Professionalism in Hand Surgery: Treating the Noncompliant Patient.

Every practicing hand surgeon has had the challenging experience of treating a patient who demonstrates difficulty with, or inability to comply with medical advice. Patient noncompliance can lead to not only poor patient outcomes but also deterioration in the therapeutic relationship, physician burnout, high cost of care, and medical-legal risk. The guiding principles in the ethical practice of medicine render it important to consider noncompliance as a potentially modifiable risk factor, and every attempt should be made to work with these noncompliant patients to achieve the best possible outcomes. Data suggest that noncompliance may be affected by socioeconomic status and race; many of these patients are among the vulnerable. However, in some instances, treatment options may warrant alteration or adjustment to reflect the noncompliance of the patient. Rarely, it may be reasonable for a physician to discharge a patient from care once any urgent problems have been managed. Ethical and responsible management of a noncompliant patient requires a thoughtful and measured approach.

Iliac Crest Bone Graft Harvest for Alveolar Cleft Repair: A Systematic Review Comparing Minimally Invasive Trephine and Conventional Open Techniques.

Background: In the course of developing a standardized pathway for alveolar cleft repair, we conducted a systematic review comparing minimally invasive trephine with conventional open technique for iliac crest bone graft harvest in a pediatric population. Methods: A systematic review was conducted of studies comparing open with minimally invasive trephine techniques in pediatric populations undergoing alveolar cleft repair. Exclusion criteria included reviews, case series, editorials, abstracts, and those with adult-only populations. Data were compiled with outcome variables selected a priori. Results: Of 422 manuscripts screened, five met criteria. These comprised 257 patients (116 open, 141 trephine). Average age was 11 years. Patients undergoing trephine harvest had reduced length of stay (1.0-5.0 days trephine vs 1.25-5.4 days open), time to unassisted ambulation (16-46 hours vs 20-67 hours open), and less postoperative narcotic use (0.31 mg/kg vs 1.64 mg/kg IV morphine). Volume of cancellous bone was reported as 2.53 mL for open versus 1.22 mL for trephine in one study, and trephine graft was supplemented with demineralized bone in 54% of cases in another study. The use of anesthetic adjuncts was inconsistent but had a significant effect on postoperative pain and ambulation. Conclusions: Compared to open techniques, the minimally invasive trephine bone graft harvest is associated with a shorter time to discharge, slightly lower infection rates, and reduced opioid use. The possible benefits of trephine harvest must however be balanced against the risk of insufficient graft harvest. Finally, the choice of perioperative analgesic adjuncts significantly impacts patient outcomes regardless of the technique employed.

Contexte: Dans le cours de l'élaboration d'une méthode standardisée de réparation des fentes palatines, nous avons réalisé une revue systématique comparant la technique par tréphine peu invasive à la technique conventionnelle ouverte pour la collecte d'os de la crête iliaque dans une population pédiatrique. Méthodes: Une revue systématique a été réalisée sur les études comparant les techniques ouvertes avec les techniques utilisant une tréphine peu invasive dans des populations pédiatriques subissant une réparation de fente palatine. Les critères d'exclusion incluaient les revues, les séries de cas, les éditoriaux, les résumés et les études ne portant que sur une population adulte. Les données ont été compilées avec des variables de résultats sélectionnées a priori. Résultats: Parmi les 422 manuscrits sélectionnés, cinq répondaient aux critères. Ils incluaient 257 patients (116 techniques ouvertes, 141 tréphines). L'âge moyen des patients était de 11 ans. Les patients pour lesquels une collecte avait été obtenue par tréphine avaient une durée de séjour plus courte (tréphine : 1,0 à 5,0 jours; contre technique ouverte : 1,25 à 5,4 jours), un délai de déambulation non aidée plus court (16 à 46 heures contre 20 à 67 heures pour la technique ouverte) et un moindre recours aux antalgiques postopératoires (0,31 mg/kg contre 1,64 mg/kg de morphine IV). Le volume d'os spongieux collecté était de 2,53 ml avec les techniques ouvertes contre 1,22 ml avec la tréphine; le greffon par tréphine a été complété par de l'os déminéralisé dans 54% des cas dans une autre étude. L'utilisation de suppléments anesthésiques n'était pas homogène, mais a eu un effet significatif sur la douleur postopératoire et la déambulation. Conclusions: Comparativement aux techniques ouvertes, la collecte peu invasive de greffon osseux par tréphine est associée à une délai de congé plus court, des taux d'infections légèrement inférieurs et à une moindre utilisation d'opioïdes. Toutefois, les avantages éventuels de la collecte par tréphine doivent être soupesés par rapport au risque de collecte insuffisante de greffon. Enfin, le choix de suppléments analgésiques périopératoires a des répercussions significatives sur l'évolution des patients, indépendamment de la technique employée.

A Matched Comparison of Postoperative Complications Between Smokers and Nonsmokers Following Open Reduction Internal Fixation of Distal Radius Fractures.

PURPOSE: The purpose of the present study was to identify differences in 30-day adverse events, reoperations, readmissions, and mortality for smokers and nonsmokers who undergo operative treatment for a distal radius fracture. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for patients who had operatively treated distal radius fractures between 2005 and 2017. Patient characteristics and surgical variables were assessed. Thirty-day outcome data were collected on serious (SAEs) and minor adverse events (MAEs), as well as on infection, return to the operating room, readmission, and mortality. Multivariable logistic analyses with and without propensity-score matching was used to compare outcome measures between the smoker and the nonsmoker cohorts. RESULTS: In total, 16,158 cases were identified, of whom 3,062 were smokers. After 1:1 propensity-score matching, the smoking and nonsmoking cohorts had similar demographic characteristics. Based on the multivariable propensity-matched logistic regression, cases in the smoking group had a significantly higher rate of any adverse event (AAE) (odds ratio [OR], 1.75; 95% confidence interval [95% CI], 1.28-2.38), serious adverse event (SAE) (OR, 1.75; 95% CI, 1.22-2.50), and minor adverse event (MAE) (OR, 1.84; 95% CI, 1.04-3.23). Smokers also had higher rates of infection (OR, 1.73; 95% CI, 1.26-2.39), reoperation (OR, 2.07; 95% CI, 1.13-3.78), and readmission (OR, 1.83; 95% CI, 1.20-2.79). There was no difference in 30-day mortality rate. CONCLUSIONS: Smokers who undergo open reduction internal fixation of distal radius fractures had an increased risk of 30-day perioperative adverse events, even with matching and controlling for demographic characteristics and comorbidity status. This information can be used for patient counseling and may be helpful for treatment/management planning. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Rehydrating efficacy of maple water after exercise-induced dehydration.

Dehydration impairs physiological function and physical performance, thus understanding effective rehydration strategies is paramount. Despite growing interest in natural rehydrating beverages, no study has examined maple water (MW). PURPOSE: To investigate the rehydrating efficacy of MW after exercise-induced dehydration. METHODS: Using a single-blind, counterbalanced, crossover design, we compared the rehydrating efficacy of MW vs. maple-flavored bottled water (control) in 26 young healthy (22 ± 4 yrs., 24 ± 4 kg/m2) males (n = 13) and females (n = 13) after exercise-induced dehydration (~ 2.0%ΔBody Weight [BW]) in the heat (30 °C, 50% relative humidity [RH]). Hydration indicators (BW, salivary and urine osmolality [SOsm/UOsm], urine specific gravity [USG], urine volume [UV], urine color [UC]), thirst, fatigue, and recovery (heart rate [HR)], and HR variability [HRV]) were taken at baseline, post-exercise, 0.5, 1, and 2 h post-consumption of 1 L of MW or control. RESULTS: Following similar dehydration (~ 2%ΔBW), MW had no differential (p > 0.05) impact on any measure of rehydration. Likely due to greater beverage osmolality (81 ± 1.4 vs. 11 ± 0.7 mOsmol/kg), thirst sensation remained 12% higher with MW (p <  0.05). When sex was considered, females had lower UV, elevated UOsm (p < 0.05), trends for higher ΔBW, USG, but similar SOsm. Analysis of beverages and urine for antioxidant potential (AP) revealed a four-fold greater AP in MW, which increased peak urine AP (9.4 ± 0.7 vs. 7.6 ± 1.0 mmol, MW vs. control, p <  0.05). CONCLUSION: Electrolyte-containing MW, was similar in effectiveness to water, but has antioxidant properties. Furthermore, trends for sex differences were discovered in urinary, but not salivary, hydration markers, with discrepancies in kinetics between fluid compartments both warranting further study.

Distal radial fractures in older men. A missed opportunity?

BACKGROUND: Fractures of the distal aspect of the radius are common, yet little is known about this type of fracture among older men. The purpose of this study was to compare fracture characteristics, treatment, and osteoporosis evaluation among men and women who had sustained a distal radial fracture. We hypothesized that the men would have similar patterns of injury and lower rates of evaluation for osteoporosis. METHODS: We retrospectively reviewed the medical records of ninety-five men and 344 women over the age of fifty years who were treated for a distal radial fracture at a single institution over a five-year period. We assessed whether the patients had received a dual x-ray absorptiometry (DXA) scan and osteoporosis treatment within six months following the injury. Multivariate analysis identified independent predictors of bone mineral density (BMD) testing and osteoporosis treatment. RESULTS: Men had less severe fractures than women (a Type-C fracture rate of 20% for men compared with 40% for women; p = 0.014). While 184 (53%) of the women had a DXA scan after injury, only seventeen (18%) of the men were evaluated (p < 0.001). Among the patients who underwent DXA scan, nine men (9% of men overall) and sixty-five women (19% of women overall) had a diagnosis of osteoporosis (p = 0.01). Male sex was an independent predictor of failure to undergo BMD testing as well as receive subsequent treatment with calcium and vitamin D or bisphosphonates (p < 0.001). CONCLUSIONS: Significantly fewer men received evaluation for osteoporosis following a distal radial fracture, with rates of evaluation unacceptably low according to published guidelines.

The effect of osteoporosis on outcomes of operatively treated distal radius fractures.

PURPOSE: We hypothesized that postmenopausal osteoporotic women with distal radius fractures treated with open reduction internal fixation had worse functional outcomes than women without osteoporosis sustaining similar injuries. METHODS: We retrospectively reviewed prospectively collected data for 64 postmenopausal women treated with open reduction internal fixation for distal radius fractures between 2006 and 2010 with known bone mineral density measured by dual-energy x-ray absorptiometry at the time of injury (osteopenia, n = 44; osteoporosis, n = 20). Data collected included age, mechanism of injury, fracture severity, and associated comorbidities. Outcomes included range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and radiographic parameters of fracture reduction. We calculated patients' Charlson Comorbidity Index and tabulated complications. The primary outcome was DASH score at 12 months after injury. We applied multiple linear regression to determine whether bone mineral density status was predictive of functional outcomes 12 months after injury. We used logistic regression analysis to identify factors independently associated with poor outcomes and applied likelihood estimation to determine predictors of a high DASH score at 12 months. RESULTS: At 1 year postoperatively, women with osteoporosis had average DASH scores 15 points higher than those with osteopenia. Both osteoporosis and the Charlson Comorbidity Index were strong positive independent predictors of higher DASH scores (ie, poorer functional outcomes). There were no significant differences in range of motion or radiographic data between groups. Patients with osteoporosis had a higher rate of major complications. CONCLUSIONS: Osteoporosis had a negative impact on functional outcomes for women with distal radius fractures treated with open reduction internal fixation. Surgeons should identify high-risk patients, ensure close monitoring, and initiate appropriate preventative measures in this patient population. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.