Surgical Decision Making for Mild-to-Moderate Cubital Tunnel Syndrome.

Purpose: The management of ulnar neuropathy remains unclear as there are neither consensus guidelines nor compelling data available to inform optimal treatment. Identifying patients in the mild-to-moderate group that would benefit most from surgery is challenging as their symptoms can be subtle and less debilitating. This study investigated predictors of surgical intervention among patients presenting with McGowan mild or moderate cubital tunnel syndrome (CuTS). Methods: This is an institutional review board-approved study. Patients evaluated from March 2016 to July 2022 were included if they were diagnosed with McGowan mild or moderate CuTS and underwent concurrent electrodiagnostic and ultrasound evaluations. Patient demographics, symptom presentation, and clinical and diagnostic test findings were analyzed. Variables were analyzed using Student t test, Mann-Whitney U test, or Pearson's chi-square test. Multivariable logistic regression was used to assess the association of covariates and surgery. Results: Seventy-three patients and 103 elbows were identified. The mean age and body mass index were 51 years and 26.9, respectively. Most patients were men, right-handed, and unilaterally symptomatic in the dominant hand. Twenty-six elbows were surgically treated. Bivariable analyses by surgical treatment showed that patients who underwent surgery more often had positive electrodiagnostic findings including motor nerve conduction velocity <50 m/s and a >10 m/s conduction velocity difference across the forearm compared with elbow. Fifty-nine cases were categorized as electrodiagnostically normal. Of the electrodiagnostically normal cases, 29 had positive findings of CuTS on ultrasound. Logistic regression model showed that electrodiagnostically severe cases had 3.7 times higher odds of being surgically treated than normal counterparts (adjusted odds ratio, 3.7; 95% CI, 1.11-12.6; P = .03). Conclusions: Not many differences in objective findings identify patients who should receive operative treatment. In addition to test results, more subjective findings from patients such as patient-reported level of impairment may be able to bridge this gap in surgical decision making. Clinical relevance: This study contributes to treatment decision making for mild and moderate CuTS.

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.

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.

Incidence of Carpal Tunnel Syndrome after Distal Radius Fracture.

Purpose: Carpal tunnel syndrome (CTS) can present following distal radius fracture (DRF) and may progress to require carpal tunnel release (CTR). The primary aim of this study was to determine the incidence of CTS within 6 months of a DRF and the rate of CTR in this population. Methods: We used the PearlDiver national insurance database to determine the incidence of CTS after DRF. Patients were identified by International Classification of Diseases-10 codes, and treatment modalities for DRF and CTS were determined by respective Current Procedural Terminology codes. Patients with less than 6 months of follow-up, bilateral DRF, or preexisting CTS were excluded. Patient demographic characteristics were recorded. The time from DRF diagnosis to CTS diagnosis and CTR was determined. A multivariable analysis was performed to determine the differences between patients who underwent a CTR compared with those who were treated conservatively. Results: We identified 23,733 patients (6,015 men; 17,718 women) who sustained a DRF. Of these patients, 79.1% were treated nonsurgically and 20.9% underwent surgical fixation. In total, 9.2% (N = 2,179) were diagnosed with CTS in their ipsilateral extremity within 6 months of sustaining the DRF. Of the patients whose DRF was treated nonsurgically, 6.3% (N = 1,198) developed CTS and 2.9% (N = 546) required CTR. Of those patients whose DRF was treated surgically, 19.8% (N = 981) developed CTS and 13.3% (N = 661) required CTR. Of those patients with symptoms severe enough to warrant CTR, 18.5% required a second surgical intervention for the CTR. Conclusions: Distal radius fractures severe enough to require surgical fixation are associated with a higher incidence of perioperative CTS. Accordingly, careful evaluation for and counseling on CTS during surgical fixation may decrease the chance of a second surgery. We have identified a cohort of patients with DRFs who may benefit from prophylactic CTR. Type of study/level of evidence: Diagnostic IV.

Trapeziometacarpal Joint Arthrodesis Using a Cannulated Compression Screw and Locking Plate Construct.

Background: Trapeziometacarpal (TMC) arthrodesis is an established surgical option for the treatment of basal joint osteoarthritis. It has traditionally been indicated in younger, higher demand patients who would benefit from the increased strength afforded by a stable thumb base. Trapeziometacarpal arthrodesis has a higher reported complication rate than other treatment options, including nonunion and symptomatic hardware. Description of Technique: We describe a novel construct for TMC joint arthrodesis using a cannulated headless screw to compress the arthrodesis site and a low-profile locking plate to neutralize the considerable musculotendinous forces crossing the joint. Patients and Methods: We performed a retrospective review of 10 patients treated with this fusion construct between June 2019 and February 2021. Results: The average patient age was 56.5 years; 7 patients were female and 3 were male. The mean pain score, on a 0 to 10 point scale, decreased from 7.2 preoperatively to 1.6 at final postoperative follow-up. All patients achieved bony union; none underwent removal of hardware. Conclusions: Given the high reported rate of nonunion following TMC arthrodesis in the literature, improvements in surgical technique are needed. In a small cohort of patients, we report favorable outcomes with a new technique for TMC arthrodesis.

Outcomes of Acute Versus Subacute Scapholunate Ligament Repair.

Purpose: This study investigated the long-term outcomes of direct scapholunate ligament (SLL) repairs with or without dorsal capsulodesis performed within 6 weeks (acute repair) of a SLL tear versus 6 to 12 weeks following injury (subacute repair). Methods: A review of medical records from April 1996 to April 2012 identified 24 patients who underwent SLL repair (12 acute, 12 subacute). Patients returned to the clinic for radiographic examinations of the injured wrist, standardized physical examinations, and validated questionnaires. Results: The mean follow-up times for the acute and subacute groups were 7.2 and 6.2 years, respectively. At the final examination, patients with acute surgery regained more wrist extension (acute = 55°, subacute = 47°). The total wrist flexion-extension arcs, grip strengths, pinch strengths, and patient-rated outcome scores were found to be similar between groups. The final scapholunate gap, scapholunate angle, and the prevalence of arthritis were also found to be similar between the acute and subacute groups. Conclusions: Although SLL repair is more commonly recommended for treatment of acute SLL injuries, there were no significant long-term differences between acute and subacute SLL surgeries (repair ± capsulodesis). Type of study/level of evidence: Prognostic III.

Team Approach: Management of Brachial Plexus Injuries.

¼: Traumatic brachial plexus injuries are relatively rare but potentially devastating injuries with substantial functional, psychological, and economic consequences. ¼: Prompt referral (ideally within 6 weeks of injury) to a center with a team of experts experienced in the diagnosis and management of these injuries is helpful to achieving optimal outcomes. ¼: Preoperative and intraoperative decision-making to diagnose and plan reconstructive procedures is complex and must take into account a number of factors, including the time from injury, concomitant injuries, preservation of cervical nerve roots, and the availability of intraplexal and extraplexal donor nerves for nerve transfer. ¼: A team approach is essential to ensure accurate localization of the pathology before surgery and to maximize rehabilitation after surgery, necessitating close contact between the surgical team, physiatrists, radiologists, and therapists.

Optimizing the Virtual Interview Experience for Hand Surgery Fellowships.

Similar to many other medical training programs, fellowship interviews for hand surgery will be conducted virtually for a second consecutive year. We provide strategies for applicants to ideally portray themselves and to learn about fellowship programs. We include approaches for fellowship programs to identify candidates that match their values as a program, as well as ways to provide useful information to applicants about the program's culture. Given that components of virtual interviewing and recruitment will likely be an ongoing part of fellowship applications, we hope this article provides a framework to guide both applicants and program faculty for the 2021 to 2022 cycle and beyond.

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.

Noncontrast Magnetic Resonance Imaging of Perforators for Preoperative Evaluation of Anterolateral Thigh Flaps.

BACKGROUND: The anterolateral thigh (ALT) flap is a commonly utilized perforator-based flap in reconstructive surgery. Although previous studies have used various angiographic techniques to preoperatively image ALT perforators, none have investigated the efficacy of noncontrast magnetic resonance imaging (MRI). Our study investigates the efficacy of our institutional fat suppression noncontrast MRI sequence to characterize the number, location, and course of dominant skin perforators in the ALT for preoperative planning. METHODS: We queried our institutional database for 100 noncontrast thigh MRIs from July 2013 to July 2018 that included an axial fat suppression sequence with visualization from the lesser trochanter to the distal musculotendinous junction of the rectus femoris. Perforator course, size, and location relative to bony landmarks were determined. RESULTS: Of the 100 examinations, 70 included bilateral thighs for a total of 170 thighs for perforator analysis. An estimated 277 perforators were identified, of which 101 were septocutaneous (36.5%) and 176 were musculocutaneous (63.5%). An average of 1.63 perforators were visualized in each thigh (min, 1; max, 4). The average perforator diameter at exit from the anterior thigh compartment fascia was 2.5 mm (SD, 0.5). Perforator exit location along the anterior superior iliac spine- or lesser trochanter-patella line could be determined for n = 57 perforators and mapped into 3 predictable clusters. CONCLUSIONS: At least 1 perforator was found in each of 170 thighs imaged. Perforator course, size, and location measured with noncontrast MRI are consistent with prior literature. Noncontrast MRI is a low-morbidity imaging modality that may serve as an effective tool in preoperative planning of the ALT flap.

Pre-operative Two-Point Discrimination Predicts Response to Carpal Tunnel Release.

BACKGROUND: Limited evidence informs whether pre-operative values of two-point discrimination (2PD) in patients with carpal tunnel syndrome predict response to surgery. QUESTIONS/PURPOSES: The primary aim of this study was to determine the predictive value of pre-operative 2PD scores on outcomes following carpal tunnel release (CTR). In particular, we sought to evaluate whether a clinically relevant 2PD threshold exists that can predict symptomatic response after surgery. METHODS: Patients who underwent CTR between 2014 and 2018 were retrospectively reviewed. Static 2PD scores in each digit, as well as Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Levine-Katz scores, were collected from pre- and post-operative records. Pearson correlation coefficients assessed the relationship between pre-operative 2PD, early post-operative 2PD, and patient-reported outcome scores. Poor 2PD was defined as 2PD greater than 10 mm. RESULTS: Eighty-nine hands in 73 patients with a mean follow-up of 1.8 years were analyzed. Mean pre- and post-operative 2PD was 7.2 mm and 6.4 mm, respectively, in the most affected digit when measurable. Twenty patients had poor 2PD scores pre-operatively and 14 post-operatively. There was a positive correlation between pre- and early post-operative 2PD scores but no correlation between pre-operative 2PD score and final post-operative functional scores. Only 30% of patients with poor pre-operative 2PD scores demonstrated improvement, compared with 69% of patients with measurable 2PD. CONCLUSION: We found that greater pre-operative 2PD scores predicted greater early post-operative 2PD scores but did not lead to worse functional outcome scores post-operatively. Patients with poor pre-operative 2PD scores were likely to demonstrate improvement in functional outcomes scores, while having less reliable improvement in 2PD after CTR. Patients with poor 2PD should be counseled that improvement of tactile perception is less predictable.

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.

Prevalence of carpal tunnel syndrome presenting with symptoms in an ulnar nerve distribution: A prospective study.

INTRODUCTION: Patients presenting with symptoms of pain/paresthesias primarily in an ulnar nerve distribution may be noted to have exclusive median mononeuropathy at the wrist on subsequent electrodiagnostic testing. There has been limited research looking at the prevalence of this clinical presentation. METHODS: A cohort of adults were surveyed to assess for severity and localization of hand symptoms using the Katz hand diagram and Boston Carpal Tunnel Questionnaire Symptoms Severity Scale. Thirty volunteers met our case definition for ulnar neuropathy and underwent a standardized physical examination, electrodiagnostic testing, and nerve ultrasound. RESULTS: Eleven of 30 subjects (37%) were found to have exclusive median mononeuropathy at the wrist. DISCUSSION: Carpal tunnel syndrome should remain high on the differential for patients presenting with symptoms of pain/paresthesias primarily in an ulnar nerve distribution. Muscle Nerve 59:60-63, 2019.

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.

Elbow contracture following operative fixation of fractures about the elbow.

BACKGROUND: The rates of elbow contracture and contracture release after surgically treated elbow trauma are poorly defined. The purpose of this study was to define the incidence of elbow contracture diagnosis and release after surgical treatment for elbow trauma. METHODS: The Humana insurance database was queried using the PearlDiver Patient Records Database between 2007 and 2017. Subjects were identified using International Classification of Diseases (ICD) codes in combination with Current Procedural Terminology codes and were included if they had a minimum of 1-year follow-up. Qualifying operative elbow trauma patients were queried for development of postoperative elbow contracture. Patient demographic characteristics, risk factors for elbow stiffness, and use of postoperative anticoagulation were recorded. Fracture severity was classified based on ICD-9 and ICD-10 codes. Logistic multivariate analysis was performed to determine independent risk factors for postoperative elbow contracture. RESULTS: The study population included 10,672 patients who were surgically treated for elbow trauma. In total, 902 patients (8.4%) were diagnosed with a contracture following fracture. Of patients with a diagnosis of elbow contracture, 65 patients (7.2%) underwent contracture release. On average, time to contracture diagnosis was 3.6 months (SD 7 months) and time to contracture release was 8.4 months (SD 3.6 months). The use of postoperative anticoagulation, burn or head injury at the time of fracture, male sex, obesity, opioid use, and moderate or severe fracture severity were significantly associated with progression to elbow contracture. CONCLUSION: The development of elbow contracture after surgical treatment of elbow trauma has a relatively high incidence of 8.4%.

The Critical Portions of Carpal Tunnel Release, Ulnar Nerve Transposition, and Open Reduction and Internal Fixation of the Distal Part of the Radius.

BACKGROUND: Overlapping surgery is attracting increased scrutiny. The American College of Surgeons states that the attending surgeon must be present for all critical portions of a surgical procedure; however, critical portions of surgical procedures are not defined. We hypothesized that a Delphi panel process would measure consensus on critical portions of 3 common hand surgical procedures. METHODS: We used a Delphi process to achieve consensus on the critical portions of carpal tunnel release, ulnar nerve transposition, and open reduction and internal fixation of the distal part of the radius. The panelists were 10 hand surgeons (7 fellowship-trained surgeons and 3 fellows). Following an in-person discussion to finalize steps for each procedure, 2 online rounds were completed to rate steps from 1 (not critical) to 9 (extremely critical). We operationalized consensus as ≥80% of ratings within the same range: 1 to 3 (not critical), 4 to 6 (somewhat critical), and 7 to 9 (critical). Because of a lack of consensus on some steps after round 2, another in-person discussion and a third online round were conducted to rate only steps involving disagreement or somewhat critical ratings using a dichotomous scale (critical or not critical). RESULTS: Following the first 2 rounds, there was consensus on 19 of 24 steps (including 3 steps being somewhat critical) and no consensus on 5 of 24 steps. At the end of round 3, there was consensus on all but 2 steps (identification of the medial antebrachial cutaneous nerve in ulnar nerve transposition and clinical assessment of joint stability in open reduction and internal fixation of the distal part of the radius), with moderate disagreement (3 compared with 7) for both. CONCLUSIONS: The panel reached consensus on the designation of critical or noncritical for all steps of a carpal tunnel release, all but 1 step of an ulnar nerve transposition, and all but 1 step of open reduction and internal fixation of the distal part of the radius. The lack of consensus on whether 2 of the steps are critical leaves this determination at the discretion of the attending surgeon. The findings of our Delphi panel provide guidance to our division on which portions of the surgical procedure are critical and thus require the attending surgeon's presence.

Safety of Overlapping Inpatient Orthopaedic Surgery: A Multicenter Study.

BACKGROUND: Although overlapping surgery is used to maximize efficiency, more empirical data are needed to guide patient safety. We conducted a retrospective cohort study to evaluate the safety of overlapping inpatient orthopaedic surgery, as judged by the occurrence of perioperative complications. METHODS: All inpatient orthopaedic surgical procedures performed at 5 academic institutions from January 1, 2015, to December 31, 2015, were included. Overlapping surgery was defined as 2 skin incisions open simultaneously for 1 surgeon. In comparing patients who underwent overlapping surgery with those who underwent non-overlapping surgery, the primary outcome was the occurrence of a perioperative complication within 30 days of the surgical procedure, and secondary outcomes included all-cause 30-day readmission, length of stay, and mortality. To determine if there was an association between overlapping surgery and a perioperative complication, we tested for non-inferiority of overlapping surgery, assuming a null hypothesis of an increased risk of 50%. We used an inverse probability of treatment weighted regression model adjusted for institution, procedure type, demographic characteristics (age, sex, race, comorbidities), admission type, admission severity of illness, and clustering by surgeon. RESULTS: Among 14,135 cases, the frequency of overlapping surgery was 40%. The frequencies of perioperative complications were 1% in the overlapping surgery group and 2% in the non-overlapping surgery group. The overlapping surgery group was non-inferior to the non-overlapping surgery group (odds ratio [OR], 0.61 [90% confidence interval (CI), 0.45 to 0.83]; p < 0.001), with reduced odds of perioperative complications (OR, 0.61 [95% CI, 0.43 to 0.88]; p = 0.009). For secondary outcomes, there was a significantly lower chance of all-cause 30-day readmission in the overlapping surgery group (OR, 0.67 [95% CI, 0.52 to 0.87]; p = 0.003) and shorter length of stay (e, 0.94 [95% CI, 0.89 to 0.99]; p = 0.012). There was no difference in mortality. CONCLUSIONS: Our results suggest that overlapping inpatient orthopaedic surgery does not introduce additional perioperative risk for the complications that we evaluated. The suitability of this practice should be determined by individual surgeons on a case-by-case basis with appropriate informed consent. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

An Epidemiologic Perspective on Scaphoid Fracture Treatment and Frequency of Nonunion Surgery in the USA.

BACKGROUND: Scaphoid fractures treated non-operatively and operatively may be complicated by nonunion. QUESTIONS/PURPOSES: We sought to test the primary hypothesis that the incidence density of scaphoid fracture treatment is higher than previously estimated, to determine the frequency and risk factors for nonunion treatment, and to determine whether the frequency of surgical treatment increased over time. METHODS: The MarketScan® database was queried for all records of treatment (casting and surgery) for closed scaphoid fractures over a 6-year period. We examined subsequent claims to determine frequency of additional procedures for nonunion treatment (revision fixation or vascularized grafting occurring 28 days or more after initial treatment). Trend analyses were used to determine whether changes in frequency of surgical treatment or revision procedure occurred. RESULTS: The estimated incidence density of scaphoid fracture is 10.6 per 100,000 person-years in a commercially insured population of less than 65 years of age. Of 8923 closed scaphoid fractures, 29 and 71% were treated with surgery and casting, respectively. The frequency of surgical treatment rose significantly, from 22.1% in 2006 to 34.1% in 2012. The frequency of nonunion treatment was 10.8% after surgery and 3% after casting; neither changed over time. Younger age, male sex, and surgical treatment are associated with a higher risk of nonunion treatment. CONCLUSIONS: Our estimated incidence of scaphoid fracture is higher than previously reported. The increased enthusiasm in the USA to surgically treat scaphoid fractures is reflected by our trend analysis. The frequency of surgical treatment for presumed nonunion after initial surgical management for closed scaphoid fractures exceeded 10%. Given the increased utilization of surgery, surgeons and patients should be aware of the frequency of nonunion treatment to inform treatment decisions.

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.