Functional Outcomes of Cubital Tunnel Release in Patients with Negative Electrodiagnostic Studies.

BACKGROUND: Cubital tunnel syndrome (CuTS) is the second most common compression neuropathy of the upper extremity. Electrodiagnostic studies (EDSs) are often used to confirm diagnosis. However, negative EDSs can present a difficult clinical challenge. The purpose of this study was to determine the functional outcomes and symptom improvement for patients with a clinical diagnosis of CuTS, but with negative EDSs, who are treated surgically. METHODS: Patients who had EDSs before ulnar nerve surgery were identified by means of database search. Chart review was performed on 867 cases to identify those with negative EDSs. Twenty-five ulnar nerve operations in 23 patients were included in analysis. Chart review was performed to record preoperative and postoperative symptoms, physical examination findings, and outcome measures (ie, Disabilities of the Arm, Shoulder and Hand questionnaire and the Patient-Rated Ulnar Nerve Evaluation). RESULTS: At a mean follow-up period of 20.7 ± 14.9 months, 15 of 25 cases (60.0%) had complete resolution of all preoperative symptoms. All 10 patients who had residual symptoms endorsed improvement in their preoperative complaints. The median preoperative Disabilities of the Arm, Shoulder and Hand score was 40.0 [interquartile range (IQR), 23.9 to 58.0], which significantly decreased to a median of 6.8 (IQR, 0 to 22.7) at final follow-up ( P < 0.01). The median postoperative Patient-Rated Ulnar Nerve Evaluation score was 9.5 (IQR, 1.5 to 19.5). CONCLUSIONS: Patients with CuTS and normal EDSs treated surgically can be expected to have favorable outcomes with respect to symptoms and improvement in functional outcome scores. After ruling out confounding diagnoses, the authors continue to offer surgical intervention for these patients when nonoperative treatment has failed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Outcomes After Surgically Managed Oblique Extra-Articular Proximal Phalanx Fractures: A Comparison of Closed-Reduction Percutaneous Pinning and Open-Reduction Internal Fixation With Lag Screws.

BACKGROUND: Long oblique extra-articular proximal phalanx fractures are common orthopedic injuries. When unstable and without substantial comminution, treatment options include closed-reduction percutaneous pinning (CRPP) and open-reduction internal fixation using lag screws (ORIF-screws). The aims of this study are primarily to compare the functional outcomes and complication rates between these techniques and secondarily to assess potential factors affecting outcomes after surgery. METHODS: All patients with long oblique extra-articular proximal phalanx fractures treated surgically within a single orthopedic institution from 2010 to 2017 were identified. Outcome measures and complications were assessed at the final follow-up. RESULTS: Sixty patients were included in the study with a mean time to the final follow-up of 41 weeks (range: 12-164 weeks). Thirty-four patients (57%) were treated with CRPP and 26 patients (43%) with ORIF-screws. The mean Disabilities of the Arm, Shoulder, and Hand score across both fixation types was 8 (range: 0-43) and did not differ significantly between the 2 groups. Mean proximal interphalangeal extension at the final follow-up was 9° short of full extension after CRPP and 13° short of full extension after ORIF-screws. The rates of flexion contracture and extensor lag were 15% and 41% in the CRPP group compared with 12% and 68% in the ORIF-screws group. Reoperation rates and complication rates did not differ significantly between fixation strategies. CONCLUSIONS: Acceptable outcomes can be achieved after surgical fixation of long oblique extra-articular proximal phalanx fractures using both CRPP and ORIF-screws. Extensor lag may be more common after ORIF-screws.

Does Surgery Improve Healing After Isolated Diaphyseal Ulna Fractures?

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

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

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

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

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

Outcomes of Type I Open Distal Radius Fractures: A Comparison of Delayed and Urgent Open Reduction Internal Fixation.

BACKGROUND: Type I open distal radius fractures treated with open reduction internal fixation (ORIF) have demonstrated minimal risk of infection. For this reason, they may not require urgent surgical treatment. The purpose of this study was to evaluate the outcomes of patients with type I open distal radius fractures treated with delayed ORIF compared with urgent ORIF. METHODS: We identified all Gustilo-Anderson type I open distal radius fractures that had undergone ORIF using volar plating over a 5-year period. Patients were stratified into those treated urgently within 24 hours and those scheduled for delayed surgery. Outcomes including functional scores, complications, reoperations, and radiographic measures were compared. RESULTS: Twenty-four patients (17 treated urgently and 7 treated delayed) had open type I distal radius fractures. All patients were started on empiric antibiotics at initial presentation-patients in the delayed treatment group were prescribed oral antibiotics, whereas those admitted for urgent treatment received intravenous antibiotics. There were no infections in either group and a single reoperation in each group. The mean postoperative Quick Disabilities of the Arm, Shoulder, and Hand score was 29 (range = 0-77) and did not differ significantly between delayed (mean = 19) and urgent (mean = 38) treatment. Rate of complications and radiographic measures did not differ significantly between the groups. CONCLUSIONS: Type I open distal radius fractures appear amenable to delayed outpatient ORIF provided that the wound is clean at the time of initial presentation and that antibiotics are initiated appropriately. Further prospective studies comparing delayed and urgent treatment strategies are warranted.

Does Undergoing Outpatient Hand Surgery Lead to Prolonged Opioid Use? A Comparison of Surgical and Nonsurgical Patients.

BACKGROUND: Orthopedic surgical patients in general have been found to be at higher risk for developing opioid dependence in the postoperative period. However, there is conflicting evidence in the literature whether opioid exposure after hand surgery leads to prolonged use. In the absence of a nonoperative control group, it is not clear whether prolonged opioid use in hand surgical patients is related to undergoing a surgical intervention. The purpose of our study to compare opioid prescription fulfillment patterns in surgical and nonoperative patients in a hand surgery practice. METHODS: We retrospectively compared 320 patients that underwent elbow, wrist, and hand surgery procedures with 741 nonoperative patients treated by 2 hand surgeons. The Pennsylvania Drug Monitoring Program (PDMP), a mandatory statewide database, was used to evaluate the primary outcomes of filling more than one opioid prescription and filling opioid prescriptions beyond 6 months of the index surgery or clinic visit. Bivariate and multivariable logistic regression analysis was performed using the following variables: surgery, prior benzodiazepine use, and prior opioid use. RESULTS: There was no difference in prior opioid use (15.2% vs 16.9%, P = .51) or prior benzodiazepine (10.4% vs 8.4%, P = .33) use between the nonoperative and operative groups. Patients that underwent surgery had a higher incidence of filling more than one opioid prescription (20.9% vs 8.8%, P < .001). However, continued opioid use was not statistically different between nonoperative and operative patients (2.8% vs 5%, P = .08). Bivariate analysis demonstrated that prior opioids (odds ratio [OR] = 12.94, P < .001) and prior benzodiazepines (OR = 1.95, P < .001) were significant independent risk factors for prolonged opioid use. Multivariable analysis demonstrated prior opioid use to be the only independent risk factor for prolonged opioid use (OR = 12.58, P < .001). CONCLUSION: Undergoing outpatient hand surgery do not appear to be an independent risk factor for filling opioid prescriptions beyond 6 months. Significant risk factors for prolonged opioid use include prior use of controlled substances, particularly prior opioid use.

Evaluation of the Incidence and Etiology of Unplanned Return to Operating Room Following Open Reduction Internal Fixation of Distal Radius Fractures.

BACKGROUND: Distal radius fractures (DRF) are the most common upper extremity fractures in adults. The purpose of this study was to determine the incidence, causes, and independent predictors for unplanned return to the operating room (URTO) in a single institution within 90 days following distal radius open reduction internal fixation (ORIF). METHODS: A retrospective study of 2933 consecutive patients from January 2015 to December 2019 who underwent distal radius ORIF was undertaken. Patients who returned to the operating room within 90 days of the index procedure were identified. Patients with planned return to the operating room for staged procedures were excluded, yielding a patient cohort of those with URTO. Demographic data, causes for reoperation, and final Quick Disabilities of the Arm, Shoulder and Hand DASH (QuickDASH) scores were collected. RESULTS: Overall, 45 patients had URTO (1.5%) occurring a mean of 44 (6-89) days from the index procedure. Reasons for reoperation included nerve complications (n = 14), loss of fixation (n = 11), hardware complications (n = 9), wound complications (n = 7), and tendon complications (n = 4). Neurologic reasons for return included carpal tunnel release (n = 13) and ulnar nerve decompression (n = 1). QuickDASH scores were higher for URTO compared with control cohort at the final follow-up (33 [range: 0-91] vs 14 [range: 0-100], P < .01). CONCLUSIONS: Mechanical hardware failure and neurologic symptoms were the most common reasons for URTO after distal fracture ORIF.

Unplanned Office Visits Following Outpatient Hand Surgery.

BACKGROUND: Returning to the office for an unplanned visit postoperatively can be burdensome to both the patient and provider. The purpose of this study was to quantify the rate of unplanned office visits after common soft tissue hand surgeries and assess the reasons for these unplanned visits. METHODS: Patients who underwent common soft tissue hand surgeries over a 6-month time period were queried from an electronic medical record database. Manual chart review was performed to record patient demographics, unplanned visits within 3 months postoperatively, and specific reasons for unplanned visits. A total of 1648 postoperative follow-up visits in 1224 patients were included in analysis. RESULTS: Within 3 months of surgery, 6.3% (103/1648) of postoperative visits were found to be unplanned. There was no difference in the rate of unplanned visits among the included surgeries (P = .46). The most common reasons for an unplanned office visit overall were wound problems (34%), pain (23.3%), and stiffness (17.5%). The trigger finger release group had significantly more patients return to the office for stiffness (P = .01), the De Quervain release group had significantly more patients return for pain (P = .02), and the carpal tunnel release group had significantly more patients return for persistent symptoms (P < .05). CONCLUSIONS: Unplanned office visits represented about 1 of 16 postoperative visits. Orthopedic surgeons should be aware of the most common reasons for these visits and be prepared to address these problems promptly. Preoperative patient education on these potential problems may help decrease the frequency of unplanned follow-up visits.

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

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

Deep Infection after Distal Radius Open-reduction Internal Fixation: A Case Series.

BACKGROUND: Given its low incidence, the management of deep infection following distal radius open-reduction internal fixation (ORIF) has not been well reported. In an effort to expand our current understanding, the purpose of this case series is to present the treatment strategies and functional outcomes associated with deep infection after distal radius ORIF. METHODS: All patients with deep infections after distal radius ORIF over a ten-year period were identified and their treatment courses asessed. RESULTS: The cohort consisted of three women and one man with an average age of 55.5 ± 17.6 years. Mean time from infection presentation to irrigation and debridement (I&D) with removal of hardware (ROH) was 16 days (Range: 3 - 44 days). The identified bacterial species in all cases was Staphylococcus aureus (MRSA = 2, MSSA = 2). Three patients were treated with intravenous antibiotics, while one patient was treated with oral antibiotics. Mean time from infection presentation to final clinical follow-up was 11 months (Range: 3 - 20 months). Two patients required repeat I&D. A clinical determination of successful infection eradication was made in all cases. CONCLUSION: The reported rate of deep infection after distal radius ORIF is less than 1%. There is no well-defined treatment algorithm for patients with deep infection after distal radius ORIF. However, removal of hardware and post-operative oral or intravenous antibiotic therapy appears effective, and is consistent with the standard practices of treating infection after other orthopaedic surgeries.

Nonsurgical Providers Provide the Majority of Postoperative Opioid Prescriptions After Hand Surgery.

Introduction The increased use of Prescription Drug Monitoring Program (PDMP) websites has helped physicians to limit overlapping controlled substance prescriptions and help prevent opioid abuse. Many studies have investigated risk factors for prolonged opioid use after orthopedic surgery, but few studies have investigated who is prescribing opioids to postoperative patients. The purpose of this study is to investigate the types of medical providers prescribing opioids to hand surgery patients postoperatively. Methods Institutional Review Board approval was obtained prior to initiation of this study. An institutional database search was performed to identify all patients ≥18 years old that underwent a single hand surgery at our institution during a specified time period. Patients with more than one surgical procedure during this time were excluded to prevent potential crossover with opioid prescriptions for different surgical procedures. A search of the state PDMP website was performed to identify opioid prescriptions filled by hand surgery patients from six months preoperatively to 12 months postoperatively. Opioid prescribers were classified into several groups: 1) the patient's operating surgeon, 2) other orthopedic surgery providers, 3) general medicine providers (internal medicine, primary care, family medicine, and adult health providers), and 4) all other medical providers. Results Three hundred twenty-seven patients could be identified in the PDMP database who received an opioid prescription on the day of surgery. Of these, 108 (33.0%) filled a total of 341 additional opioid prescriptions postoperatively. Non-orthopedic providers prescribed 81.5% of all opioid prescriptions within 12 months postoperatively, with the patient's operating surgeon prescribing only 10% of all prescriptions. General medicine providers were the highest prescriber group at 28.7% of total postoperative opioid prescriptions. From six to 12 months postoperatively, the patient's operating surgeon prescribed only 4.9% of total opioid prescriptions filled. The patient's operating surgeon prescribed significantly smaller average opioid prescriptions in total morphine milligram equivalents compared to all other provider groups. Conclusions Surgeons should be aware that their surgical patients may be receiving opioid prescriptions from a wide variety of medical providers postoperatively, and that these other providers may be prescribing larger prescriptions. The findings of this study emphasize the importance of collaboration across medical specialties to mitigate the risks of prolonged opioid use after hand surgery.

Post-operative Opioid, Benzodiazepine and Sedative Usage in Medicare versus Commercial Insurance Hand Surgery Patients.

BACKGROUND: Opioid usage has increased in recent years. The purpose of this study is to assess post-operative opioid, sedative, and benzodiazepine usage in a Medicare population. METHODS: Consecutive patients undergoing elbow, wrist, and hand surgery by hand surgeons at one academic outpatient surgical center were prospectively enrolled. Patients were excluded if they were minors or if they underwent more than one surgical procedure during the study period. There were 269 patients enrolled, and this group was divided by insurance type into younger commercial insurance (CI) and older Medicare (MC) groups. The Pennsylvania Physician Drug Monitoring Program website was used to document all prescriptions of controlled substances filled six months prior to and after the surgical procedure. RESULTS: The mean age in the CI group was 45.8 years (range: 16-88) and 69.2 years (range: 43-91) in the MC group. Postoperatively, the CI patients filled significantly less opioid prescriptions than the MC group, 1.10 vs. 1.79. Patients in the CI group were given an average of 0.3 benzodiazepine prescriptions before surgery and 0.2 after surgery. Patients in the MC group were given 0.6 prescriptions before and 0.5 prescriptions of benzodiazepines after surgery. The CI group was given an average of 0.1 sedative/hypnotic prescriptions before surgery and 0.1 after surgery. The MC group was given 0.7 prescriptions before and 0.4 prescriptions of sedative/hypnotics after surgery.There were 0.17 prescriptions per patient in the CI group and 0.75 per patient in the MC group (P <.05). Twenty-two of 208 (10.6%) of CI and 16/61 (26.2%) of MC patients filled a prescription between 3-8 months post-operatively. CONCLUSION: Prolonged use of opioid, benzodiazepine and sedative medications is common after upper extremity surgical procedures. Older patients are also at risk, and may be even more likely than younger patients to use these medications post-operatively.

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

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

Are Plain X-Rays Necessary in the Diagnosis of De Quervain's Tenosynovitis?

Background The routine use of plain radiography represents a significant expenditure and has been proven unnecessary in several orthopedic conditions. The utility of plain radiographs in the diagnosis of De Quervain's tenosynovitis (DeQ) is not clear. Questions/Purpose This study evaluates whether plain radiographic findings routinely predict the need for surgery or alter treatment courses in the initial diagnosis of DeQ. Patients and Methods A total of 200 patients who received wrist X-rays and had a diagnosis of DeQ were retrospectively selected at random. Their images were evaluated for relevant findings, including radial styloid abnormalities, arthritis, and tendon calcification. A chart review was performed to determine whether these X-rays altered the treatment courses. Results Of the 200 patients, 141 (69.1%) cases had at least one positive radiographic finding. Carpometacarpal joint (CMC) arthritis was the most common finding, seen in 63 (30.9%) cases. Of all patients, 141 (69.1%) were treated with corticosteroid injection only, 54 (26.5%) with corticosteroid injection and ultimately surgery, and 9 (4.4%) with surgery alone. There were no significant differences in the rates of surgery with positive X-ray findings. There were no cases in which radiographic findings resulted in a change in management, per the report of the treating physician. Conclusions Despite the high proportion of positive findings on X-ray, no radiographic findings altered the course of treatment in patients with isolated DeQ. Obtaining plain radiographs for isolated DeQ represents a significant cost and should be reserved for cases in which the results are preemptively deemed likely to influence the treatment course. Level of Evidence This is a level IV study.

MRI Utility in Hand Surgery.

Background: Magnetic resonance imaging (MRI) is frequently used in the diagnosis of upper extremity conditions. We hypothesize that the results often do not change treatment. The purpose of the present study was to prospectively assess the extent to which MRI findings alter patient management. Methods: Ten hand surgeons who were ordering an MRI (elbow or distal) completed a standardized questionnaire. Prior to obtaining the MRI, the surgeon recorded their pre-MRI diagnosis and recommended treatment if no MRI could be obtained. Following the MRI, the surgeon recorded their post-MRI diagnosis and ultimate treatment recommendation. Finally, the surgeon answered whether the MRI was helpful, and if so, how it helped guide their treatment. Descriptive statistics were performed. Results: One hundred eighty-seven MRIs were ordered. The most common reasons for ordering an MRI were the evaluation of presumed occult scaphoid fracture, ulnar wrist pain, metacarpophalangeal joint collateral ligament injury, and mass. The surgeon agreed with the radiologist's interpretation of the MRI in 88% of cases. Overall, surgeons found the MRI to be helpful in 92% of cases, and the recommended treatment changed as a result of the MRI findings in 19% (35/187) of patients. Of these 35 patients, 9 had a pre-MRI diagnosis that was concordant with the MRI findings, but the proposed management of the patient changed after the MRI. Conclusions: Hand surgeons infrequently change their treatment plan based on MRI findings. Given the importance of cost-efficient care, indications for use of MRI may need to be re-evaluated.

Overall Opioid Consumption Is Not Associated With the Amount of Opioids Administered and Prescribed on the Day of Upper Extremity Surgery.

Background: Orthopedic surgeons need to better understand the effect their opioid-prescribing habits have on patients. The purpose of our study was to evaluate whether the type of procedure or initial amount of opioids prescribed postoperatively leads to increased consumption of opioids. Methods: Consecutive patients undergoing upper extremity surgery were enrolled. The medical record and Pennsylvania Prescription Drug Monitoring Program Web site were used to record all prescriptions of controlled substances consumed intraoperatively, in the recovery room, and in prescriptions filled 6 months postoperatively. Morphine equivalent units (MEUs) were used to quantify the amount of opioids. Results: Two hundred ninety patients were included in the study. The mean MEU administered intraoperatively was 25.1 (0-50). The MEU provided in the recovery room was 2.9 (0-60). The MEU prescribed on the day of surgery was 155.6 (137-178). We used the Pearson correlation coefficient of r = 0, meaning no/weak correlation, and r = 1, meaning a strong correlation. Neither MEUs provided intraoperatively or in recovery, nor MEUs prescribed postoperatively correlated with prescriptions filled (r = 0.13, 0.02, 0.09, respectively). Although patients undergoing bony procedures were prescribed more opioids (P < .001), opioid consumption intraoperatively, in recovery, and in prescriptions filled was not significantly different. Conclusions: The MEUs administered and prescribed on the day of surgery did not affect the amount of prescriptions filled postoperatively. Finally, patients undergoing bony procedures were prescribed more opioids than those undergoing soft tissue procedures, but they did not consume or fill more opioids postoperatively.

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

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

Morphometric Assessment of the Residual Width of the Distal Hamate Articular Surface after Graft Harvest for Hemi-hamate Arthroplasty.

BACKGROUND: The hemi-hamate arthroplasty (HHA) can restore joint congruity and stability in chronic fracture-dislocations of the proximal interphalangeal joint (PIPJ). Purpose of this study was to compare the width of the distal hamate articular surface (DHAS) to the width of the base of the middle phalanges (P2) of the fingers. We hypothesized the dimensions of the width of the DHAS would be similar to those of P2, leaving a small amount of residual DHAS width after autograft harvest. METHODS: Fifty-nine CT scans of the hand without any bony pathology were evaluated. Three observers measured the following parameters and compared: (a) Width of the DHAS in the axial and coronal planes; (b) Width of the P2 articular bases of all four fingers; (c) Maximum capitate length (MaxCap) in the coronal plane. RESULTS: The residual DHAS on the coronal plane after graft harvest (bone remaining on the radial and ulnar aspects each, not accounting for saw blade or osteotomy width thickness) among all patients was 1.3, 0.9, 1.4, and 2.4 mm for the index, long, ring and small fingers respectively. There was a strong correlation between DHAS and MaxCap r=0.76. CONCLUSION: There is likely to be a very small amount of residual hamate articular surface width left after the graft is harvested if the entire base of P2 is reconstructed.

Volume of the Thumb Carpometacarpal Joint.

Background The volume of the carpometacarpal joint of the thumb (TCMC) and its capacity to accommodate fluid injection is unknown. Questions/Purpose The purpose of the present study is to assess the volume of the TCMC. Methods Forty-two thumbs undergoing surgical treatment for symptomatic TCMCJ osteoarthritis (OA) were evaluated. Prior to the start of the surgical procedure saline was injected into the TCMC until resistance was felt and no further saline could be injected. The maximum volume (MaxVol) of injectate was measured and recorded. Results Mean MaxVol among all patients was 0.9 cc (range: 0.2-3.0 cc). There were 15 patients with 1 cc or more injected, the rest were less than 1 cc. The mean MaxVol for Eaton 2 thumbs was 1.5 cc, for Eaton 3 thumbs 0.9 cc, and for Eaton 4 thumbs 0.7 cc, with negative correlation between Eaton stage and MaxVol. Conclusion TCMC has limited capacity for injected fluid. Level of Evidence This is a Level II, diagnostic study.