaire (bMHQ) and Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) in a hand and upper extremity surgery cohort within the context of varying patient-reported mental health. METHODS: Data were analyzed from 1,262 adult patients who received surgical care at a single center between January 1, 2018, and December 31, 2019. Patients completed PROMIS PI, PROMIS Global Health (including global mental health [GMH] component), bMHQ, and a pain-focused anchor question before each clinic visit. Data were collected 8 ± 2 weeks before and after surgery. A distribution-based MCID then was calculated for the general patient population, lowest 10th percentile of GMH scores, and top 10th percentile of GMH scores. RESULTS: Minimal clinically important difference estimates were 10.4 for the bMHQ and 4.3 for PROMIS PI. Analysis of MCID across different GMH score groups showed a mean score of 11.5 for bMHQ for the lowest 10th percentile of GMH, 9.6 for bMHQ for the top 10th percentile, 4.5 for PI for the lowest 10th percentile, and 4.9 for PI for the top 10th percentile. CONCLUSIONS: Analysis of subgroups stratified by preoperative patient-reported mental health condition found that preoperative mental health status, as indicated by GMH score, does not have a meaningful impact on responsiveness of bMHQ or PROMIS PI. CLINICAL RELEVANCE: A patient's reported mental health condition does not meaningfully change how these common PRO instruments reflect the patient condition after hand and upper extremity surgery.

Arterial Perfusion of the Proximal Phalanx Revisited: New Insights Based on Micro-Computed Tomography.

PURPOSE: To characterize the periosteal and endosteal arterial perfusion of the proximal phalanx using micro-computed tomography angiography (micro-CTA). METHODS: Cadaveric upper extremities were injected with a barium sulfate/gelatin suspension. Phalanges were imaged using micro-CTA and analyzed with a focus on osseous arterial anatomy. Periosteal and endosteal perfusion was characterized by number of vessels, length, anatomic course, and caliber. RESULTS: The base of the proximal phalanx had a significantly greater number (8.0 ± 3.5) of periosteal vessels than those of the shaft (4.1 ± 1.6) and head (1.3 ± 1.1). One-third (34.4%) of the specimens demonstrated a complete absence of periosteal vessels in the head. A nutrient endosteal vessel was noted in 100% of the specimens. Entering at the junction of the middle and distal third of the bone (25.8 ± 3.9 mm from base), the nutrient vessel entered the proximal phalanx of the index finger along its ulnar aspect (8 of 8 specimens), the middle finger along its radial aspect (6 of 8), the ring finger along its ulnar aspect (5 of 8), and the little finger along its radial aspect (7 of 8). The nutrient vessel branched into proximal and distal extensions toward the shaft and head, respectively, with an average endosteal length of 10.7 ± 5.2 mm and average diameter of 0.36 ± 0.11 mm. CONCLUSIONS: Periosteal contributions to the perfusion of the proximal phalanx appear to diminish distally. The endosteal arterial anatomy remains consistent, with a single nutrient vessel entering the intramedullary canal with reliable laterality on each digit. This is often the only vessel supplying the head of the proximal phalanx, making this area particularly susceptible to vascular compromise. CLINICAL RELEVANCE: An understanding of the patterns of perfusion of the proximal phalanx provides some insight into clinically observed pathology, as well as guidance for operative management.

The Curtis Hand Injury Matrix Score: Determining the Need for Specialized Upper Extremity Care.

PURPOSE: Given the limited impact of transfer guidelines and the lack of comparative metrics for upper extremity trauma, we introduced the Curtis Hand Injury Matrix (CHIM) score to evaluate upper extremity injury acuity from the specialist perspective. Our goal was to evaluate the CHIM score as an indicator of complexity and specialist need by correlating the score with arrival mode, length of stay (LOS), discharge disposition, and procedure location. METHODS: We identified all hand and upper extremity emergency room visits at our institution in 2018 and 2019. On initial evaluation, our institution's hand surgery team assigned each patient an alphanumeric score with a number (1-5) and letter (A-H) corresponding to injury severity and pathology, respectively. Patients were divided into 5 groups (1-5) with lower scores indicating greater severity. We compared age, LOS, discharge disposition, procedure location, transfer status, and arrival mode between groups and assessed the relationships between matrix scores and discharge disposition, procedure performed, and LOS. RESULTS: There were 3,822 patients that accounted for 4,026 upper extremity evaluations. There were significant differences in LOS, discharge dispositions, procedure locations, transfer status, and arrival modes between groups. Patients with more severe scores had higher rates of admission and more operating room procedures. Higher percentages of patients who arrived via helicopter, ambulance, or transfer had more severe scores. Patients with more severe scores were significantly more likely to have a procedure, hospital admission, and longer hospital stay. CONCLUSIONS: The CHIM score provides a framework to catalog the care and resources required when covering specialized hand and upper extremity calls and accepting transfers. This clinical validation supports considering broader use. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Surprise Out-of-Network Bills for Hand and Upper Extremity Trauma Patients.

PURPOSE: Patients may receive surprise out-of-network bills even when they present to in-network facilities. Surprise bills are common following emergency care. We sought to characterize and determine risk factors for surprise billing in hand and upper extremity trauma patients in the emergency department (ED). METHODS: We used IBM MarketScan data to evaluate hand and upper extremity trauma patients who received care in the ED from 2010 to 2017. Our primary outcome was the surprise billing incidence, defined as encounters in in-network EDs with out-of-network claims. We used descriptive and bivariate analyses to characterize surprise billing and used multivariable logistic regression to evaluate independent factors associated with surprise billing. RESULTS: Of 710,974 ED encounters, 97,667 (14%) involved surprise billing. The incidence decreased from 26% in 2010 to 11% in 2017. Mean coinsurance payments were higher for surprise billing encounters and had double the growth from 2010 to 2017 compared to those without surprise billing. Receiving care from different provider types-especially therapists, radiologists, and pathologists, as well as hand surgeons-was associated with significantly higher odds of surprise billing. Transfer to another facility was not significantly associated with surprise billing. CONCLUSIONS: Although the incidence of surprise billing decreased, more than 10% of patients treated in an ED for hand trauma remain at risk. Coinsurance for surprise billing encounters increased by twice as much as encounters without surprise billing. Patients requiring services from therapists, radiologists, pathologists, and hand surgeons were at greater risk for surprise bills. The federal No Surprises Act, passed in 2020, targets surprise billing and may help address some of these issues. CLINICAL RELEVANCE: Many hand and upper extremity patients requiring ED care receive surprise bills from various sources that result in higher out-of-pocket costs.

Preoperative Patient-Reported Data Indicate the Risk of Prolonged Opioid Use After Hand and Upper Extremity Surgeries.

PURPOSE: Opioids play an important role in pain management after surgery but also increase the risk of prolonged opioid use in patients. The identification of patients who are more likely to use opioids after intended short-term treatment is critical for employing alternative management approaches or targeted interventions for the prevention of opioid-related problems. We used patient-reported data (PRD) and electronic health record information to identify factors predictive of prolonged opioid use after surgery. METHODS: We used our institutional registry containing data on all patients who underwent elective upper extremity surgeries. We evaluated factors associated with prolonged opioid use in the cohort from the year 2018 to 2019. We then validated our results using the 2020 cohort. The predictive variables included preoperative PRD and electronic health record data. Opioid use was determined based on patient reports and/or filled opioid prescriptions 3 months after surgery. We conducted bivariate regression, followed by multivariable regression analyses, and model validation using area under the receiver operating curve. RESULTS: We included 2,114 patients. In our final model on the 2018-2019 electronic health records and PRD data (n = 1,589), including numerous patient-reported outcome questionnaire scores, patients who were underweight and had undergone trauma-related surgery had higher odds of being on opioids at 3 months. Additionally, each 5-unit decrease in the preoperative Patient-Reported Outcomes Measurement Information System Global Physical Health score was associated with a 30% increased odds of being on opioids at 3 months. The area under the receiver operating curve of our model was 70.4%. On validation using data from the 2020 cohort, the area under the receiver operating curve was 60.3%. The Hosmer-Lemeshow test indicated a good fit. CONCLUSIONS: We found that preoperative questionnaire scores were associated with prolonged postoperative opioid use, independent of other variables. Furthermore, PRD may provide unique patient-level insights, alongside other factors, to improve our understanding of postsurgical pain management. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Risk Factors for Preventable Emergency Department Use After Outpatient Hand Surgery.

PURPOSE: Emergency department (ED) visits for postoperative concerns that could be safely addressed in outpatient clinics have an impact on cost, quality measures, and care workflows. Patient-reported data (PRD) may give unique insights into individual-level factors that predict overuse of health care resources, and guide opportunities for intervention and prevention. We investigated the relationship between preoperative PRD and preventable ED use after outpatient hand surgery to determine whether the preoperative PRD can be used to identify patients at higher odds of having preventable ED visits. METHODS: All adult patients undergoing outpatient surgery at our hand center between January 1, 2018, and December 31, 2019, were included. Questionnaires, including the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) and pain interference (PI) scales, were completed before surgery. We used our regional health information exchange to identify ED visits within 90 days of surgery. RESULTS: Our cohort included 2,819 patients. Within 90 days after surgery, 106 (3.8%) had preventable ED visits. Race, insurance status, and transportation issues increased odds of a preventable ED visit. Multivariable models found that each 1-point increase in the preoperative PROMIS UE score was associated with 4% decreased odds of ED presentation (odds ratio, 0.96; 95% confidence interval, 0.94-0.99), and each 1-point increase in the preoperative PROMIS PI score was associated with 4% increased odds of ED presentation (odds ratio, 1.04; 95% confidence interval, 1.0-1.1). Any PROMIS UE or PI scores ≥1SDs worse than population norms increased the probability of a preventable ED visit, independent of other factors. CONCLUSIONS: Worse preoperative PROMIS UE and PI scores were associated with increased odds of preventable ED visits. Preoperative PRD may allow for identification of outliers at higher risk for preventable ED use, and facilitate preventative interventions. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

The Syringe External Fixator: Short- and Medium-Term Functional Outcomes From This Inexpensive and Customizable Treatment for Comminuted Intra-Articular Fractures of the Hand.

PURPOSE: Comminuted intra-articular fractures and fracture dislocations of the metacarpophalangeal (MCP) and interphalangeal joints are challenging. Dynamic external fixation, permitting early joint motion while still minimizing forces across the healing joint, can result in acceptable postoperative active range of motion (AROM). However, some fractures are not initially stable enough for early dynamic motion; further, many available dynamic external fixation systems are costly and cumbersome. We reviewed our experience using an external fixator made from a 1-mL syringe and K-wires and report outcomes using it as a static fixator, dynamic fixator, or configured as a static fixator and then converted to a dynamic fixator in the clinic. METHODS: Patients with intra-articular fractures and fracture dislocations of the MCP and proximal interphalangeal (PIP) joints treated between 2014 and 2020 using syringe external fixators were retrospectively reviewed. We reviewed demographics, mechanisms, treatment types and durations, and postoperative AROM, as well as complications including infection, pin loosening, nonunion, hardware failure, and need for further surgery. Patients were analyzed by the level of joint injury (MCP versus PIP) and by treatment pattern. RESULTS: After excluding 23 patients with 25 joint injuries who were lost to follow-up or had inadequate outcome data, 27 patients with 29 joint injuries were reviewed. The average follow-up was 171 days after surgery. The postoperative AROM at the MCP level averaged 55° for static fixation and 30° for static-to-dynamic fixation. The postoperative AROM at the PIP level averaged 64° for static fixation, 66° for static-to-dynamic fixation, and 80° for dynamic fixation. Three pin site infections and 2 loose pins were reported. CONCLUSIONS: The syringe external fixator is an inexpensive, effective, and customizable treatment for intra-articular MCP and interphalangeal fractures and fracture dislocations, and results in acceptable postoperative AROM outcomes and complication rates. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.