Diagnostic Performance of Artificial Intelligence for Detection of Scaphoid and Distal Radius Fractures: A Systematic Review.

PURPOSE: To review the existing literature to (1) determine the diagnostic efficacy of artificial intelligence (AI) models for detecting scaphoid and distal radius fractures and (2) compare the efficacy to human clinical experts. METHODS: PubMed, OVID/Medline, and Cochrane libraries were queried for studies investigating the development, validation, and analysis of AI for the detection of scaphoid or distal radius fractures. Data regarding study design, AI model development and architecture, prediction accuracy/area under the receiver operator characteristic curve (AUROC), and imaging modalities were recorded. RESULTS: A total of 21 studies were identified, of which 12 (57.1%) used AI to detect fractures of the distal radius, and nine (42.9%) used AI to detect fractures of the scaphoid. AI models demonstrated good diagnostic performance on average, with AUROC values ranging from 0.77 to 0.96 for scaphoid fractures and from 0.90 to 0.99 for distal radius fractures. Accuracy of AI models ranged between 72.0% to 90.3% and 89.0% to 98.0% for scaphoid and distal radius fractures, respectively. When compared to clinical experts, 13 of 14 (92.9%) studies reported that AI models demonstrated comparable or better performance. The type of fracture influenced model performance, with worse overall performance on occult scaphoid fractures; however, models trained specifically on occult fractures demonstrated substantially improved performance when compared to humans. CONCLUSIONS: AI models demonstrated excellent performance for detecting scaphoid and distal radius fractures, with the majority demonstrating comparable or better performance compared with human experts. Worse performance was demonstrated on occult fractures. However, when trained specifically on difficult fracture patterns, AI models demonstrated improved performance. CLINICAL RELEVANCE: AI models can help detect commonly missed occult fractures while enhancing workflow efficiency for distal radius and scaphoid fracture diagnoses. As performance varies based on fracture type, future studies focused on wrist fracture detection should clearly define whether the goal is to (1) identify difficult-to-detect fractures or (2) improve workflow efficiency by assisting in routine tasks.

Current Implementation of Quality Measures on American Society for Surgery of the Hand Touching Hands Project Outreach Trips.

PURPOSE: As hand and upper extremity outreach trips increase, guidelines for assessing quality of care are being established. The Global Quality in Upper Extremity Surgery and Training investigators have published validated quality measures deemed to be essential for outreach trips to low and middle-income countries (LMICs). The purpose of this study was to assess baseline implementation of these quality measures across nine international hand surgery outreach sites to LMICs. Additionally, we investigated barriers and facilitators to implementing quality measures and documentation of their implementation. METHODS: We included nine of 12 scheduled 2019 Touching Hands Project trips, excluding independent outreach and teaching mission trips without surgical logs. The team leader from each site received an online questionnaire assessing the documentation and implementation of all 22 quality measures, as well as educational efforts. RESULTS: A total of 350 surgeries were performed in 2019 with seven reported minor complications and no major complications or mortalities. For analysis, 20 of 22 quality measures were included. Of 20 included validated quality measures, 10 were implemented across all surgical outreach sites. Two sites (Bolivia, Nepal) implemented all of the validated quality measures. Quality measures with the lowest implementation rates included ensuring availability of continuous electricity and oxygen supply with associated documentation of a backup plan. All outreach sites reported formal educational efforts. CONCLUSIONS: Implementation of validated quality measures across surveyed outreach sites is variable, indicating an opportunity for improvement. Standardizing documentation of quality measure implementation for each site, confirming availability of resources, increasing accountability by the visiting teams, and fostering stronger relationships with local health care, may increase quality measure implementation and improve quality health care delivery and patient safety in LMICs. CLINICAL RELEVANCE: Benchmarking the implementation of validated quality measures across hand surgical outreach trips provides an opportunity to improve the quality of health care delivered during future hand surgical outreach efforts.

The Effect of Standardized Perioperative Patient Education on Opioid Use After Minor Soft Tissue Procedures Distal to the Wrist.

PURPOSE: Several studies have explored opioid consumption and opioid prescriber education for upper extremity procedures; however, less literature has focused on patient-centered interventions and their impact on opioid consumption after surgery. The purpose of this study was to create a standardized perioperative patient education program regarding postoperative pain management after hand surgery and to determine if it could reduce opioid use after hand surgery. METHODS: Patients scheduled to undergo elective outpatient hand surgery comprising minor soft tissue procedures at and distal to the wrist were randomized to receive pain management education or standard care. Before the surgery, all patients viewed a webinar with instructions for participation, whereas the education group received an additional 10 minutes of education on postoperative pain management and a pain management reference card for review after the surgery. All patients completed a postoperative daily log documenting the number of opioids consumed, other pain management modalities used, and pain scores. The primary outcome of the number of opioid pills consumed by the patients was compared between the groups. We constructed a linear regression model to determine the risk factors for postoperative opioid use after surgery. RESULTS: One hundred seventy-four patients completed the study (n = 90 education group; n = 84 standard care group). Patients in the education group took significantly fewer opioid pills (median = 0, range 0-13) than those in the standard care group (median = 0.5, range 0-40). A linear regression model showed that average week-1 pain (B = 0.93; 95% confidence interval, 0.56-1.3) and the number of pills prescribed (B = 0.12; 95% confidence interval, 0.017-0.22) were predictive of greater opioid use. CONCLUSIONS: Perioperative patient education significantly reduced postoperative opioid use following a minor soft tissue hand surgery, with greater than 70% of the patients taking no opioids. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

How Do Areas of Work Life Drive Burnout in Orthopaedic Attending Surgeons, Fellows, and Residents?

BACKGROUND: Concerning levels of burnout have been reported among orthopaedic surgeons and residents. Defined as emotional exhaustion and depersonalization, physician burnout is associated with decreased productivity, increased medical errors, and increased risk of suicidal ideation. At the center of burnout research, person-centered approaches focusing on individual characteristics and coping strategies have largely been ineffective in solving this critical issue. They have failed to capture and address important institutional and organizational factors contributing to physician burnout. Similarly, little is known about the relationship between burnout and the working environments in which orthopaedic physicians practice, and on how orthopaedic surgeons at different career stages experience and perceive factors relevant to burnout. QUESTIONS/PURPOSES: (1) How does burnout differ among orthopaedic attending surgeons, fellows, and residents? (2) What specific areas of work life are problematic at each of these career stages? (3) What specific areas of work life correlate most strongly with burnout at each of these career stages? METHODS: Two hundred orthopaedic surgeons (residents, fellows, and attending physicians) at a single institution were invited to complete an electronic survey. Seventy-four percent (148 of 200) of them responded; specifically, 43 of 46 residents evenly distributed among training years, 18 of 36 fellows, and 87 of 118 attending physicians. Eighty-three percent (123 of 148) were men and 17% (25 of 148) were women. Two validated questionnaires were used. The Maslach Burnout Inventory was used to assess burnout, measuring emotional exhaustion and depersonalization. The Areas of Worklife Survey was used to measure congruency between participants and their work environment in six domains: workload, control, reward, community, fairness, and values. Participants were invited to openly share their experiences and suggest ways to improve burnout and specific work life domains. The main outcome measures were Maslach Burnout Inventory subdomains of emotional exhaustion and depersonalization, and Areas of Worklife Survey subdomains of workload, control, reward, community, fairness and values. We compared outcome measures of burnout and work life between groups. Simple linear regression models were used to report correlations between subscales. Stratified analyses were used to identify which group demonstrated higher correlations. All open comments were analyzed and coded to fully understand which areas of work life were problematic and how they were perceived in our population. RESULTS: Nine percent (7 of 80) of attending surgeons, 6% (1 of 16) of fellows, and 34% (14 of 41) of residents reported high levels of depersonalization on the Maslach Burnout Inventory (p < 0.001). Mean depersonalization scores were higher (worse) in residents followed by attending surgeons, then fellows (10 ± 6, 5 ± 5, 4 ± 4 respectively; p < 0.001). Sixteen percent (13 of 80) of attending surgeons, 31% (5 of 16) of fellows, and 34% (14 of 41) of residents reported high levels of emotional exhaustion (p = 0.07). Mean emotional exhaustion scores were highest (worse) in residents followed by attending surgeons then fellows (21 ± 12, 17 ± 10, 16 ± 14 respectively; p = 0.11). Workload was the most problematic work life area across all stages of orthopaedic career. Scores in the Areas of Worklife Survey were the lowest (worse) in the workload domain for all subgroups: residents (2.6 ± 0.4), fellows (3.0 ± 0.6), and attending surgeons (2.8 ± 0.7); p = 0.08. Five problematic work life categories were found through open comment analysis: workload, resources, interactions, environment, and self-care. Workload was similarly the most concerning to participants. Specific workload issues identified included administrative load (limited job control, excessive tasks and expectations), technology (electronic medical platform, email overload), workflow (operating room time, patient load distribution), and conflicts between personal, clinical, and academic roles. Overall, worsening emotional exhaustion and depersonalization were most strongly associated with increasing workload (r = - 0.50; p < 0.001; and r = - 0.32; p < 0.001, respectively) and decreasing job control (r = - 0.50; p < 0.001, and r = - 0.41; p < 0.001, respectively). Specifically, in residents, worsening emotional exhaustion and depersonalization most strongly correlated with increasing workload (r = - 0.65; p < 0.001; and r = - 0.53; p < 0.001, respectively) and decreasing job control (r = - 0.49; p = 0.001; and r = - 0.51; p = 0.001, respectively). In attending surgeons, worsening emotional exhaustion was most strongly correlated with increasing workload (r = - 0.50; p < 0.001), and decreasing job control (r = - 0.44; p < 0.001). Among attending surgeons, worsening depersonalization was only correlated with increasing workload (r = - 0.23; p = 0.04). Among orthopaedic fellows, worsening emotional exhaustion and depersonalization were most strongly correlated with decreasing sense of fairness (r = - 0.76; p = 0.001; and r = - 0.87; p < 0.001, respectively), and poorer sense of community (r = - 0.72; p = 0.002; and r = - 0.65; p = 0.01, respectively). CONCLUSIONS: We found higher levels of burnout among orthopaedic residents compared to attending surgeons and fellows. We detected strong distinct correlations between emotional exhaustion, depersonalization, and areas of work life across stages of orthopaedic career. Burnout was most strongly associated with workload and job control in orthopaedic residents and attending surgeons and with fairness and community in orthopaedic fellows. CLINICAL RELEVANCE: Institutions wishing to better understand burnout may use this approach to identify specific work life drivers of burnout, and determine possible interventions targeted to orthopaedic surgeons at each stage of career. Based on our institutional experience, leadership should investigate strategies to decrease workload by increasing administrative support and improving workflow; improve sense of autonomy by consulting physicians in decision-making; and seek to improve the sense of control in residents and sense of community in fellows.

The Epidemiology of Carpal Tunnel Revision Over a 1-Year Follow-Up Period.

PURPOSE: To establish the incidence of revision carpal tunnel surgery within a 1-year postoperative period using a national administrative database. This information has been unknown until this point because of the absence of laterality-specific coding with the International Classification of Diseases, Ninth Edition and earlier coding systems. METHODS: Data were collected from the Humana insurance database using PearlDiver patient records from 2015 to 2017. Subjects were identified using Current Procedural Terminology and International Classification of Diseases procedure codes related to carpal tunnel diagnosis and release. Codes were used to identify patients who underwent carpal tunnel release (CTR) and had revision CTR within a 1-year follow-up period. Patient demographic characteristics, including age, sex, medical comorbidities, and smoking status, were collected. In addition, multivariable analysis of the risk of a revision procedure within 1 postoperative year was performed to determine independent risk factors, including the surgical approach, associated with revision CTR. RESULTS: Among 4,549 patients who underwent a primary CTR during the study period, 207 patients (4.8%) underwent a revision CTR within 1 year. The average time from the primary CTR to the revision CTR was 135 days (standard deviation, 99.1 days; range, 21-365 days). Primary endoscopic CTR was associated with an increased rate of revision CTR (odds ratio, 1.3; 95% confidence interval, 1.2-1.6). Patient factors associated with a higher likelihood of requiring revision CTR included diabetes mellitus, tobacco use, psychiatric condition, cervical disease, and history of cubital tunnel release. CONCLUSIONS: This study identified a rate of revision CTR of 4.8% within the first postoperative year. Both the surgical technique and patient-specific risk factors influence the likelihood of requiring revision surgery. Notably, an endoscopic approach is associated with a higher risk of revision surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Level of Evidence and Publication Rates of Abstracts Presented at the American Society for Surgery of the Hand Annual Meetings: Comparison Over 23 Years.

PURPOSE: The primary aims of this study were to determine how level of evidence and publication rates of American Society for Surgery of the Hand (ASSH) abstracts presented at the national meeting have changed over the past 23 years. METHODS: Abstracts presented at the ASSH annual meeting from 1992 to 2014 were reviewed. Level of evidence (LoE) and publication status for each abstract were recorded. We calculated annual and overall LoE, publication rates, average time to publication, and top journals of publication for abstracts presented from 1992 to 2014. The LoE was categorized into level 1 or 2 studies, levels 3 to 5 studies, or nonclinical study. RESULTS: A total of 1,757 abstracts were presented at ASSH meetings from 1992 to 2014; 942 abstracts were published in peer-reviewed journals for an overall publication rate of 53.6%. There was a significant increase in the proportion of levels 1 to 2 LoE abstracts over time (18% in 2007-2014 vs 11% in 1999-2006 and 2% in 1992-1998). There was also a significantly higher percentage of abstracts published over time (62% in 2007-2014 vs 52% in 1999-2006 and 47% in 1992-1998). Levels 1 to 2 LoE studies were associated with higher publication rates than nonclinical or levels 3 to 5 LoE studies. CONCLUSIONS: This research provides historical trends on the LoE of abstracts presented at the ASSH annual meetings. Our study shows there are increasing numbers of levels 1 to 2 studies as well as higher publication rates of abstracts presented at more recent ASSH annual meetings. Levels 1 to 2 studies are more likely to be published than nonclinical or levels 3 to 5 studies. CLINICAL RELEVANCE: Although not all questions can be feasibly answered with level 1 or level 2 studies, authors should continue to search for ways to strengthen study designs, producing more valid and comparable results with increased likelihood of publication driving forward the quality of hand surgery research. Higher recent publication rates may be partially due to the increased number of available journals for publication.

Cadaveric Evaluation of Myelinated Nerve Fiber Count in the Nerve to the Gracilis Muscle in Relation to Use as a Free Functional Muscle Transfer for Elbow Flexion.

BACKGROUND: Optimizing axon count is essential for successful nerve transfer surgery, and a donor-to-recipient axon count ratio greater than 0.7:1 has been associated with improved outcomes. A gracilis free functioning muscle transfer (FFMT) is an option to restore elbow flexion, but its axon count has not been evaluated. Our aim was to quantify the axon count of the nerve to the gracilis muscle. METHODS: The nerve to the gracilis was dissected in 10 fresh frozen adult cadaveric hindquarter specimens (four females and six males). The length of the nerve to the gracilis was measured and a biopsy taken. A validated histologic preparation technique was utilized, and axons were counted. The mean length and axon counts were calculated. RESULTS: The average axon count in the nerve to the gracilis was 818 (range = 684-1,000, standard deviation [SD] = 116). The average length was 98 mm (range = 81-115 mm, SD = 13 mm). CONCLUSION: Our study found the average axon count in the nerve to the gracilis was 818. Prior literature suggests axon count ratio greater than 0.7:1 is associated with better clinical outcomes. Using data from prior studies, the spinal accessory, three intercostal, and two intercostal nerves are all sufficient for the transfer to the nerve to the gracilis with donor to recipient ratios of 1.7:1, 1.3:1, and 0.9:1, respectively.

Current Fixation Options for Elbow, Forearm, Wrist, and Hand Fractures.

The universal goals of upper limb fracture management are to restore anatomic alignment, establish stable fracture fixation (while preserving blood supply), and allow for early mobilization of the elbow, wrist, and digits. However, the indications for operative management and fixation constructs are specific to each fracture type. This article systematically reviews current classifications and treatment options for adult fractures of the distal humerus, radius, ulna, scaphoid, metacarpals, and phalanges. For each anatomic location, we discuss the salient imaging features to guide management decisions (conservative versus internal and/or external fixation). Specifically, we emphasize the amount of displacement, angulation, comminution, and/or intra-articular involvement typically guiding operative management for each fracture type. Through this understanding of the surgical indications, rationale behind different fixation options, and common complications, the radiologist can better support the orthopaedic surgeon via more informed fracture reporting.

The Relationship Between Pain-Related Psychological Factors and Postoperative Opioid Use After Ambulatory Hand Surgery.

PURPOSE: Pain-related psychological factors, including pain catastrophizing and dispositional mindfulness, have been shown to influence patient pain levels and outcomes after orthopedic surgery. Less is known about the relationship between these factors and postoperative opioid use after hand surgery. The purpose of this study was to examine the association between preoperative pain catastrophizing and mindfulness and postoperative opioid use in patients undergoing ambulatory hand surgery. METHODS: Patients undergoing ambulatory hand surgery at our institution between May 2017 and January 2018 were prospectively enrolled in an ongoing clinical trial. Patients completed the Pain Catastrophizing Scale (PCS) and Mindfulness Attention Awareness Scale (MAAS) before surgery. Patients completed a pain medication diary for 2 weeks after surgery and were contacted on postoperative days 3, 8, and 15 to review their medication usage and pain levels. Analyses were performed to evaluate the association between PCS, MAAS scores, and postoperative opioid use, average patient reported pain levels, and refill rates. RESULTS: A total of 85 patients were included in the analysis. Higher PCS scores (representing more pain catastrophizing) were associated with increased number of opioid pills consumed, higher average pain levels during the first postoperative week, and higher refill rates. Higher MAAS scores (representing more mindfulness) were associated with lower average week-1 pain levels but not significantly associated with opioid use or refill rates. CONCLUSIONS: Patients demonstrating higher PCSs before surgery used more opioids after surgery after a range of ambulatory hand surgeries. In the setting of the opioid epidemic, hand surgeons should be aware of pain-related psychological factors that can influence postoperative opioid use. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Opioid Prescriber Education and Guidelines for Ambulatory Upper-Extremity Surgery: Evaluation of an Institutional Protocol.

PURPOSE: Recent studies demonstrated the overprescription of opioids after ambulatory hand surgery in the setting of a national opioid epidemic. Prescriber education has been shown to decrease these practices on a small scale; however, currently no nationally standardized prescriber education or postoperative opioid prescribing guidelines exist. The purpose of this study was to evaluate the effect of prescriber opioid education and postoperative opioid guidelines on prescribing practices after ambulatory hand surgery. MATERIALS AND METHODS: This retrospective study was performed at an academic orthopedic hospital. In November, 2016, all prescribers were mandated to undergo a 1-hour opioid education program. Prescribing guidelines for the hand service were formulated based on literature review and expert opinion and were released in February, 2017. We reviewed all postoperative opioid prescriptions for patients who underwent ambulatory hand and upper-extremity surgery 4 months before the mandatory education (preeducation group) and 4 months (immediate postguideline group) and 9 to 11 months (intermediate postguideline group) after the guideline dissemination. RESULTS: A total of 1,348 ambulatory hand surgeries (435 in the preeducation, 490 in the immediate postguideline group, and 423 in the intermediate postguidelines groups) with postoperative opioid prescriptions met inclusion criteria. Mean reduction in total prescribed oral morphine equivalents was 52.3% after guidelines disseminated. The number of opioid pills prescribed to patients decreased significantly in the postguideline groups when stratified by procedure type and surgery level. CONCLUSIONS: Prescriber education and postoperative opioid guideline dissemination led to significant decreases in the number of opioid pills prescribed after ambulatory hand surgery. Development and dissemination of nationally standardized prescriber education and opioid guidelines may significantly reduce the amount of opioid medications prescribed after hand surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Insulin Dependence Is Associated With Increased Risk of Complications After Upper Extremity Surgery in Diabetic Patients.

Diabetes mellitus (DM) is associated with the development of carpal tunnel syndrome, Dupuytren disease, trigger digits, and limited joint mobility. Despite descriptions of poorer response to nonsurgical treatment, previous studies have not shown increased complication rates in diabetic patients after hand surgery. Few studies, however, differentiate between insulin-dependent (IDDM) and non-insulin-dependent (NIDDM) diabetes mellitus. The purpose of this study was to evaluate the impact of insulin dependence on the postoperative risk profile of diabetic patients after hand surgery using a national database. MATERIALS AND METHODS: The data were obtained through the National Surgical Quality Improvement Program (NSQIP) database. Patients undergoing surgery from the distal humerus to the hand, between 2005 and 2015, were identified using 297 distinct Current Procedural Terminology codes. Thirty-day postoperative complications were collected and categorized into medical complications, surgical site complications, and readmission. Surgical complications, medical complications, and readmissions were compared between patients with NIDDM or IDDM to those without DM using multivariable logistic regression, adjusting for baseline patient and operative characteristics. RESULTS: The study cohort included 52,727 patients. Patients with IDDM had a 5.7% overall complication rate compared with 2.3% and 1.5% in NIDDM and nondiabetic patients, respectively. After controlling for differences in patient and surgical characteristics, patients with IDDM had a statistically significant increased rate of any complication, surgical site complications, superficial surgical site infections, and readmission. There was no significant difference in complication rates between patients with NIDDM and nondiabetic patients. CONCLUSIONS: Our data demonstrate a greater risk of complications following hand and upper extremity surgery for patients with IDDM, specifically surgical site infections. The NIDDM patients did not have an increased rate of complications relative to nondiabetic patients. These findings are important for patient risk stratification and may guide further investigation to decrease complication rates in IDDM patients after upper extremity surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Postburn contractures of the hand.

Several functionally limiting sequelae can follow deep thermal injury to the hand. Despite appropriate initial management, contractures are common. Whereas acute burn care is often managed by multidisciplinary, specialized burn units, postburn contractures may be referred to hand surgeons, who should be familiar with the patterns of burn contracture and nonsurgical and operative options to improve function and expected outcomes. The most common and functionally limiting sequelae are contractures of the webspace, hand, and digits. Webspace contractures and postburn syndactyly are managed with scar excision and local soft tissue rearrangement or skin grafting. The burn claw hand presents as extension contracture of the metacarpophalangeal joints and flexion contractures of the proximal interphalangeal joints. The mainstays of management of these contractures include complete surgical excision of scar tissue and resurfacing of the resultant soft tissue defect, most commonly with full-thickness skin grafts. If scar contracture release results in major exposure of the tendons or joints, distant tissue transfer may be required. Early motion and rehabilitative modalities are essential to prevent initial contracture formation and recontracture after surgical release.

Opportunities for Increasing Diversity in Orthopaedics Through Virtual Mentorship Programs.

Orthopaedic surgery lags in recruiting women and under-represented minorities (URMs). In addition, women and URMs hold fewer leadership roles across orthopaedic subspecialties. This inequity is geographically heterogeneous, with female URM residents and attendings being more concentrated in some areas of the country. For instance, practicing female orthopaedic surgeons are more prevalent in Northeast and Pacific programs. Mentorship and representation in leadership positions play a notable role in trainee recruitment. Video communication platforms offer a novel mechanism to reach historically under-represented students across the country. We reviewed five established mentorship programs focused on women and URMs. Each program emphasized a longitudinal relationship between mentors and mentees. In reviewing these programs, we sought to identify the successful components of each program. Leveraging and integrating effective components already established by conventional mentorship programs into virtual programming will aid in optimizing those programs and improve geographic equity in access to mentorship resources. It is critical to extend the principles of successful mentorship programs to technology-enabled programs moving forward.

Epidemiology of carpal tunnel syndrome in patients with single versus multiple trigger digits.

PURPOSE: Previous studies have identified the association between trigger digit and carpal tunnel syndrome (CTS). However, whether the presence of multiple trigger digits affects the prevalence of CTS is unknown. The purpose of this study was to determine the incidence of carpal tunnel symptoms in patients treated for single versus multiple trigger digits. METHODS: We performed a retrospective review of 300 patients treated for trigger digit by injection or surgical release and recorded CTS symptoms, signs, and treatment for either the ipsilateral or contralateral hand documented within 24 months before trigger digit treatment and for an average of 35 months (range, 7- 66 mo) after treatment. Patients were categorized as having single (n = 160) or multiple (n = 140) trigger digits. Binary logistic regression modeled risk factors for development of CTS. Patient age, sex, number of trigger digits (single or multiple), and presence of diabetes, gout, thyroid disease, or thumb osteoarthritis were considered independent variables. RESULTS: A total of 58 of 140 patients (41%) who presented with multiple trigger digits exhibited concomitant carpal tunnel symptoms, compared with 26 of 160 (16%) patients who presented with a single trigger digit. Significant independent predictors of CTS associated with trigger digits in the final regression model included multiple trigger digits (odds ratio = 3.6; subjects with multiple trigger digits had significantly higher odds of carpal tunnel presentation than subjects with a single trigger digit) and diabetes (odds ratio = 1.9; diabetic subjects had significantly higher odds of carpal tunnel presentation than nondiabetics). CONCLUSIONS: A greater than 3-fold increase in the relative risk of CTS development exists in patients undergoing treatment for multiple trigger digits, compared with those undergoing treatment for a single trigger digit. Awareness of this association may aid in the early diagnosis and treatment of CTS in patients presenting with multiple trigger digits. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.

Incidence of Trigger Finger in Surgically and Nonsurgically Managed Carpal Tunnel Syndrome.

Purpose: The purpose of this study was to determine whether extremities undergoing carpal tunnel release (CTR) have an increased rate of trigger finger (TF) compared with conservatively managed carpal tunnel syndrome. Methods: Data were collected from the Humana Insurance Database, and subjects were chosen on the basis of a history of CTR with propensity matching performed to develop a nonsurgical cohort. Following propensity matching, 16,768 patients were identified and equally split between surgical and nonsurgical treatments. Demographic information and medical comorbidities were recorded. Univariate and multivariate analyses were performed to identify risk factors for the development of TF within 6 months of carpal tunnel syndrome diagnosis. Results: Patients in the surgical cohort were more likely to develop TF than those in the nonsurgical cohort whether in the ipsilateral or contralateral extremity. Whether managed surgically or nonsurgically, extremities with carpal tunnel syndrome demonstrated an increased prevalence of TF than their contralateral, unaffected extremity. Conclusions: Surgeons should be aware of the association of TF and CTR both during the presurgical and postsurgical evaluations as they might impact patient management. With knowledge of these data, surgeons may be more attuned to detecting an early TF during the postsurgical period and offer more aggressive treatment of TF pathology during CTR. Type of study/level of evidence: Prognostic III.

No Difference in Reintervention at 1-Year Between Ultrasound-Guided versus Blind Dorsal Carpal Ganglion Aspiration.

Purpose: The purpose of this retrospective comparative study was to compare the efficacy of dorsal carpal ganglion aspiration in patients who underwent either "blind" (using surface anatomy alone) or ultrasound-guided (US-guided) aspiration. Methods: Outcome measures were conducted during the coronavirus disease 2019 pandemic via telephone for a minimum of 12 months after aspiration, with efficacy defined by reintervention with either repeat aspiration or surgical excision. Results: Data are reported for 141 patients (46 blind; 95 US-guided) at an average of 28 months (range, 12-55 months) from aspiration. Reintervention was not significantly different based on the mode of aspiration-26% and 24% for blind aspiration and US-guided, respectively. Patient-perceived recurrence was higher at 65% for the entire cohort. Patients who received steroid injection at the time of aspiration perceived lower rates of recurrence-44% versus 77% for patients who received a steroid injection and patients who did not, respectively. Conclusions: This study found no significant difference between blind or US-guided aspiration in reintervention at a minimum of 1-year follow-up. Patients who received steroids at the time of aspiration perceived lower rates of recurrence. Type of study/level of evidence: Therapeutic III.

Evaluation of Racial, Ethnic, and Socioeconomic Disparities in Indication for Carpal Tunnel Release.

BACKGROUND: Disparities in the utilization of orthopaedic surgery based on race and ethnicity continue to be reported. We examined the impact of sociodemographic factors on treatment recommendation by hand surgeons for carpal tunnel syndrome (CTS) of similar disease severity. METHODS: Patients with electrodiagnostic study (EDS)-confirmed CTS were evaluated at a single institution between 2016 and 2020. Data including patient age, sex, race/ethnicity, ZIP Code, and EDS severity were collected. The primary outcome was the recommended treatment by the hand surgeon at the first clinic visit according to patient race/ethnicity and the Social Deprivation Index (SDI). Secondary outcomes included the treatment selected by patients (nonsurgical or surgical) and the time to surgery. RESULTS: The 949 patients had a mean age of 58 years (range, 18 to 80 years); 60.5% (n = 574) were women. The race/ethnicity of the patient cohort was 9.8% (n = 93) Black non-Hispanic, 11.2% (n = 106) Hispanic/Latino, 70.3% (n = 667) White non-Hispanic, and 8.7% (n = 83) "other." Overall, Black non-Hispanic patients (38.7%; odds ratio, [OR] 0.62; 95% confidence interval [CI], 0.40 to 0.96) and Hispanic/Latino patients (35.8%; OR, 0.55; 95% CI, 0.36 to 0.84) were less likely to have surgery recommended at their first visit compared with White non-Hispanic patients (50.5%). This was no longer apparent after adjusting for demographic and clinical variables including EDS severity and SDI (Black non-Hispanic patients: adjusted odds ratio [aOR], 0.67; 95% CI, 0.4 to 1.11; Hispanic/Latino patients: aOR, 0.69: 95% CI, 0.41 to 1.14). Across all categories of EDS severity, surgeons were less likely to recommend surgery to patients with a higher SDI (aOR: 0.66, 0.64, and 0.54 for quintiles 2, 3 and 4, respectively). When surgery was recommended, patients in the highest SDI quintile were less likely to proceed with surgery (p = 0.032). There was no association between patient race/ethnicity and the treatment selected by the patient or time to surgery (p = 0.303 and p = 0.725, respectively). CONCLUSIONS: Patients experiencing higher levels of social deprivation were less likely to be recommended for CTS surgery and were less likely to proceed with surgery, regardless of patient race/ethnicity. Additional investigation into the social factors influencing both surgeon and patient selection of treatment for CTS, including the impact of patient socioeconomic background, is warranted. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Assessing Gender Differences in Technical Skills and Confidence in Orthopaedic Surgery Residency Applicants.

INTRODUCTION: Variations in confidence for procedural skills have been demonstrated when comparing male and female medical students in surgical training. This study investigates whether differences in technical skill and self-reported confidence exist between male and female medical students applying to orthopaedic residency. METHODS: All medical students (2017 to 2020) invited to interview at a single orthopaedic residency program were prospectively evaluated on their technical skills and self-reported confidence. Objective evaluation of technical skill included scores for a suturing task as evaluated by faculty graders. Self-reported confidence in technical skills was assessed before and after completing the assigned task. Scores for male and female students were compared by age, self-identified race/ethnicity, number of publications at the time of application, athletic background, and US Medical Licensing Examination Step 1 score. RESULTS: Two hundred sixteen medical students were interviewed, of which 73% were male (n = 158). No gender differences were observed in suture task technical skill scores or mean difference in simultaneous visual task scores. The mean change from pre-task and post-task self-reported confidence scores was similar between sexes. Although female students trended toward lower post-task self-reported confidence scores compared with male students, this did not achieve statistical significance. Lower self-reported confidence was associated with a higher US Medical Licensing Examination score and with attending a private medical school. DISCUSSION: No difference in technical skill or confidence was found between male and female applicants to a single orthopaedic surgery residency program. Female applicants trended toward self-reporting lower confidence than male applicants in post-task evaluations. Differences in confidence have been shown previously in surgical trainees, which may suggest that differences in skill and confidence may develop during residency training.

Boston Carpal Tunnel Questionnaire Scores Alone Do Not Predict Surgical Intervention for Patients With Carpal Tunnel Syndrome.

BACKGROUND: With the expanded indications for telemedicine, there is increased utility for screening methods to determine which patients are likely to progress to surgical intervention, requiring in-person visits. Patient-rated tools such as the Boston Carpal Tunnel Questionnaire (BCTQ) may be one such tool for screening patients with carpal tunnel syndrome (CTS). The aim of the study was to evaluate whether BCTQ scores were predictive of offering conservative treatment or surgical intervention for CTS. METHODS: Patients diagnosed with CTS from January 2017 to February 2020 completed BCTQ questionnaires prior to in-person office visits. Demographics, comorbidities, and highest level of intervention recommended were recorded for each patient as conservative, injection, or surgery. Pearson χ2 and independent-samples t tests were conducted to determine whether BCTQ symptom severity and functional scores were associated with intervention type. RESULTS: A total of 200 patients with CTS were included. Of these, 103 were recommended conservative or injection treatment and 97 were recommended surgery. There were no differences in comorbidities between groups, including other upper extremity pathology (P = .57), previous upper extremity surgery (P = .32), hypertension (P = .17), hypothyroidism (P = .15), rheumatoid arthritis (P = .34), and diabetes (P = .30). Between these groups, there were no differences in BCTQ symptom severity score (symptom severity scale [SSS]; P = .16) or BCTQ functional severity score (functional severity scale [FSS]; P = .96). CONCLUSIONS: There is no correlation between comorbidities and BCTQ SSS or FSS score, and offering surgery for CTS. In an era of minimizing non-essential health care visits, the BCTQ is insufficient in screening patients as potential surgical candidates.

Magnetic Resonance Angiography of the Hand Vasculature in Patients With Systemic Sclerosis and Systemic Lupus Erythematosus.

BACKGROUND: When patients with systemic sclerosis (SSc) and systemic lupus erythematosus (SLE) develop digital ischemia, conventional angiography (CA) is traditionally used to assess hand vasculature. Recently, Chang et al described an angiographic classification system for patients with SSc. Conventional angiography uses intravascular contrast agents that are nephrotoxic and vasoconstrictive. Owing to these limitations, this study assesses the use of contrast-enhanced magnetic resonance angiography (MRA) as an alternative to CA to evaluate hand vasculature in patients with digital ischemia. METHODS: This retrospective case series reports on 38 contrast-enhanced MRAs of hand vasculature from 30 symptomatic patients with SSc (N = 21) or SLE (N = 9). The radial and ulnar arteries (RA, UA) and the superficial and deep palmar arches were evaluated at standard reference points both quantitatively and qualitatively for their diameter, patency, and Chang classification. RESULTS: In SSc MRAs (n = 26), the UA was significantly smaller than the RA and was occluded in 46%. In SLE MRAs (n = 12), the UA and RA had no difference in diameter and the UA was occluded in 25%. In SSc, the most common Chang classification was type 2 (UA involvement) in 44%. In SLE, the most common Chang classification was type 4 (UA and RA involvement) in 45%, with 18% classified as type 2. CONCLUSIONS: Contrast-enhanced MRA used to assess hand vasculature in SSc patients with digital ischemia shows similar patterns of vascular involvement as previously demonstrated by CA. While vascular involvement in SSc predominantly involves the UA, the RA is also frequently involved in SLE.