Unplanned Postoperative Phone Calls and Electronic Messages for Patients With and Without Opioid Prescriptions After Carpal Tunnel Release.

Purpose: The purpose of our study was to compare unplanned postoperative patient communication in the form of phone calls and/or electronic patient portal messages (EPPM) after carpal tunnel release (CTR) for patients with and without a postoperative opioid prescription. Methods: We identified all patients ≥18 years of age who underwent primary CTR between 2017 and 2022 without an opioid ordered within 90 days prior to surgery. The following two groups were created: cases with and without an opioid prescribed on the day of surgery. We recorded baseline demographics for all patients and recorded all unplanned communication (phone calls and EPPM) sent from a patient to the surgeon's office within 14 days after surgery. Unadjusted associations between unplanned communication and case characteristics were evaluated. Multiple logistic regression models were used to assess the relationship between opioid status and unplanned communication. Results: A total of 5,735 CTRs were included, and 54% of the patients were prescribed an opioid on the day of surgery. Forty-two percent of cases had unplanned postoperative communication, and 48.1% of cases, without an opioid prescription, had unplanned communication compared with 36.8% in the opioid group. Patients who were prescribed opioids were 0.62 times less likely to contact the surgeon's office via phone calls or EPPM (95% confidence interval [CI]: 0.56, 0.70). Increased age was associated with a reduction in the odds of unplanned contact (odds ratios [OR] = 0.95, 95% CI: 0.93, 0.97), whereas higher body mass index was significantly associated with increased communication (OR = 1.05, 95% CI: 1.01, 1.09). Conclusions: Patients prescribed opioids after CTR are 0.62 times less likely to contact the surgeon's office after surgery. Considering the 11% increase in unplanned postoperative communication after CTR, surgeons should consider alternative methods that have previously been demonstrated to reduce opioid consumption. Type of study/level of evidence: Prognostic II.

Surgeon Factors and Trends Associated With the Use of Subacromial Decompression at the Time of Rotator Cuff Repair.

PURPOSE: Subacromial decompression (SAD) has historically been described as an essential part of the surgical treatment of rotator cuff disorders. However, investigations throughout the 21st century have increasingly questioned the need for routine SAD during rotator cuff repair (RCR). Our purpose was to assess for changes in the incidence of SAD performed during RCR over a 12-year period. In addition, we aimed to characterize surgeon and practice factors associated with SAD use. METHODS: Records from two large tertiary referral systems in the United States from 2010 to 2021 were reviewed. All cases of RCR with and without SAD were identified. The outcome of interest was the proportion of SAD performed during RCR across years and by surgeon. Surgeon-specific characteristics included institution, fellowship training, surgical volume, academic practice, and years in practice. Yearly trends were assessed using binomial logistic regression modeling, with a random effect accounting for surgeon-specific variability. RESULTS: During the study period, 37,165 RCR surgeries were performed by 104 surgeons. Of these cases, 71% underwent SAD during RCR. SAD use decreased by 11%. The multivariable model found that surgeons in academic practice, those with lower surgical volume, and those with increasing years in practice were significantly associated with increased odds of performing SAD. Surgeons with fellowship training were significantly more likely to use SAD over time, with the greatest odds of SAD noted for sports medicine surgeons (odds ratio = 3.04). CONCLUSIONS: Although SAD use during RCR appears to be decreasing, multiple surgeon and practice factors (years in practice, fellowship training, volume, and academic practice) are associated with a change in SAD use. CLINICAL RELEVANCE: These data suggest that early-career surgeons entering practice are likely driving the trend of declining SAD. Despite evidence suggesting limited clinical benefits, SAD remains commonly performed; future studies should endeavor to determine factors associated with practice changes among surgeons.

A Comparison of Early Complication Rates of Endoscopic Carpal Tunnel Release With and Without Resident Involvement.

PURPOSE: The purpose of this study was to compare the complication rates of endoscopic carpal tunnel release (ECTR) relative to orthopedic resident trainee involvement in the procedure. METHODS: All patients undergoing isolated, elective ECTR by two attending surgeons within a 59-month period were analyzed. Cases were categorized as the following according to the degree of resident involvement: ECTR performed by attending with either no resident or a resident as an assistant (group 1), resident performing a portion of the procedure (group 2), and resident performing the entire procedure (group 3). Early postoperative complications and/or intraoperative conversion to an open procedure were the outcomes of interest. We used a noninferiority design, hypothesizing that resident involvement would not be associated with inferior outcomes compared with cases without resident involvement. Multiple logistic regression models, adjusted for patient demographic and surgical characteristics, were fit to assess the relationship between resident involvement groups and complication/conversion outcomes. RESULTS: A total of 1,167 ECTR cases (895 patients) were performed and returned for postoperative follow-up for at least 2 weeks after surgery. Operative time was significantly shorter for group 1 cases versus group 2 and 3 cases. The early postoperative complication and conversion rates were 1.7% and 1.0%, respectively. Superficial infection (1.2%), deep infection (0.3%), and transient neuropraxia (0.3%) occurred infrequently and did not differ relative to resident involvement. No differences in the odds of complication and/or conversion relative to resident involvement were observed. CONCLUSIONS: The results of ECTR performed entirely or in part by attending-supervised resident trainees were not inferior to ECTR performed by an attending surgeon regarding the odds of experiencing complications or conversion to an open procedure. With appropriate supervision, ECTR can be performed safely by orthopedic and plastic surgery residents. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Statistical Literacy in Hand and Upper-Extremity Patients.

Purpose: Statistical literacy is the ability of a patient to apply basic statistical concepts to their health care. Understanding statistics is a critical component of shared decision making. The purpose of this investigation was to define levels of statistical literacy in an upper-extremity (UE) patient population. We aimed to determine if patient demographics would be associated with statistical literacy. Methods: An electronic survey was administered to a consecutive series of UE patients at a single institution. We recorded baseline demographics, Single Assessment Numeric Evaluation scores, the Berlin Numeracy Test (BNT), and General Health Numeracy Test. We also included a surgical risk question, which asked: "Approximately 3% of patients who get carpal tunnel surgery develop an infection. If 100 patients get this surgery, how many would you expect to develop an infection?" A covariate-controlled adjusted odds ratio reflecting the association between each statistical literacy outcome measure and patient characteristics was reported. Results: A total 254 surveys were administered, 148 of which were completed and included. Fifty percent of respondents had a high-school education or less. For the BNT, 78% scored in the bottom quartile, and 52% incorrectly answered all questions. For the General Health Numeracy Test, 34% answered 0 or 1/6 questions correctly. For the surgical risk question, 24% of respondents answered incorrectly. Respondents who had a college or graduate degree had 2.62 times greater odds (95% confidence interval, 1.09-6.32) of achieving a BNT score in a higher quartile than patients who did not have a college or graduate degree. Conclusions: Overall levels of statistical literacy are low for UE patients. Clinical relevance: When engaging in management discussions and shared decision making, UE surgeons should assume low levels of statistical literacy. Consideration of alternative formats, such as frequencies, video-based materials, and pictographs, may be warranted when discussing outcomes and risks of surgical procedures.

Adherence to Complication Reporting for Randomized Controlled Trials Contained in Clinical Practice Guidelines for the Management of Carpal Tunnel Syndrome.

Purpose: Randomized controlled trials (RCTs) are frequently used in creating recommendations contained within clinical practice guidelines (CPGs). However, investigations outside of hand surgery have reported that RCTs within CPGs infrequently report complications and harms-related data. Our purpose was to assess adherence to complication reporting and harms-related outcomes contained in the Consolidated Standards for Reporting (CONSORT) Extension of Harms and Standards for Reporting of Diagnostic Accuracy Studies (STARD) reporting checklists for RCTs within the American Academy of Orthopaedic Surgery (AAOS) CPGs for carpal tunnel syndrome (CTS). Methods: We identified all RCTs within the AAOS CTS CPGs. All therapeutic RCTs and diagnostic studies were included. We used the CONSORT Harms Checklist criteria to assess adherence to the reporting of adverse events for therapeutic RCTs and the STARD criteria to assess the diagnostic accuracy of the articles. We defined adequate compliance as adherence to ≥50% of the checklist items. Results: We identified 82 therapeutic RCTs and 90 diagnostic accuracy articles within the AAOS CTS CPG. For therapeutic RCTs, we found that the average compliance with the published checklists was 19%. For diagnostic studies, the average compliance with checklists was found to be 55%. Eleven therapeutic RCTs (13%) and 60 diagnostic studies (67%) were determined to have adequate compliance for the CONSORT and STARD checklists, respectively. Conclusions: Randomized controlled trials in the AAOS CPGs for CTS have low compliance with the CONSORT Extension for Harms Checklist. Although the overall adherence to the items published in the STARD statement for diagnostic accuracy evaluation remains higher, future efforts should be made to improve the adherence rates to both checklists. Clinical relevance: Improved standardization of complication reporting may aid in comparing outcomes across multiple clinical investigations of upper-extremity procedures.

Defining Nonunion for Metacarpal Fractures: A Systematic Review.

Purpose: Our purpose was to assess how nonunion of the metacarpals has been defined in prior investigations with respect to both clinical and radiographic criteria. We hypothesized that the definitions of nonunion would be highly variable. Methods: A systematic review was conducted using MEDLINE and Embase databases for clinical articles related to the treatment of metacarpal fractures (surgical and nonsurgical) from 2010 to 2021. Included articles were searched to assess how nonunion was defined based on clinical and radiographic criteria. We assessed the treatment type, method of union assessment, time to union, and incidence of union as well as article factors such as the following: date of publication, level of evidence, and publishing journal. Results: A total of 641 articles were identified, of which 102 were included for a definition of nonunion and 97 were included for the assessment of clinical management and outcomes. Of the included articles, 62% contained level IV evidence. A definition of nonunion was provided in 47% of the articles. Radiographic criteria alone, clinical criteria alone, or a combination of the 2 was used in 22%, 6%, and 19% of the cases, respectively, to define nonunion. The most common definition of nonunion was presence of fracture-site tenderness (with no time defined) in 20 articles (20%), followed by lack of radiographic healing at 6 months (15%). In the 97 included articles, the total number of fracture cases was 4,435 and nonunion was reported in 0.45%. Cases with nonunion were reported in a total of six articles that used a variety of treatment modalities. Conclusions: The definition of metacarpal nonunion remains highly variable and lacks standardization with respect to clinical and radiographic criteria. Clinical relevance: Standardizing the definition of nonunion for metacarpal fractures would allow for more accurate assessments of the incidence of this complication and may aid in improving diagnostic and management strategies.

The Effect of an Intraoperative Real-Time Counter on Radiation Exposure Events During Operative Treatment of Distal Radius Fractures.

PURPOSE: Occupational radiation exposure can have adverse health consequences for surgeons. The purpose of this study was to determine if utilization of an intraoperative, real-time radiograph counter results in decreased radiation exposure events (REEs) during open reduction and internal fixation (ORIF) of distal radius fractures (DRFs). METHODS: We reviewed all cases of isolated ORIF DRFs performed at a single center from January 2021 to February 2023. All cases performed on or after January 1, 2022 used an intraoperative radiograph counter, referred to as a "shot-clock" (SC) group. Cases prior to this date were performed without a SC and served as a control group (NoSC group). Baseline demographics, fracture, and surgical characteristics were recorded. Final intraoperative radiographs were reviewed to record reduction parameters (radial inclination, volar tilt, and ulnar variance). REEs, fluoroscopy exposure times, and total radiation doses milligray (mGy) were compared between groups. RESULTS: A total of 160 ORIF DRF cases were included in the NoSC group, and 135 were included in the SC group. The NoSC group had significantly more extra-articular fractures compared with the SC group. Reduction parameters after ORIF were similar between groups. The mean number of REEs decreased by 48% in the SC group. Cases performed with the SC group had significantly lower total radiation doses (0.8 vs 0.5 mGy) and radiation exposure times (41.9 vs 24.2 seconds). Mean operative times also decreased for the SC group (70 minutes) compared with that for the NoSC group (81 minutes). CONCLUSIONS: A real-time intraoperative radiograph counter was associated with decreased REEs, exposure times, and total radiation doses during ORIF DRFs. Cases performed with a SC had significantly shorter operative times without compromising reduction quality. Using an intraoperative SC counter during cases requiring fluoroscopy may aid in decreasing radiation exposure, which serves as an occupational hazard for hand and upper-extremity surgeons. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

An Analysis of Gender Diversity in Hand and Upper Extremity Surgery Webinars.

PURPOSE: Some female upper extremity (UE) surgeons face unique barriers to participation at in-person academic and professional society meetings due to disparate childcare and household duties relative to male surgeons. Webinars may alleviate some of this travel burden and allow for more balanced participation. Our purpose was to evaluate gender diversity within academic webinars with a focus on UE surgery. METHODS: We queried webinars conducted by the following professional societies: American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand (ASSH), American Association for Hand Surgery, and American Shoulder and Elbow Surgeons societies. Webinars with an UE focus produced between January 2020 and June 2022 were included. Demographic characteristics, including sex and race, were recorded for webinar speakers and moderators. RESULTS: A total of 175 UE webinars were identified, with 173 of 175 (99%) having functioning video links. The 173 webinars had 706 speakers and 173 (25%) were women. Female representation in professional society webinars exceeded their overall participation in their sponsoring organizations. Although women comprise 6% and 15% of the overall American Academy of Orthopaedic Surgeons and ASSH membership, respectively, they accounted for 26% of American Academy of Orthopaedic Surgeons webinar speakers and 19% of ASSH webinar speakers. CONCLUSIONS: Between 2020 and 2022, women comprised 25% of speakers for professional society academic webinars with a focus on UE surgery, which exceeds the proportion of women in the individual sponsoring professional societies. CLINICAL RELEVANCE: Online webinars may mitigate some of the barriers that female UE surgeons face with respect to professional development and academic advancement. Although female participation in UE webinars often exceeded the current rates of female members in the individual professional societies, women remain underrepresented in UE surgery, relative to the percentage of female medical students.

Arthroscopic approach in initial training: Study of a novice cohort using inverse direct and indirect approaches and its implication in the development of training programs.

INTRODUCTION: Arthroscopic training includes successive stages of observation, reproduction and then repetition. Learning through simulation in 2D virtual reality makes it possible to repeat these different stages to enhance the learner's experience in complete safety and a shorter timeframe. Some procedures require inversion of the optical and instrumental approaches in the axial plane, disrupting the existing psychomotor and technical skills. The objective of this study was to compare the degree of difficulty and the distribution of results for the same exercise carried out alternately in classical holding and inverted holding of the instruments in a cohort of novice learners. MATERIALS AND METHODS: Twenty-two medical students, novices in arthroscopic surgery, participated in the study. Each performed an exercise consisting of grasping ten targets with arthroscopic forceps and placing them in a basket on the VirtaMed ArthroS™ simulator. The exercise was performed with the scope and grasping instrument pointed away from the operator, "catch the stars front" (CTSF), then directed towards the operator, "catch the stars back" (CTSB). The simulator recorded several parameters making up an overall composite score ("overall performance score", OPS) out of 120 points. Voluntary abandonment of the exercise was also collected. RESULTS: All students completed the CTSF exercise but 6 dropped out of the CTSB exercise (27%, p=0.01). In the CTSF exercise, the average OPS was higher with 45.9 points versus 22.8 points in the CTSB exercise (p<0.001). By detailing the components of the OPS score, the parameters of interest on the Fundamentals of Arthroscopic Training (FAST) module of the simulator included: the distance traveled by the scope and the grasping forceps was significantly greater in the CTSB group (p<0.001), the duration of the exercise was significantly greater in the CTSB group (p<0.001), the time spent with the instruments in the videoscopic field was significantly lower in the CTSB group (p=0.001) and finally the absence of a significant difference in the camera alignment compared to the horizontal plane between the two groups. CONCLUSION: The exercise with the instruments directed towards the operator is more difficult with a greater distribution for all the secondary criteria except for the camera alignment, which suggests that it could be more discriminating. The dropout rate is also higher. It would therefore be interesting to introduce CTSB type training in initial training programs in arthroscopy. LEVEL OF EVIDENCE: III, comparative prospective study.