Operative treatment of Mason Type III radial head fractures - A comparative analysis using PROMIS.

Objectives: The purpose of this study is to evaluate the outcomes of operatively treated Mason Type III radial head fractures. Additionally, this project seeks to assess efficacy of PROMIS in evaluating post-operative outcomes for this patient population. Methods: A total of 143 patients who underwent operative treated Mason Type III radial head fractures were analyzed retrospectively. PROMIS physical function (PF), PROMIS upper extremity (UE), PROMIS pain interference (PI), demographic variables, and range of motion were collected and analyzed over 12-month follow-up. Results: Radial head arthroplasty (RHA) was performed on 89 patients, open reduction and internal fixation (ORIF) was performed on 47 patients, and radial head excision was performed on 7 patients. Among the RHA patients, PROMIS PF, PI and UE demonstrated a change of -1.33 (p < 0.05), -1.48 (p < 0.05), and 2.23 (p < 0.05) respectively from injury to 12-months. Among the ORIF patients, PROMIS PF, PI and UE demonstrated a change of 3.22 (p < 0.05), -1.56 (p < 0.05), and 2.09 (p < 0.05) respectively from injury to 12-months. At the pre-operative and 12-month visits, the RHA group demonstrated lower PROMIS PF scores 34.75 vs 38.02 (p < 0.05) and 33.42 vs 41.24 (p < 0.05) respectively. Ther was no difference in PROMIS PI, UE, or elbow range of motion between the two groups at 6- or 12-month follow-up (p > 0.05). Conclusion: Comparing the RHA and ORIF groups, there was no difference in PROMIS PI or UE scores nor was there a clinically significant improvement at the 6- or 12-month mark. The ORIF group demonstrated improved PROMIS PF at all follow-up periods and did show a clinically significant improvement. Patient Acceptable Symptom State (PASS) correlated only with PROMIS UE at 6- and 12- months for both groups.

Association between electrodiagnosis and neuromuscular ultrasound in the diagnosis and assessment of severity of carpal tunnel syndrome.

BACKGROUND: Neuromuscular ultrasound plays an increasing role in diagnosing carpal tunnel syndrome (CTS). There are limited data supporting the correlation between the electrodiagnostic studies and ultrasound measurements in CTS. OBJECTIVE: To assess the association between different electrodiagnostic severities and ultrasound measurements of the median nerve in CTS. DESIGN: A retrospective cohort study. SETTING: An academic tertiary care center. PATIENTS: Patients 18 years or older evaluated with upper limb electrodiagnostic studies and neuromuscular ultrasound. MAIN OUTCOME MEASUREMENT: Ultrasound measurements of the median nerve cross-sectional area (CSA) at the wrist and the calculated wrist-to-forearm ratio (WFR) were compared with the electrodiagnostic severity (normal, mild, moderate, and severe). Mean analysis and analysis of variance test (α = 0.05) were performed to assess the association. RESULTS: A total of 1359 limbs were identified. There was a statistically significant association between electrodiagnostic severity of CTS and median nerve CSA at the wrist (p < .001), as well as the WFR (p < .001). The mean median nerve CSA at the wrist and WFR were 7.01 ± 2.06 mm2 (95% CI: 6.80-7.20) and 1.24 ± 0.36 (95% CI: 1.16-1.24) in electrodiagnostically normal median nerves, 10.47 ± 2.82 mm2 (95% CI: 10.25-10.75) and 2.06 ± 0.67 (95% CI: 2.04-2.16) in electrodiagnostically mild CTS, 12.95 ± 4.74 mm2 (95% CI: 12.41-13.59) and 2.49 ± 1.04 (95% CI: 2.37, 2.63) in electrodiagnostically moderate CTS, and 14.69 ± 5.38 mm2 (95% CI: 13.95-15.44) and 2.71 ± 1.02 (95% CI: 2.56-2.84) in electrodiagnostically severe CTS, respectively. CONCLUSION: This study suggests a direct association between electrodiagnostic severity and ultrasound measurements of the median nerve in patients with suspected CTS.

Comparison of Low-Dose Computed Tomography Versus Conventional-Dose Computed Tomography in the Evaluation of Distal Radius Fractures.

BACKGROUND: Distal radius fractures (DRFs) are common upper extremity fractures and often require surgical fixation when they are intraarticular. Preoperative computed tomography (CT) has emerged as a surgical planning tool to evaluate intraarticular DRFs. Although CT affords additional details, patients receive higher radiation doses than standard radiographs. We aim to develop a low-dose CT (LDCT) protocol, relative to the institutional standard-dose CT wrist for intraarticular DRFs although providing adequate detail for surgical decision-making. METHODS: A single-institution prospective study was conducted on patients with intraarticular DRFs who underwent closed reduction and below-elbow splinting who otherwise would undergo wrist CT. Observations were defined as total measurements taken, with each view undergoing 44 measurements. Patients underwent 2 scans with a standard dose and a 10× dose reduction. Articular step and gap measurements were recorded in the sagittal and coronal images. RESULTS: A total of 11 patients were enrolled (7 women and 4 men). The mean age was 55 years (SD = 20.1). There were a total of 4 reviewers: 1 attending surgeon, 2 resident physicians, and 1 student. When comparing LDCT and conventional-dose CT (CDCT), there were no significant differences in step and gap measurements across all reviewers. CONCLUSION: This study demonstrated that LDCT provides comparable imaging quality for surgical planning as a CDCT without significant diagnostic decay in the setting of DRFs. This comes with the added benefit of a 10-fold reduction in radiation exposure. These results suggest that LDCT is an opportunity to reduce effective radiation in patients although providing beneficial preoperative imaging.

Acquired Aquagenic Syringeal Keratoderma Following COVID-19 Infection.

Aquagenic syringeal keratoderma (ASK), rare in males, is characterized by the rapid onset of edematous palmar wrinkling with small white papules after brief contact with water or sweat. A 24-year-old atopic male presented with a 2-week subacute history of bilateral palmar edema with whitish-colored papules after exposure to water, 3 months after having had COVID-19 infection treated with a full course of ritonavir-boosted nirmatrelvir (PAXLOVIDTM). He had received 3 COVID-19 vaccines (Pfizer, New York, NY) about 12 months prior. Workup was negative. Initial spontaneous near-resolution 2 months after onset was temporary, with recurrence 1 month later. Treatment with 12% topical aluminum chloride was ineffective. Botulinum toxin injection to both palms led to resolution of symptoms that has been sustained for 7 months. The association between atopy and ASK remains weak. We present a case of new-onset ASK in an adult male 3 months following COVID-19 infection without a history of excessive handwashing. Our patient may have had a predisposition to recurrent ASK due to his history of atopy including atopic dermatitis and food allergy anaphylaxis combined with prior COVID-19 infection. It is possible that ASK is a novel manifestation of post-acute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (PASC) infection or long COVID.

Best-Evidence Systematic Review and Meta-Analysis of Mini-Open Carpal Tunnel Release.

Purpose: This study aimed to evaluate the safety and effectiveness of mini-open carpal tunnel release (mOCTR) using best-evidence synthesis methods. Methods: We systematically searched for prospective studies published from January 2013 to July 2023 that reported outcomes from a minimum of 50 mOCTR cases. The outcomes included Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire, Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQ-SSS) and Functional Status Scale (BCTQ-FSS), pain visual analog scale (VAS), complication rate, and reoperation rate. Data analysis was performed using a random-effects meta-analysis, with metaregression to identify the associations between patient- and study-level factors with surgical outcomes. Results: The meta-analysis included 23 studies with 2,303 patients followed for median durations ranging from 6 to 12 months depending on the outcome. Mini-open carpal tunnel release resulted in statistically significant and clinically important improvements in Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (mean difference = -25.5; 95% confidence interval [CI]: -36.4 to -14.5; P < .001), BCTQ-SSS (mean difference = -2.2; 95% CI: -2.5 to -1.9; P < .001), BCTQ-FSS (mean difference = -2.1; 95% CI: -2.4 to -1.7; P < .001), and pain VAS (mean difference = -5.1; 95% CI: -6.2 to -4.1; P < .001). The sole predictor of improvement in BCTQ-SSS, BCTQ-FSS, and pain VAS was a higher preoperative score for the respective variable (all P < .001). The risk of complications (mainly short-term pillar pain or scar complications) was 8.9% (95% CI: 4.0%-13.8%) and increased with longer incision lengths (P = .008). Revision carpal tunnel release was performed in 0.6% (95% CI: 0.1%-1.0%) of the cases during follow-up. No cases of median nerve transection were reported. Conclusions: Based on a best-evidence meta-analysis of contemporary studies, mOCTR significantly improved function and pain, with a relatively low risk of mainly temporary complications. Patient outcomes after mOCTR were influenced by patient symptomatology and surgical incision length. Clinical relevance: Mini-open carpal tunnel release is an effective surgical option that significantly improves symptoms and function, especially for patients with more severe baseline dysfunction. Surgeons should use the shortest incision that allows adequate visualization to safely divide the transverse carpal ligament.

Best-Evidence Systematic Review and Meta-Analysis of Endoscopic Carpal Tunnel Release Outcomes.

Purpose: The aim of this systematic review and meta-analysis was to evaluate the safety and effectiveness of endoscopic carpal tunnel release (ECTR) using best-evidence synthesis methods. Methods: A systematic search of multiple databases was conducted for prospective contemporary studies published between January 2013 and January 2023 with at least 50 ECTR cases. Outcomes included the Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (Q-DASH) measured on a 0-100 scale, Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQ-SSS) and Functional Status Scale (BCTQ-FSS) on a 1-5 scale, pain visual analog scale on a 0-10 scale, conversion to open carpal tunnel release (CTR), complications, and reoperations. Outcomes were analyzed using a random-effects meta-analysis model. Metaregression was used to determine the association of patient- and study-level factors with ECTR outcomes. Results: A total of 17 studies with 1,632 patients treated with ECTR were included. Median follow-up durations ranged from 4 to 7 months depending on the outcome. Statistically significant and clinically important improvements were noted after ECTR for Q-DASH, BCTQ-SSS, BCTQ-FSS, and pain visual analog scale scores, with mean differences from baseline of -28.8, -1.8, -1.5, and -5.1, respectively (P < .001 for all). In metaregression, the strongest predictor of improvement in Q-DASH, BCTQ-SSS, and BCTQ-FSS was a greater preoperative score for that variable (all P ≤ .005), indicating that patients with worse symptoms improved the most. The risks of conversion to open CTR, complications, and revision CTR were 0.7%, 0.7%, and 0.5%, respectively. Conclusions: In a best-evidence synthesis of contemporary studies, ECTR resulted in significant improvements in function and pain, with a low risk of conversion to open surgery, complications, and reoperations over short-term follow-up. Clinical relevance: Patients treated with ECTR can expect generally favorable clinical outcomes over the short term. However, long-term outcomes after ECTR are not well characterized.

Incidence and Risk Factors for Revision Within 1 Year of Primary Carpal Tunnel Release.

BACKGROUND: The annual volume of carpal tunnel release (CTR) in the United States has been estimated to be 577 000 per year. Our objectives were to evaluate the incidence and risk factors for revision CTR within 1 year of primary CTR. METHODS: We identified all adult patients undergoing primary CTR from October 2015 to September 2019 in the New York Statewide Planning and Research Cooperative System database using Current Procedural Terminology (CPT) codes. We used the CPT modifier codes to determine laterality of index and revision procedures. We estimated multivariable hierarchical logistic regression models to evaluate risk factors for revision CTR within 1 year. RESULTS: Of the 80 423 primary CTR procedures, 178 (0.22%) underwent a revision CTR within 1 year of the index surgery. The mean (SD) age of the entire cohort was 58.69 (14.43) years, 61.1% were women, 73.2% were non-Hispanic white, 42.9% were covered through private insurance, and 9.5% had diabetes mellitus. Workers' compensation insurance (odds ratio [OR] = 1.83, 95% confidence interval [CI], 1.13-2.98, P = .02) and simultaneous bilateral CTR (OR = 14.91, 95% CI, 9.62-23.12, P < .001) were associated with revision CTR within 1 year of the index procedure. No models demonstrated an association between endoscopic technique or surgeon volume and revision CTR. CONCLUSIONS: The incidence of revision CTR within 1 year was lower than that previously reported. Patients covered by workers' compensation and those undergoing simultaneous bilateral CTR had higher likelihood of a revision CTR within 1 year, whereas endoscopic technique and surgeon volume were not associated with revision CTR within 1 year.

An Analysis of Patient-Reported Outcomes Measurement Information System (PROMIS) in Non-operative Posterolateral Elbow Dislocations.

INTRODUCTION: The purpose of our study is to analyze the outcomes of traumatic posterolateral elbow dislocations using patient-reported outcomes measurement information system (PROMIS). We hypothesized that physical function (PF) and upper extremity (UE) scores in PROMIS will significantly improve over six months of follow-up and correlate with a positive change in the patient-acceptable symptom state (PASS). METHODS: This is a seven-year retrospective study of 165 consecutive adult patients with traumatic posterolateral elbow dislocations. Demographic information, PROMIS PF, PROMIS UE, PROMIS pain interference (PI), PROMIS depression, and PASS were recorded over six months of follow-up. RESULTS: At the time of injury, mean PROMIS scores were PF 41.24 (SD 11.16), UE 34.27 (SD 11.87), PI 60.44 (SD 8.07), and depression 49.82 (SD 10.42). At six months, the mean PROMIS scores were PF 39.71 (SD 9.71), UE 33.95 (SD 9.09), PI 57.35 (SD 8.59), and depression 51.43 (SD 10.62). The overall six-month changes in PROMIS scores were PF -1.53, UE -0.32, PI -3.09, and depression +1.61. At the 6-month follow-up, 41.7% responded positively on the PASS, which correlated only with PROMIS PI. CONCLUSIONS: Among patients who improved from negative to positive response on PASS, the PROMIS PF, UE, and depression scores did not significantly improve. Only PROMIS PI correlated with PASS at the six-month follow-up; PROMIS PI significantly improved among simple posterolateral elbow dislocation patients at both short-term and long-term follow-up points. PROMIS PF, UE, and depression did not significantly differ between time of injury and short-term and long-term follow-up points.

Non-operative Treatment of Mason Type I Radial Head Fractures: A Comparative Analysis Using Patient-Reported Outcomes Measurement Information System (PROMIS).

OBJECTIVES: The purpose of this study is to compare the outcomes of Mason type I radial head fractures. This information will help to provide physicians with a critical decision-making tool when considering non-operative intervention and evaluate Patient-Reported Outcomes Measurement Information System (PROMIS) as a potentially valuable measure to track outcomes. METHODS: We retrospectively identified 527 patients undergoing non-operative intervention. Demographic information, physical exam measurements, patient acceptable symptom state (PASS), and PROMIS Upper Extremity (UE), Physical Function (PF), and Pain Interference (PI) scores were analyzed over 12 months. RESULTS: At the initial outpatient post-injury visit (within one week of injury), the average PROMIS PF, UE, PI, and Depression were 42.04 (SD: 6.3), 35.31 (SD: 7.3), 59.18 (SD: 9.2), and 48.68 (SD: 6.8), respectively. The average change in PROMIS PF, UE, PI, and Depression scores from the time of injury to six weeks were -0.23 (p=0.7), 1.43 (p=0.03), -2.1 (p=0.01), and -0.99 (p=0.1). The average change in PROMIS PF, UE, PI, and Depression scores from the time of injury to six months was -0.56 (p=0.56), 1.84 (p<0.001), -1.84 (p<0.001), and -0.13 (p=0.68). Among patients initially reporting "not acceptable" on PASS and reporting "acceptable" at the six-month visit, the average PROMIS PF, UE, PI, and Depression scores were 42.14, 38.91, 56.91, and 47.51 respectively. This represents an average difference of 1.11 (p=0.07), 2.82 (p<0.01), -1.19 (p=0.04), and -1.7 (p=0.01) respectively. CONCLUSION: PROMIS UE and PI significantly improved among Mason I radial head fractures treated non-operatively at both six-week and six-month follow-up points but did not meet the mean clinically important difference (MCID) PROMIS PF did not significantly differ between the time of injury, six-week or six-month follow-up points. Only PROMIS UE correlated with PASS at six-week and six-month follow-up. Among patients who improved from negative to positive responses on PASS, PROMIS UE, and PI significantly improved.

Carpometacarpal Joint Pathology in the Thumb and Hand: Evaluation and Management of Difficult Conditions.

Thumb carpometacarpal arthroplasty with complete trapeziectomy with or without suspensionplasty, ligament reconstruction, and/or tendon interposition is largely considered equivalent techniques in providing pain relief and improving function for patients with thumb carpometacarpal arthritis. In cases of continued pain, instability, and dysfunction following an index surgery, one must first identify the cause of failure. Any options for revision surgery depend on addressing the specific cause of persistent symptoms with awareness of available options. Most of the patients undergoing revision surgeries can achieve good to fair outcomes.

Bringing Patient-Reported Outcome Measures (PROMs) Into Practice: A Review of the Latest Developments in PROM Use in the Evaluation and Treatment of Carpal Tunnel Syndrome.

As health care systems globally shift toward optimizing value, defined as health outcomes achieved per dollar spent across a full cycle of care, there has been increasing focus on using patient-reported outcome measures (PROMs) to gauge success. Patient-reported outcome measures are validated questionnaires that allow patients to share their health status across several domains (eg, pain or physical function). This trend has been particularly notable in hand surgery, with PROM use investigated for many common hand conditions, including carpal tunnel syndrome, Dupuytren contracture, trigger finger, osteoarthritis, and wrist ganglion. The purpose of this article is to review recent developments in the use of PROM instruments, including the Boston Carpal Tunnel Questionnaire; Michigan Hand Outcomes Questionnaire; Disabilities of the Arm, Shoulder, and Hand; and Patient-Reported Outcomes Measurement Information System, for the evaluation and treatment of patients with carpal tunnel syndrome. The considerable progress in establishing PROMs for use in carpal tunnel syndrome is reviewed, and future improvements are proposed to standardize PROM use and bring PROMs into day-to-day clinical practice for individualized patient treatment decision-making and counseling.

External Fixation Prior to Fasciectomy Leads to Substantial Improvement of Advanced Dupuytren's PIP Contractures at Mean Follow-up 15 Months.

BACKGROUND: The Digit Widget is an external fixation device that can be used to reverse proximal interphalangeal joint (PIPJ) contractures in the hand. Our hypothesis is that usage of the Digit Widget prior to fasciectomy in patients with severe Dupuytren's proximal interphalangeal (PIP) contractures will result in short-term improvement and maintenance of the PIPJ contracture after fasciectomy. METHODS: Patients who underwent placement of the Digit Widget soft tissue distractor prior to fasciectomy for Dupuytren's disease were identified between January 2015 and December 2018. Multiple fingers were considered separately. Patient Reported Outcome Measurement Information System (PROMIS) Physical Function (PF), Pain Interference, and Depression scores were collected. Patients treated for contractures from etiologies other than Dupuytren's were not included. Multiple linear regression was used to compare initial PIP contractures, PF scores, and final contractures. RESULTS: There were 28 fingers in 24 patients with average age of 56 ± 12 (30.5-69.9) years. Initial mean PIPJ contracture was 81° (50°-120°), which had corrected to 23° at time of removal. Average time between application and fasciectomy was 58 (28-112) days. At final follow-up, average 449 (58-1641) days, the average contracture was 39° (0°-105°). Contracture immediately following fasciectomy was found to be strongly correlated with the contracture at final follow-up. There was no statistical relationship between final PROMIS PF scores and final change in contracture. CONCLUSIONS: Digit Widget external fixation is an effective treatment for the correction of advanced PIPJ contractures related to Dupuytren's disease, with an average of 52% improvement in contracture at 15 months.

Endoscopic Versus Open Carpal Tunnel Surgery: Risk Factors and Rates of Revision Surgery.

PURPOSE: The purpose of our study was to compare the 1-year revision surgery rates and outcomes of open versus endoscopic carpal tunnel release. Our hypothesis was that, compared to open release, endoscopic carpal tunnel release was an independent risk factor for revision surgery within 1-year. METHODS: This was a retrospective cohort study of 4338 patients undergoing isolated endoscopic or open carpal tunnel release. Demographic data, medical comorbidities, surgical approach, need for revision surgery, hand dominance, history of prior injection, and Patient Reported Outcomes Measurement Information System upper extremity (UE), pain interference (PI) and physical function scores were analyzed. Multivariable analysis was used to identify the risk factors for revision surgery within one year of the index procedure. RESULTS: In total, 3280 patients (76%) underwent open and 1058 (24%) underwent endoscopic carpal tunnel release. Within one year of the index procedure, 45 patients required revision carpal tunnel release. The average time to revision was 143 days. The rate of revision carpal tunnel release in the open group was 0.71% compared to 2.08% in the endoscopic group. Multivariable analysis demonstrated that endoscopic surgery, male sex, cubital tunnel syndrome, tobacco use, and diabetes were associated independently with revision surgery. CONCLUSIONS: In this study, we found that endoscopic carpal tunnel release was associated independently with a 2.96 times greater likelihood of requiring revision carpal tunnel release within one year, compared to open carpal tunnel release. Male sex, concurrent cubital tunnel syndrome, tobacco use, and diabetes also were associated independently with greater risk of needing revision carpal tunnel release within one year. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Using MaxDiff Analysis to Elicit Patients' Treatment Preferences for Distal Radius Fractures in Patients Aged 60 Years and Older.

PURPOSE: The objective of our study was to determine how the attributes of surgical and nonsurgical distal radius fracture (DRF) treatments affect patient treatment preferences. METHODS: Two hundred fifty patients aged 60 years and older were contacted from a single-hand surgeon's practice, and 172 chose to participate. We built a series of best-worst scaling experiments for the MaxDiff analysis to determine the relative importance of treatment attributes. Hierarchical Bayes analysis was used to generate individual-level item scores (ISs) for each attribute that together have a total sum of 100. RESULTS: One hundred general hand clinic patients without a history of a DRF and 43 patients with a history of a DRF completed the survey. For the general hand clinic patients, the most important attributes to avoid when choosing a DRF treatment (in descending order) were the longer time to full recovery (IS, 24.9; 95% confidence interval [CI]: 23.4-26.3), longer time spent in a cast (IS, 22.8; 95% CI, 21.5-24.2), and higher complication rates (IS, 18.4; 95% CI, 16.9-19.8). Meanwhile, for patients with a history of a DRF, the most important attributes to avoid (in descending order) were a longer time to full recovery (IS, 25.6; 95% CI, 23.3-27.9), longer time spent in a cast (IS, 22.8; 95% CI, 19.9-25.7), and abnormal alignment of the radius on x-ray (IS, 18.3; 95% CI, 15.4-21.3). For both the groups, the least concerning attributes based on the IS were appearance-scar, appearance-bump, and the need for anesthesia. CONCLUSIONS: Eliciting patient preferences is a vital component of shared decision-making and advancing patient-centered care. As conceptualized in this MaxDiff analysis, when choosing a DRF treatment, patients mostly want to avoid a longer time to full recovery and a longer time in a cast, whereas patients have the least concern about appearance and need for anesthesia. CLINICAL RELEVANCE: Eliciting patient preferences is a vital component of shared decision-making. Our results may provide guidance to surgeons in discussions on the relative benefits of surgical and nonsurgical DRF treatments, by quantifying the most and least important factors to patients.

Protocol of a Multicenter Prospective Trial of Office-Based Carpal Tunnel Release With Ultrasound Guidance (ROBUST).

Background Carpal tunnel release (CTR) is a common surgical procedure for patients with severe or refractory carpal tunnel syndrome (CTS) symptoms. Historically, CTR procedures have been performed in a hospital or an ambulatory surgery center (ASC). However, due to advancements in techniques, greater patient demand, and concerns about growing healthcare costs, there is a distinct trend toward performing CTR procedures in an office-based setting. Several small studies with limited follow-up duration have demonstrated the feasibility of CTR with ultrasound guidance (CTR-US) when performed in an office-based setting. The objective of this study is to evaluate the safety and effectiveness of office-based CTR-US in a large cohort of patients (n=140) with symptomatic CTS followed for two years post-treatment. Design and methods ROBUST is a prospective multicenter observational study in which 140 subjects at up to 12 sites in the United States will be treated with CTR-US in an office-based setting. The primary endpoint of the study is the change in the Boston Carpal Tunnel Questionnaire Symptom Severity Scale score. Secondary endpoints include time to return to normal daily activities, time to return to work among employed subjects, change in the Boston Carpal Tunnel Questionnaire Functional Status Scale score, change in the Michigan Hand Questionnaire overall and domain scores, change in the Numeric Pain Scale score, change in the EuroQoL-5 Dimension 5-Level score, global satisfaction scores, and the incidence of device or procedure-related adverse events. The primary analysis of study endpoints will occur three months post-treatment. Patient follow-up in this study will continue for two years. Conclusions A central institutional review board approved the study protocol, and a data safety monitoring board will provide study oversight. The authors plan to report study results at medical conferences and in peer-reviewed medical journals. The outcomes of ROBUST will provide physicians, patients, and payors with important safety and effectiveness data regarding the clinical utility of CTR-US when performed in an office setting.

What Factors Are Associated With Revision Cubital Tunnel Release Within 3 Years?

BACKGROUND: It has been shown that patient demographics such as age, payer factors such as insurance type, clinical characteristics such as preoperative opioid use, and disease grade but not surgical procedure are associated with revision surgery to treat cubital tunnel syndrome. However, prior studies evaluating factors associated with revision surgery after primary cubital tunnel release have been relatively small and have involved patients from a single institution or included only a single payer. QUESTIONS/PURPOSES: (1) What percentage of patients who underwent cubital tunnel release underwent revision within 3 years? (2) What factors are associated with revision cubital tunnel release within 3 years of primary cubital tunnel release? METHODS: We identified all adult patients who underwent primary cubital tunnel release from January 1, 2011, to December 31, 2017, in the New York Statewide Planning and Research Cooperative System database using Current Procedural Terminology codes. We chose this database because it includes all payers and nearly all facilities in a large geographic area where cubital tunnel release may be performed. We used Current Procedural Terminology modifier codes to determine the laterality of primary and revision procedures. The mean age of the cohort overall was 53 ± 14 years, 43% (8490 of 19,683) were women, and 73% (14,308 of 19,683) were non-Hispanic White. The Statewide Planning and Research Cooperative System database organization does not include a listing of all state residents and thus does not allow for censoring of patients who move out of state. All patients were followed for 3 years. We developed a multivariable hierarchical logistic regression model to model factors independently associated with revision cubital tunnel release within 3 years. Key explanatory variables included age, gender, race or ethnicity, insurance, patient residential location, medical comorbidities, concomitant procedures, whether the procedure was unilateral or bilateral, and year. The model also controlled for facility-level random effects to account for the clustering of observations among these entities. RESULTS: The risk of revision cubital tunnel release within 3 years of the primary procedure was 0.7% (141 of 19,683). The median time to revision cubital tunnel release was 448 days (interquartile range 210 to 861 days). After controlling for patient-level covariates and facility random effects, and compared with their respective counterparts, the odds of revision surgery were higher for patients with workers compensation insurance (odds ratio 2.14 [95% confidence interval 1.38 to 3.32]; p < 0.001), a simultaneous bilateral index procedure (OR 12.26 [95% CI 5.93 to 25.32]; p < 0.001), and those who underwent submuscular transposition of the ulnar nerve (OR 2.82 [95% CI 1.35 to 5.89]; p = 0.006). The odds of revision surgery were lower with increasing age (OR 0.79 per 10 years [95% CI 0.69 to 0.91]; p < 0.001) and a concomitant carpal tunnel release (OR 0.66 [95% CI 0.44 to 0.98]; p = 0.04). CONCLUSION: The risk of revision cubital tunnel release was low. Surgeons should be cautious when performing simultaneous bilateral cubital tunnel release and when performing submuscular transposition in the setting of primary cubital tunnel release. Patients with workers compensation insurance should be informed they are at increased odds for undergoing subsequent revision cubital tunnel release within 3 years. Future work may seek to better understand whether these same effects are seen in other populations. Future work might also evaluate how these and other factors such as disease severity could affect functional outcomes and the trajectory of recovery. LEVEL OF EVIDENCE: Level III, therapeutic study.

State of the art review: The management of chronic vascular disorders in the hand and upper limb.

This review article summarizes the basic principles of vascular anatomy, physiology, diagnostic work-up and treatment for patients with nontraumatic upper extremity vascular disorders. Vascular disorders can be considered vasospastic or occlusive. The most commonly encountered vasospastic condition is Raynaud's Phenomenon secondary to scleroderma. While historically this has been managed medically with vasodilators, more advanced cases can benefit from surgical treatment to improve blood flow and minimize tissue loss, with compelling evidence that earlier surgical intervention can modify disease process and should be considered. Occlusive disease can present as aneurysm or thrombosis and often requires surgical treatment with resection of the occluded segment with or without vascular reconstruction. In advanced atherosclerotic disease or end stage ischemia, arterialization of the venous system can be considered to avoid more proximal amputations.

Evaluation of PROMIS Outcomes for Surgical Treatment of Cubital Tunnel Syndrome With and Without Carpal Tunnel Syndrome.

BACKGROUND: Assessment of outcomes for cubital tunnel syndrome (CuTS) surgeries has been difficult due to heterogeneity in outcome reporting. Our objective was to evaluate the outcomes for 2 cohorts treated surgically for isolated CuTS and for combined CuTS and carpal tunnel syndrome (CTS) using Patient Reported Outcomes Measurement Information System (PROMIS). METHODS: There were 29 patients in the isolated CuTS cohort and 30 patients in the combined CuTS and CTS cohort. PROMIS Physical Function (PF), Pain Interference (PI), Depression, and Upper Extremity (UE) were completed preoperatively and 1-week, 6-weeks, and 3-months postoperatively. Responsiveness was evaluated by standardized response means (SRM). RESULTS: Significant improvements from the 1-week to 6-week postoperative period are shown in the isolated CuTS cohort for PROMIS PF (P = .002), PI (P = .0002), and UE (P = .02), but scores plateau after 6-weeks postoperatively. A similar pattern for the same time points was seen for the combined CuTS and CTS group for PROMIS PF (P = .001), PI (P = .02), and UE (P = .04), with a plateau of scores beyond 6 weeks postoperatively. PROMIS UE was more responsive (SRM range: 0.11-1.03) than the PF (SRM range: 0.02-0.52) and PI (SRM range: 0.11-0.40), which were both mildly responsive for both cohorts. CONCLUSIONS: PROMIS lacks the sensitivity to show improvement beyond 6-weeks postoperatively for both isolated CuTS and combined CuTS and CTS. Patients with combined nerve compressions follow similar trajectories in the postoperative period as those with isolated CuTS. LEVEL OF EVIDENCE: Level IV.

Responsiveness of PROMIS Instruments for Trigger Digit After Corticosteroid Injection or A1 Pulley Release.

PURPOSE: The purpose of the study was to determine if the patient-reported outcomes measurement information system (PROMIS) is sufficiently sensitive to detect improvement after 2 common treatments of trigger finger: corticosteroid injection or A1 pulley release. METHODS: This retrospective cohort study included 72 patients in the injection group and 51 in the A1 pulley release group. PROMIS physical function (PF), pain interference (PI), and upper extremity (UE) scores were collected at baseline and 6 weeks after injection for the injection group and at baseline, and 1 week, 6 weeks, and 3 months after surgery for A1 pulley release patients. Descriptive statistics and paired t tests were used to compare PROMIS scores within each cohort. Standardized response means (SRMs) were calculated for each PROMIS domain to gauge instrument responsiveness. RESULTS: Average age was 62 years, 65% were female patients, and 86% were White for the steroid injection cohort, compared to 60 years, 71%, and 88%, respectively, for the A1 pulley release cohort. For the steroid injection group, mean PROMIS PI scores (-4.0 points; SRM = -0.6) and PROMIS UE scores (+3.3 points; SRM = 0.5) improved significantly at 6 weeks after injection compared to baseline. Meanwhile, A1 pulley release patients improved significantly in mean PI scores (-3.7 points; SRM = -0.5) and in UE scores (+4.9 points; SRM = 0.7) at 3 months after surgery compared to baseline. CONCLUSIONS: Clinical improvements after trigger digit treatments are reflected in improved PROMIS PI and UE scores that reach previously accepted minimum clinically important difference values for hand patients. PROMIS PI and UE also are more responsive than PROMIS PF in capturing improvement for trigger digit treatments. CLINICAL RELEVANCE: As health care payers continue to emphasize patient-reported outcomes to determine treatment value and set reimbursement rates, this study helps establish that clinical improvement after trigger digit treatments are reflected in PROMIS PI and UE domains by reaching previously established minimum clinically important difference values for hand patients.