Lateral Femoral Condyle Allograft in the Treatment of Elbow Capitellar Avascular Necrosis: A Case Report.

CASE: A 27-year-old woman developed capitellar osteonecrosis after long-term corticosteroid use to treat non-Hodgkin lymphoma. She underwent an osteochondral reconstruction using a lateral femoral condyle (LFC) allograft. This graft was selected because it has a similar radius of curvature to the capitellum. The patient had osseous integration, painless, near full range of motion of her elbow 6 months postoperatively and good shoulder function 1.0 year postoperatively. CONCLUSION: The LFC allograft should be considered a viable option in treating capitellar osteonecrosis.

Interspecialty Variation in Perioperative Health Care Resource Usage for Carpal Tunnel Release.

BACKGROUND: We investigated whether any interspecialty variation exists, regarding perioperative health care resource usage, in carpal tunnel releases (CTRs). METHODS: The 2010 to 2021 PearlDiver Mariner Database, an all-payer claims database, was queried to identify patients undergoing primary CTRs. Physician specialty IDs were used to identify the specialty of the surgeon-orthopedic versus plastic versus general surgery versus neurosurgery. Multivariate logistic regression analysis was used to identify whether there was any interspecialty variation between the use of health care resources. RESULTS: A total of 908 671 patients undergoing CTRs were included, of which 556 339 (61.2%) were by orthopedic surgeons, 297 047 (32.7%) by plastic surgeons, 44 118 (4.9%) by neurosurgeons, and 11 257 (1.2%) by general surgeons. In comparison with orthopedic surgeons, patients treated by plastic surgeons were less likely to have received opioids, nonsteroidal anti-inflammatory drugs, oral steroids, and preoperative antibiotic prophylaxis but were more likely to have received steroid injections and electrodiagnostic studies (EDSs) preoperatively. Patients treated by neurosurgeons were more likely to have received preoperative opioids, gabapentin, oral steroids, preoperative antibiotic prophylaxis, EDSs, and formal preoperative physical/occupational therapy and less likely to have received steroid injections. Patients treated by general surgeons were less likely to receive oral steroids, steroid injections, EDSs, preoperative formal physical therapy, and preoperative antibiotic prophylaxis, but were more likely to be prescribed gabapentin. CONCLUSIONS: There exists significant variation in perioperative health care resource usage for CTRs between specialties. Understanding reasons behind such variation would be paramount in minimizing differences in how care is practiced for elective hand procedures.

The therapeutic effects of gingival mesenchymal stem cells and their exosomes in a chimeric model of rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis is a chronic systemic autoimmune disease that involves transformation of the lining of synovial joints into an invasive and destructive tissue. Synovial fibroblasts become transformed, invading and destroying the bone and cartilage of the affected joint(s). Due to the significant role these cells play in the progression of the disease process, developing a therapeutic strategy to target and inhibit their invasive destructive nature could help patients who are afflicted with this debilitating disease. Gingival-derived mesenchymal stem cells are known to possess immunomodulatory properties and have been studied extensively as potential cell-based therapeutics for several autoimmune disorders. METHODS: A chimeric human/mouse model of synovitis was created by surgically implanting SCID mice with a piece of human articular cartilage surrounded by RASF. Mice were injected once with either GMSC or GMSCExo at 5-7 days post-implantation. Histology and IHC were used to assess RASF invasion of the cartilage. Flow cytometry was used to understand the homing ability of GMSC in vivo and the incidence of apoptosis of RASF in vitro. RESULTS: We demonstrate that both GMSC and GMSCExo are potent inhibitors of the deleterious effects of RASF. Both treatments were effective in inhibiting the invasive destructive properties of RASF as well as the potential for these cells to migrate to secondary locations and attack the cartilage. GMSC home to the site of the implant and induce programmed cell death of the RASF. CONCLUSIONS: Our results indicate that both GMSC and GMSCExo can block the pathological effects of RASF in this chimeric model of RA. A single dose of either GMSC or GMSCExo can inhibit the deleterious effects of RASF. These treatments can also block the invasive migration of the RASF, suggesting that they can inhibit the spread of RA to other joints. Because the gingival tissue is harvested with little difficulty, relatively small amounts of tissue are required to expand the cells, the simple in vitro expansion process, and the increasing technological advances in the production of therapeutic exosomes, we believe that GMSCExo are excellent candidates as a potential therapeutic for RA.

Wrist Arthritis and Arthrodesis: Preserving Function, Minimizing Problems.

Wrist arthritis is a common condition with numerous causes and presentations. Several management options exist, and treatment should be individualized based on patient age, comorbidities, occupation, duration of symptoms, and failed treatment modalities. Arthroscopy and denervation are appealing because of shorter recovery time and preservation of motion, but duration of effectiveness varies between patients. Patients who fail these smaller procedures or those with pancarpal arthrosis are treated effectively with total wrist arthrodesis or total wrist arthroplasty in lower-demand patients. This article reviews causes and patterns of wrist arthritis and discusses treatment strategies aimed at preserving function and minimizing complications.

Therapeutic Effects of Gingival Mesenchymal Stem Cells and Their Exosomes in a Chimeric Model of Rheumatoid Arthritis.

Background: Rheumatoid arthritis is a chronic systemic autoimmune disease that involves transformation of the lining of synovial joints into an invasive and destructive tissue. Synovial fibroblasts become transformed, invading and destroying bone and cartilage of the affected joint(s). Due to the significant role these cells play in the progression of the disease process, developing a therapeutic strategy to target and inhibit their invasive destructive nature could help patients who are affiicted with this debilitating disease. Gingival-derived mesenchymal stem cells are known to possess immunomodulatory properties and have been studied extensively as potential cell-based therapeutics for several autoimmune disorders. Methods: A chimeric human/mouse model of synovitis was created by surgically implanting SCID mice with a piece of human articular cartilage surrounded by RASF. Mice were injected once with either GMSC or GMSCExo at 5-7 days post-implantation. Histology and IHC were used to assess RASF invasion of the cartilage. Flow cytometry was used to understand the homing ability of GMSC in vivo and the incidence of apoptosis of RASF in vitro. Results: We demonstrate that both GMSC and GMSCExo are potent inhibitors of the deleterious effects of RASF. Both treatments were effective in inhibiting the invasive destructive properties of RASF as well as the potential of these cells to migrate to secondary locations and attack the cartilage. GMSC home to the site of the implant and induce programmed cell death of the RASF. Conclusions: Our results indicate that both GMSC and GMSCExo can block the pathological effects of RASF in this chimeric model of RA. A single dose of either GMSC or GMSCExo can inhibit the deleterious effects of RASF. These treatments can also block the invasive migration of the RASF, suggesting that they can inhibit the spread of RA to other joints. Because the gingival tissue is harvested with little difficulty, relatively small amounts of tissue are required to expand the cells, the simple in vitro expansion process, and the increasing technological advances in the production of therapeutic exosomes, we believe that GMSCExo are excellent candidates as a potential therapeutic for RA.

Declining Trend in Anti-osteoporotic Treatment, Despite a Rise in DEXA Screening Following "Sentinel" Distal Radius Fractures.

PURPOSE: To understand national trends and costs associated with the utilization of anti-osteoporotic medication and DEXA screening within the year following a sentinel/primary distal radius fracture. METHODS: The 2008-2015Q1 Humana Administrative Claims database was queried to identify patients aged ≥50 years, with a "sentinel" occurrence of a primary closed distal radius fracture. Linear regression models were used to report and assess for significant trends in utilization of anti-osteoporotic medication and DEXA screenings within the year following the fracture. Multivariate logistic regression analyses were used to assess for factors associated with receiving or not receiving anti-osteoporotic medication. RESULTS: A total of 14 526 sentinel distal radius fractures were included in the study. Only 7.2% (n = 1046) of patients received anti-osteoporosis medication in the year following the distal radius fracture. Treatment with medication for osteoporosis declined from 8.2% in 2008 to 5.9% in 2015, whereas the rate of DEXA screening increased from 14.8% in 2008 to 23.6% in 2015. The most common prescribed treatment was alendronate sodium (n = 835; 79.8%-$49/patient). Factors associated with increased odds of receiving anti-osteoporotic medication were age 70 to 79 years (odds ratio [OR], 1.45; P = .014), age 80 to 89 years (OR, 1.66; P = .001), Asian (OR, 2.95; P = .002) or Hispanic (OR, 1.77; P = .006) ethnicity, belonging to South (OR, 1.19; P = .029) or West (OR, 1.37; P = .010), and having an Elixhauser Comorbidity Index score of 3 (OR, 2.14; P = .024) or > 3 (OR, 2.05; P = .022). CONCLUSIONS: Despite a rising utilization of DEXA screening following "sentinel" distal radius fractures, the proportion of individuals who receive anti-osteoporotic treatment is decreasing over time.

Total Wrist Fusion with an Intramedullary Device: A Single-Institution Series with a Minimum of One Year Follow-Up.

Objective The primary purpose of this study was to evaluate the functional and surgical outcomes of total wrist fusion (TWF) following the use of a locked intramedullary nail (IMN). Methods A single institution study was performed, which entailed in-person reexamination of 18 patients ( n = 19 wrists), out of 35 eligible patients, who underwent TWF with an IMN from 2010 to 2017. For each patient, demographic, preoperative diagnosis, physical examination, wrist radiograph, and outcome questionnaire data were obtained. The questionnaires included the visual analog scale (VAS), quick disabilities of the arm, shoulder, and hand (QuickDASH), and Mayo Wrist Score assessments. In addition, complication and reoperation data for all TWFs with an IMN during the 2010 to 2017 period (35 patients, n I = 38 wrists) were noted. Results In the 18 patients, age was 47.6 ± 13.9 years, 12 (63.2%) were female, and median follow-up was 150 weeks (range: 74-294). The VAS score was 0 ± 0 in 5 of 19 wrists with rheumatoid arthritis (RA) and 1.82 ± 2.78 in 14 of 19 wrists without RA. It was found that 21 of 38 wrists (55.3%) had an implant-related complication and 5 wrists (13%) underwent a reoperation due to the implant itself. Conclusions To date, no sufficient data are present demonstrating a clear advantage of an IMN over dorsal plating for TWF at intermediate-term follow-up. Surgeons should be knowledgeable of the several potential complications of this IMN prior to its use for TWF. Level of Evidence This is a Level IV, therapeutic study.

Early Postoperative Improvement in Sleep and Pain After Carpal Tunnel Release.

Background: Carpal tunnel syndrome (CTS) is the most common compressive neuropathy of the upper extremity. We sought to assess the subjective improvement in preoperative symptoms related to CTS, particularly those affecting sleep, and describe opioid consumption postoperatively. Methods: All patients undergoing primary carpal tunnel release (CTR) for electromyographically proven CTS were studied prospectively. All procedures were performed by hand surgery fellowship-trained adult orthopedic and plastic surgeons in the outpatient setting. Patients underwent either endoscopic or open CTR from June 2017 to December 2017. Outcomes assessed were pre- and postoperative Quick Disabilities of Arm, Shoulder and Hand (QuickDASH), visual analog scale (VAS), and Pittsburgh Sleep Quality Index (PSQI) scores as well as postoperative pain control. Results: Sixty-one patients were enrolled. At 2 weeks, all showed significant (P < .05) improvement in QuickDASH scores. At 6 weeks, 40 patients were available for follow-up. When compared with preoperative scores, QuickDASH (51 vs 24.5; P < .05), VAS (6.7 vs 2.9; P < .05), and PSQI (10.4 vs 6.4; P < .05) scores continued to improve when compared with preoperative scores. At 2-week follow-up, 39 patients responded to the question, "How soon after your carpal tunnel surgery did you notice an improvement in your sleep?" Seventeen patients (43.6%) reported they had improvement in sleep within 24 hours, 12 patients (30.8%) reported improvement between 2 and 3 days postoperatively, 8 patients (20.5%) reported improvement between 4 and 5 days postoperatively, and 2 patients (5.1%) reported improvement between 6 and 7 days postoperatively. Conclusions: The present study demonstrates rapid and sustained improvement in sleep quality and function following CTR.

Comparison of Local-Only Anesthesia Versus Sedation in Patients Undergoing Staged Bilateral Carpal Tunnel Release: A Randomized Trial.

Purpose: Carpal tunnel syndrome is a common disease treated operatively. During the operation, the patient may be wide-awake or sedated. The current literature has only compared separate cohorts. We sought to compare patient experience with both local-only anesthesia and sedation. Methods: Staged bilateral carpal tunnel release utilizing open or endoscopic technique was scheduled and followed through to completion of per-protocol analysis in 31 patients. Patients chose initial hand laterality and were randomized regarding initial anesthesia method: local-only or sedation. Data collection via questionnaires began at consent and continued to 6 weeks postoperatively from second procedure. Primary outcome measures included patient satisfaction and patient anesthesia preference. Results: At final follow-up, 6 weeks postoperatively, high satisfaction (30 of 31 patients per method) was reported with both types of anesthesia. Among these patients, 17 (54%) preferred local-only anesthesia, 10 (34%) preferred sedation, 2 had no preference, and 2 opted out of response. Although anesthesia fees were approximately $390 lower with local-only anesthesia, total costs for carpal tunnel release were not significantly different with respect to the anesthesia cohorts. Total time in surgical facility was approximately 26 minutes quicker with local-only anesthesia, largely due to shorter time in the post-anesthesia care unit. Scaled comparison of worst postoperative pain following the 2 procedures revealed no difference between local-only anesthesia and sedation. Conclusions: Patients reported equal satisfaction scores with carpal tunnel release whether performed under local-only anesthesia or with sedation. In addition, local-only anesthesia was indicated as the preference of patients in 59% of cases.

Reduction of Opioid Use After Upper-Extremity Surgery through a Predictive Pain Calculator and Comprehensive Pain Plan.

PURPOSE: For outpatient hand and upper-extremity surgeries, opioid prescriptions may exceed the actual need for adequate pain control. The purposes of this study were to (1) determine rates of opioid wasting and consumption after these procedures and (2) create and implement a patient-specific calculator for opioid requirements with a detailed multimodal analgesic plan to guide postoperative prescriptions. METHODS: Patients undergoing hand and upper-extremity surgery at a single ambulatory surgery center were recruited before (n = 305) and after (n = 221) implementation of a postoperative pain control program. On the first postoperative visit, patients were given a questionnaire regarding opioid use and pain control satisfaction. Demographic and procedural data were collected via chart review. With these data from the first cohort, we developed a patient-specific opioid calculator and pain plan that was implemented for the second cohort of patients. Bivariate analysis and multivariable regression analysis were used to determine the effect of the intervention. RESULTS: Pre-intervention data suggested that younger age; baseline opioid use; use of regional block; unemployment; procedures involving bony, tendinous, or ligamentous work (as opposed to soft tissue alone); and longer procedure time were predictive of higher opioid consumption. Pre- and post-intervention cohorts had similar age and sex distributions as well as procedure length. After the intervention, opioids prescribed decreased 63% from a mean of 32.0 ± 15.0 pills/surgery or 194.5 ± 120.2 morphine milligram equivalents (MMEs) to 11.7 ± 8.9 pills/surgery or 86.4 ± 67.2 MMEs. Opioid consumption decreased 58% from a mean of 21.7 ± 25.0 pills/surgery (137.7 ± 176.4 MMEs) to 9.3 ± 16.7 (64.4 ± 113.4 MMEs). Opioid wastage decreased 62% from 13.8 ± 13.5 pills/surgery (62.8 ± 138.0 MMEs) to 5.2 ± 10.3 (24.8 ± 89.9 MMEs). Implementation of the pain plan and calculator did not affect the odds of unsatisfactory patient-rated pain control or unplanned opioid refills. CONCLUSIONS: With implementation of a comprehensive pain plan for ambulatory upper-extremity surgery, it is possible to reduce opioid prescription, consumption, and wastage rates without compromising patient satisfaction with pain control or increasing rates of unplanned pain medication refills. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Multi-Modal Pain Control in Ambulatory Hand Surgery.

We evaluated postoperative pain control and narcotic usage after thumb carpometacarpal (CMC) arthroplasty or open reduction and internal fixation (ORIF) of the distal radius in patients given opiates with or without other non-opiate medication using a specific dosing regimen. A prospective, randomized study of 79 patients undergoing elective CMC arthroplasty or ORIF of the distal radius evaluated postoperative pain in the first 5 postoperative days. Patients were divided into 4 groups: Group 1, oxycodone and acetaminophen PRN; Group 2, oxycodone and acetaminophen with specific dosing; Group 3, oxycodone, acetaminophen, and OxyContin with specific dosing; and Group 4, oxycodone, acetaminophen, and ketorolac with specific dosing. During the first 5 postoperative days, we recorded pain levels according to a numeric pain scale, opioid usage, and complications. Although differences in our data did not reach statistical significance, overall pain scores, opioid usage, and complication rates were less prevalent in the oxycodone, acetaminophen, and ketorolac group. Postoperative pain following ambulatory hand and wrist surgery under regional anesthesia was more effectively controlled with fewer complications using a combination of oxycodone, acetaminophen, and ketorolac with a specific dosing regimen.

Hand Surgery Questions on the Orthopaedic In-Training Examination: Analysis of Content and Reference.

PURPOSE: To provide an updated analysis of the hand surgery section of the Orthopaedic In-Training Examination (OITE) from 2009 to 2015. The goal was to contribute to the existing literature on the analysis of OITE questions, to aid both residents and residency programs in preparation for the OITE and board examination. METHODS: The authors analyzed all OITE questions pertaining to hand surgery between 2009 and 2015. Hand questions were analyzed for category and subcategory of content, cited reference, treatment intervention, and imaging modality used. RESULTS: Hand-related questions comprised 157 of the 1,872 OITE questions (8.4%). Nine general topic areas were identified, the most common of which were fracture-dislocation, tendon/ligament, nerve, congenital, and amputation. Trends existed in the recommended references; the 5 journals and 2 textbooks that were consistently cited included the Journal of Hand Surgery (American Volume), the Journal of the American Academy of Orthopaedic Surgeons, the Journal of Bone and Joint Surgery (American Volume), the Journal of Hand Surgery (European Volume), Hand Clinics, Orthopaedic Knowledge Update, and Green's Operative Hand Surgery, respectively. CONCLUSIONS: Knowledge regarding topics and resources used for OITE hand questions could be mutually beneficial to both residents and residency programs. This information would consolidate resident OITE and board examination study time. Furthermore, this analysis could help residency programs develop or improve educational conferences and journal clubs. CLINICAL RELEVANCE: An understanding of question content and sources should enable efficient learning and improved scores on this section of the examination.

The Effect of Trigger Finger Injection Site on Injection-Related Pain.

BACKGROUND: Stenosing tenosynovitis, or trigger digit, is a common condition for which patients often seek relief. Corticosteroid injections have been shown to provide relief in many cases, and several different approaches for delivering the injection have been described in the literature. We compared patients' perception of pain following each of 3 accepted injection methods, namely, palmar proximal, palmar distal, and webspace approaches. METHODS: We prospectively followed 38 patients with 39 symptomatic digits in this trial, with varying severities of trigger finger as graded by the Patel and Moradia classification. The patients were divided into 3 groups representing the 3 approaches without randomization, based upon the treating surgeons' preference. Disabilities of the Arm, Shoulder and Hand and visual analog scale (VAS) pain scores were calculated pre-injection and at 4-week and 8-week follow-up visits. RESULTS: No statistically significant differences in age, sex, affected extremity, grade, or duration of symptoms were observed among the 3 approaches. No statistically significant differences in VAS score were found between the palmar proximal (mean = 6.6, SD = 2.6), palmar distal (mean = 6.0, SD = 2.8), and webspace (mean = 6.8, SD = 1.8) approaches. CONCLUSION: Our data suggest that injection approach does not affect patient pain perception scores or outcomes. We recommend that the technique that is most comfortable to the surgeon be utilized, with the understanding that one injection alone has a low likelihood of relieving symptoms.

Surgeon Preference, Influence, and Treatment of Thumb Carpometacarpal Arthritis.

BACKGROUND: The purpose of this study was to evaluate current surgical practice patterns, the factors that influence these patterns, and overall trends in the treatment of thumb carpometacarpal osteoarthritis. METHODS: An online survey containing 14 questions was sent to all active members of the American Society for Surgery of the Hand. Information on demographics and treatments was collected. Results were anonymously uploaded to an online spreadsheet. RESULTS: A total of 823 responses were recorded. Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) using whole flexor carpi radialis was the most popular technique at 37.44%. In all, 26.38% of surgeons with fewer than 5 years of experience utilize trapeziectomy with suture suspension (bone anchor based or tendon based); 55.76% choose a particular procedure because of "Personal Clinical Experience" over "Current Evidence" and "Training." In addition, 24.17% of surgeons who have been practicing for longer than 5 years have changed procedures in the last 5 years. In the United States, 97.2% of hand surgeons prescribe either oxycodone or hydrocodone postoperatively compared with just 23.75% of international hand surgeons. CONCLUSIONS: The results show that trapeziectomy with LRTI remains the most popular treatment of choice. The use of trapeziectomy with suture suspension is on the rise, particularly in younger surgeons. International hand surgeons rely more on current evidence, utilize less postoperative therapy and opioid medications, and change procedures more often than US hand surgeons.

Use of a Bicortical Button to Safely Repair the Distal Biceps in a Two-Incision Approach: A Cadaveric Analysis.

PURPOSE: No consensus has been reached on the most effective anatomic approach or fixation method for distal biceps repair. It is our hypothesis that, using a cortical biceps button through a 2-incision technique, the distal biceps can be safely and anatomically repaired. METHODS: A 2-incision biceps button distal biceps repair was completed on 10 fresh-frozen cadavers. The proximity of the guide pin to the critical structures of the forearm, including the posterior interosseous nerve and recurrent radial artery, was measured. The location of repair was mapped and compared with anatomic insertion. RESULTS: The average distance from the tip of the guide pin to the posterior interosseous nerve was 11.4 mm (range, 8-14 mm). The average distance from the tip of the guide pin to the recurrent radial artery was 12.5 mm (range, 8-19 mm). The distal biceps tendon was repaired to the anatomic insertion site on the tuberosity using the biceps button technique in all specimens. CONCLUSIONS: The 2-incision biceps button repair described here allows safe and accurate repair of the tendon to the radial tuberosity in this cadaveric study. CLINICAL RELEVANCE: The goal of distal biceps repair is to safely, securely, and anatomically repair the torn biceps tendon to the radial tuberosity. The most commonly performed techniques (single anterior incision with cortical button and the double-incision procedure with bone tunnels and trough) have limitations. A 2-incision button repair safely and anatomically repairs the distal biceps tendon.

Acute hand injuries in athletes.

Hand and wrist injuries in athletes are common, representing between 3 and 25% of all sports injuries. As many as a quarter of all sports injuries involve the hand or wrist. We review the recent literature regarding acute hand injuries in athletes based on the structures involved - bone, muscle/tendon, ligament, and neurovascular - including diagnosis and pathophysiology of these injuries, focusing on athlete-specific facets of treatment, and when available, opinions on return to play.

MRI Correlation of Radial Head Fractures and Forearm Injuries.

Background: Radial head fractures can be associated with soft tissue injuries of the forearm and wrist. The Essex-Lopresti injury can lead to significant morbidity, especially if the diagnosis is not made acutely. Better identification of such injuries is needed to allow optimal surgical treatment and prevent long-term sequelae. We used magnetic resonance imaging (MRI) to correlate the degree of soft tissue injuries with radial head fractures. Methods: Sixteen pairs of forearms with an associated radial head fracture in 15 patients prospectively underwent an MRI within 2 weeks of their injury. MRI findings were correlated with fracture type, associated soft tissue injury, and presence of symptomatic wrist pain. Results: According to the modified Mason classification, there were 8 type I, 5 type II, and 3 type III radial head fractures. Wrist pain was reported in 8 of 16 extremities, and 2 had associated wrist pathology, including an acute scaphoid fracture in 1 patient and a preexisting stage II scapholunate advanced collapse (SLAC) wrist in another patient. The MRI findings included an elbow effusion in all 16 patients, edema in the proximal third of the radius in 15 extremities, which extended to the middle third in 3 extremities, edema of the interosseous membrane (IOM) in 5 extremities, and edema of the soft tissues including the supinator and/or pronator quadratus in 13 extremities. Conclusions: Eighty percent of patients with edema of the IOM had associated wrist pain. Soft tissue injuries of the forearm did not correlate with the severity of the radial head fracture.

Silicone Arthroplasty After Ankylosis of Proximal Interphalangeal Joints in Rheumatoid Arthritis: A Case Report.

Rheumatoid arthritis (RA) can cause severe disability of the hand and fingers. Ankylosis of the finger joints is a known yet underreported manifestation of RA of the hand. We report the case of a patient who had RA and developed autofusion of the proximal interphalangeal (PIP) joints. At presentation, the PIP joints were fused in 15° of flexion. Silicone PIP arthroplasty was performed. Function improved with 60° of PIP joint motion and no pain.

Trends in carpal tunnel surgery: an online survey of members of the American Society for Surgery of the Hand.

PURPOSE: To investigate the current treatment patterns of carpal tunnel surgery by members of the American Society of Surgeons of the Hand today and to assess how several elements of practice vary by surgeon location and experience. METHODS: An online survey consisting of 10 questions was sent electronically to members of the American Society of Surgeons of the Hand (N = 2,413). A brief description of the study and a link were sent to participants by the investigators. Results were anonymously uploaded to an online spreadsheet. RESULTS: 716 hand surgeons (30%) responded to the survey. Surgeons were nearly equally represented by region. A wide variation in surgeon experience was observed. A majority (65%) performed most of their surgery at an outpatient surgical center. Preoperative electrodiagnostic testing was used, at least occasionally, by 90% of surgeons. Approximately one-half did not administer preoperative antibiotics at the time of surgery. Intravenous sedation with local anesthesia was the most common practice (43%), followed by Bier block (18%). A mini-open incision was most commonly used (50%). A minority reported using an orthosis postoperatively (29%), and they rarely prescribed a course of postoperative therapy (12%). Postoperative pain management was variable, with hydrocodone and derivatives given most commonly (61%). International practitioners were much less likely to operate in an outpatient surgical center (45%) or use antibiotics (13%). Younger surgeons were more likely to use electrodiagnostic testing (96%) compared with the mean (90%). CONCLUSIONS: When compared with several previous similar studies, we noted a trend toward increased use of electrodiagnostic testing and decreased use of postoperative therapy and immobilization. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and decision analysis V.