No Difference in Reintervention at 1-Year Between Ultrasound-Guided versus Blind Dorsal Carpal Ganglion Aspiration.

Purpose: The purpose of this retrospective comparative study was to compare the efficacy of dorsal carpal ganglion aspiration in patients who underwent either "blind" (using surface anatomy alone) or ultrasound-guided (US-guided) aspiration. Methods: Outcome measures were conducted during the coronavirus disease 2019 pandemic via telephone for a minimum of 12 months after aspiration, with efficacy defined by reintervention with either repeat aspiration or surgical excision. Results: Data are reported for 141 patients (46 blind; 95 US-guided) at an average of 28 months (range, 12-55 months) from aspiration. Reintervention was not significantly different based on the mode of aspiration-26% and 24% for blind aspiration and US-guided, respectively. Patient-perceived recurrence was higher at 65% for the entire cohort. Patients who received steroid injection at the time of aspiration perceived lower rates of recurrence-44% versus 77% for patients who received a steroid injection and patients who did not, respectively. Conclusions: This study found no significant difference between blind or US-guided aspiration in reintervention at a minimum of 1-year follow-up. Patients who received steroids at the time of aspiration perceived lower rates of recurrence. Type of study/level of evidence: Therapeutic III.

Current Implementation of Quality Measures on American Society for Surgery of the Hand Touching Hands Project Outreach Trips.

PURPOSE: As hand and upper extremity outreach trips increase, guidelines for assessing quality of care are being established. The Global Quality in Upper Extremity Surgery and Training investigators have published validated quality measures deemed to be essential for outreach trips to low and middle-income countries (LMICs). The purpose of this study was to assess baseline implementation of these quality measures across nine international hand surgery outreach sites to LMICs. Additionally, we investigated barriers and facilitators to implementing quality measures and documentation of their implementation. METHODS: We included nine of 12 scheduled 2019 Touching Hands Project trips, excluding independent outreach and teaching mission trips without surgical logs. The team leader from each site received an online questionnaire assessing the documentation and implementation of all 22 quality measures, as well as educational efforts. RESULTS: A total of 350 surgeries were performed in 2019 with seven reported minor complications and no major complications or mortalities. For analysis, 20 of 22 quality measures were included. Of 20 included validated quality measures, 10 were implemented across all surgical outreach sites. Two sites (Bolivia, Nepal) implemented all of the validated quality measures. Quality measures with the lowest implementation rates included ensuring availability of continuous electricity and oxygen supply with associated documentation of a backup plan. All outreach sites reported formal educational efforts. CONCLUSIONS: Implementation of validated quality measures across surveyed outreach sites is variable, indicating an opportunity for improvement. Standardizing documentation of quality measure implementation for each site, confirming availability of resources, increasing accountability by the visiting teams, and fostering stronger relationships with local health care, may increase quality measure implementation and improve quality health care delivery and patient safety in LMICs. CLINICAL RELEVANCE: Benchmarking the implementation of validated quality measures across hand surgical outreach trips provides an opportunity to improve the quality of health care delivered during future hand surgical outreach efforts.

Assessing Gender Differences in Technical Skills and Confidence in Orthopaedic Surgery Residency Applicants.

INTRODUCTION: Variations in confidence for procedural skills have been demonstrated when comparing male and female medical students in surgical training. This study investigates whether differences in technical skill and self-reported confidence exist between male and female medical students applying to orthopaedic residency. METHODS: All medical students (2017 to 2020) invited to interview at a single orthopaedic residency program were prospectively evaluated on their technical skills and self-reported confidence. Objective evaluation of technical skill included scores for a suturing task as evaluated by faculty graders. Self-reported confidence in technical skills was assessed before and after completing the assigned task. Scores for male and female students were compared by age, self-identified race/ethnicity, number of publications at the time of application, athletic background, and US Medical Licensing Examination Step 1 score. RESULTS: Two hundred sixteen medical students were interviewed, of which 73% were male (n = 158). No gender differences were observed in suture task technical skill scores or mean difference in simultaneous visual task scores. The mean change from pre-task and post-task self-reported confidence scores was similar between sexes. Although female students trended toward lower post-task self-reported confidence scores compared with male students, this did not achieve statistical significance. Lower self-reported confidence was associated with a higher US Medical Licensing Examination score and with attending a private medical school. DISCUSSION: No difference in technical skill or confidence was found between male and female applicants to a single orthopaedic surgery residency program. Female applicants trended toward self-reporting lower confidence than male applicants in post-task evaluations. Differences in confidence have been shown previously in surgical trainees, which may suggest that differences in skill and confidence may develop during residency training.

Evaluation of Racial, Ethnic, and Socioeconomic Disparities in Indication for Carpal Tunnel Release.

BACKGROUND: Disparities in the utilization of orthopaedic surgery based on race and ethnicity continue to be reported. We examined the impact of sociodemographic factors on treatment recommendation by hand surgeons for carpal tunnel syndrome (CTS) of similar disease severity. METHODS: Patients with electrodiagnostic study (EDS)-confirmed CTS were evaluated at a single institution between 2016 and 2020. Data including patient age, sex, race/ethnicity, ZIP Code, and EDS severity were collected. The primary outcome was the recommended treatment by the hand surgeon at the first clinic visit according to patient race/ethnicity and the Social Deprivation Index (SDI). Secondary outcomes included the treatment selected by patients (nonsurgical or surgical) and the time to surgery. RESULTS: The 949 patients had a mean age of 58 years (range, 18 to 80 years); 60.5% (n = 574) were women. The race/ethnicity of the patient cohort was 9.8% (n = 93) Black non-Hispanic, 11.2% (n = 106) Hispanic/Latino, 70.3% (n = 667) White non-Hispanic, and 8.7% (n = 83) "other." Overall, Black non-Hispanic patients (38.7%; odds ratio, [OR] 0.62; 95% confidence interval [CI], 0.40 to 0.96) and Hispanic/Latino patients (35.8%; OR, 0.55; 95% CI, 0.36 to 0.84) were less likely to have surgery recommended at their first visit compared with White non-Hispanic patients (50.5%). This was no longer apparent after adjusting for demographic and clinical variables including EDS severity and SDI (Black non-Hispanic patients: adjusted odds ratio [aOR], 0.67; 95% CI, 0.4 to 1.11; Hispanic/Latino patients: aOR, 0.69: 95% CI, 0.41 to 1.14). Across all categories of EDS severity, surgeons were less likely to recommend surgery to patients with a higher SDI (aOR: 0.66, 0.64, and 0.54 for quintiles 2, 3 and 4, respectively). When surgery was recommended, patients in the highest SDI quintile were less likely to proceed with surgery (p = 0.032). There was no association between patient race/ethnicity and the treatment selected by the patient or time to surgery (p = 0.303 and p = 0.725, respectively). CONCLUSIONS: Patients experiencing higher levels of social deprivation were less likely to be recommended for CTS surgery and were less likely to proceed with surgery, regardless of patient race/ethnicity. Additional investigation into the social factors influencing both surgeon and patient selection of treatment for CTS, including the impact of patient socioeconomic background, is warranted. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

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.

Teaching in Orthopaedic Surgery: Effective Strategies for Educating the Modern Learner in a Modern Surgical Practice.

Prioritizing the education of orthopaedic surgery residents and fellows is essential for the future of the field. This review highlights strategies that educators may find useful in improving their teaching skills for the modern orthopaedic surgery learner. Educators may benefit from focusing on active, effortful, and repetitive engagement in lecture; setting clear expectations to help track progress in clinic; and breaking skills into smaller steps in context of a framework when teaching procedural skills. Providing objective assessment and growth-oriented feedback helps establish a close rapport between educator and trainee while encouraging personal development. Through a remediation process that examines deficiency in core areas and equitability of the learning environment, the trainee and the educator may engage in a fair discussion that prevents trainees from falling behind. Finally, in the era of COVID-19, e-learning and virtual simulations have become increasingly used as effective modalities for teaching clinical knowledge and procedures to trainees. The medical education landscape has been changing at a rapid pace, and by evaluating and adapting to the novel educational models of today, the modern orthopaedic surgeon ensures a learning environment that is equitable, effective, and inspiring for the orthopaedic surgeon of tomorrow.

Sonographic Changes in the Median Nerve Predict Conversion to Surgery after Corticosteroid Injection of the Carpal Tunnel.

BACKGROUND: Risk factors for conversion to surgical management of moderate severity carpal tunnel syndrome are poorly understood. The authors hypothesized that sonographic findings along the carpal tunnel could predict failure of conservative management for carpal tunnel syndrome. METHODS: The authors report on 96 wrists with moderate clinical signs and symptoms of carpal tunnel syndrome. Sonographic evaluation with measurement of median nerve cross-sectional area was performed at three consistent anatomic locations. The authors recorded median nerve morphology, inlet and outlet dimensions of the carpal tunnel, and maximal thickness of the transverse carpal ligament. Steroid injection was performed. Patients were followed up for a minimum of 1 year after injection and progression to surgical management was recorded. RESULTS: A total of 54 percent ( n = 52) of patients converted to surgical management within 1 year after injection. Median nerve cross-sectional area decreased over the course of the carpal tunnel from proximal to distal in 81 of 96 wrists. A greater decrease in cross-sectional area of the median nerve between the pisiform and the hamate was associated with conversion to operative intervention for carpal tunnel syndrome, with the average decrease in median nerve cross-sectional area among those whose conservative treatment failed being 5.01 mm 2 compared with 2.97 mm 2 among those who did not progress to surgical treatment. CONCLUSIONS: This study demonstrates that ultrasound may be an additional tool used by clinicians to better counsel patients about the severity and progression of their disease. Patients who demonstrate a decrease in cross-sectional area of the median nerve along the carpal tunnel demonstrate a higher likelihood of progression to operative management. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Assessing and Addressing Gender Gaps in the American Society for Surgery of the Hand.

Gender disparities persist among medical subspecialty societies, including the American Society for Surgery of the Hand (ASSH). Surgical subspecialties in particular have lagged behind other medical specialties with respect to the number of women in training and practice. Orthopedic surgery, one of the surgical subspecialties making up hand surgery, has the lowest percentage of female residents and faculty among medical subspecialties. Institutions such as the ASSH have an important role in narrowing these gaps by creating environments that welcome female engagement by recognizing and promoting female surgeons into leadership positions. By summarizing demographic data, prior literature, and drawing from examples in other specialties, this article has 3 aims: (1) to review trends in female engagement in the ASSH; (2) outline the strategies that have been implemented to improve gender diversity within the ASSH; and (3) recommend feasible methods to address historical and ongoing barriers to promotion of women within the ASSH.

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.