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Journal of Hand Surgery Global Online
Number of Followers: 0  

  This is an Open Access Journal Open Access journal
ISSN (Online) 2589-5141
Published by Elsevier Homepage  [3184 journals]
  • A Basic Spanish Language Template for the Upper Extremity Patient
           Encounter

    • Abstract: Publication date: Available online 13 September 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Adil S. Ahmed, Ryan L. Kim, Benjamin Ogden, Michael J. Garcia, Jason A. NydickEffective communication is fundamental to the quality and safety of healthcare. In the U.S., language and cultural differences combined with low health literacy are challenges that physicians must overcome. The Spanish-speaking patient population continues to grow and is disproportionately affected by this, with 25% speaking little to no English. In our hand and upper extremity surgery practice, a common problem arises both with verbal Spanish communication and with the physical exam. The hand and upper extremity examination requires a high level of patient involvement to elucidate subtle derangements in individual tendon or nerve function. Our purpose is to summarize a model upper extremity clinical encounter in Spanish and provide a guide for patient-physician interaction, particularly during the physical exam where visual aids can be more useful than simple verbal commands. This guide is a simple step towards enhanced communication and understanding between providers and patients, with the goal of providing higher quality care with greater efficiency and satisfaction. The purpose is not to replace the professional interpreter, but to augment the physician-patient interaction during the upper extremity clinical encounter. Incorporating a cross-language template may yield improved patient understanding, enhanced participation in the examination leading to better diagnosis, and improved satisfaction for both patient and provider.
       
  • Chimeric Thoracodorsal Artery Perforator (TAP) Flap–Scapula Flap for
           Repair of Congenital Floating Thumb

    • Abstract: Publication date: Available online 11 September 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Isao Koshima, Hirofumi Imai, Shuhei Yoshida, Shogo Nagamatsu, Kazunori Yokota, Shuji Yamashita, Haruki Mizuta, Jason H. Ko, Susie Zhi-Jie YaoWhen reconstructing a congenital floating thumb, we describe two children in whom preservation of all five digits is achieved through successful transfer of a thoracodorsal artery perforator (TAP) flap and vascularized scapula.
       
  • The Reading Level of Surgical Consent Forms in Hand Surgery

    • Abstract: Publication date: July 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 3Author(s): Kevin Mertz, Matthew B. Burn, Sara L. Eppler, Robin N. KamalPurposeThe average United States adult reads at an eighth-grade reading level. In an effort to ensure that patients understand written medical information, the National Institutes of Health and American Medical Association suggest that patient-directed material be written at a sixth- to eighth-grade reading level. We hypothesized that the mean reading level of surgical consent forms for hand surgery is not at or below an eighth-grade reading level (the suggested maximum from the National Institutes of Health).MethodsWe conducted a retrospective review of consecutive consent forms used for hand surgery patients from 7 hand surgeons at our institution from June, 2017 to October, 2017. Consent forms were reviewed to collect the hand-written portion describing the procedure. We also assessed our institution’s consent form template. This text was assessed for readability and reading level with the following tools: Flesch-Kincaid Grade Level and Flesch Reading Ease. We categorized the procedures written on each consent form by procedure type and then created simplified language for the same procedure below an eighth-grade reading level.ResultsMean Flesch-Kincaid grade level of all consent forms was 10.5 (SD, 5.8) and mean Flesch readability was 33.6 (SD, 38.8), or difficult to read. A total of 78% and 58% of forms were written above the sixth- and eighth-grade reading levels, respectively. Readability was remarkedly poor; 94% and 88% of consent forms were written above sixth- and eighth-grade readability, respectively. The grade level of the consent form template was 17.1.ConclusionsMost consent forms were written above a sixth- to eighth-grade reading level and may not have been well-understood by patients. It is possible for physicians to write on surgical consent forms at a reading level that patients are more likely to understand by opting for less specialty-specific words and writing in shorter sentences. Improving the readability of patient-directed materials is an approach to improving patient-centered care.Type of study/level of evidencePrognostic IV.
       
  • Outcome Measures Utilized in the Capitellum and Trochlea Fracture
           Literature: A Systematic Review

    • Abstract: Publication date: July 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 3Author(s): Lindsay Flynn, Kelly Mamelson, Bradley S. Schoch, Thomas W. Wright, Joseph J. KingPurposeThis study aimed to evaluate the outcome measures that the current isolated capitellar and trochlear fracture literature has used.MethodsA systematic literature review identified capitellar and/or trochlear fracture treatment articles published between January 1, 2006 and December 31, 2016. Exclusion criteria included review articles, meta-analyses, technique articles, and biomechanical/anatomic studies. Included studies were reviewed for patient demographics and reports of range of motion, outcome measures, satisfaction rate, return to previous level of activity, complication rate, and reoperation rate. The use of different outcome measures was compared among smaller and larger case series and in journals with higher and lower impact factors.ResultsOf 285 articles, 45 met inclusion criteria. Mean number of capitellum and/or trochlea fractures per study was 11.3 (mean patient age, 34.6 years). Average follow-up was 29.4 months. Eight outcome measures were used, the most common of which were the Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder, and Hand/Quick–Disabilities of the Arm, Shoulder, and Hand, and American Shoulder and Elbow Surgeons scores. An average of 1.09 outcome measures were reported per study; 15% of studies reported a satisfaction rate. Larger studies were associated with more outcome measures and used the MEPS more often. Studies in journals with an impact factor of 1 or greater had more patients, more reported outcome scores, and higher use of the MEPS compared with studies with an impact factor of less than 1.ConclusionsCapitellum and trochlea fracture studies have major outcome-measure reporting inconsistencies. The MEPS is the most frequently reported measure. Higher-level journals and studies with 5 or more fractures reported more outcome scores. Future studies should include commonly reported outcome measures to allow for cross-study comparison.Type of study/level of evidenceTherapeutic IV.
       
  • Rates of Corrective Osteotomy After Distal Radius Fractures Treated
           Nonsurgically and Surgically

    • Abstract: Publication date: July 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 3Author(s): Hannah A. Dineen, Shawn D. Feinstein, Dax T. Varkey, Jamie A. Jarmul, Reid W. DraegerPurposeDistal radius fractures commonly occur and can be a major cause of morbidity in the aging population; yet the rates of osteotomy for malunited fractures have not been described for nonsurgical and surgical treatment. We hypothesized that the rate of corrective osteotomy would be lower in fractures treated surgically compared with nonsurgically.MethodsUsing the PearlDiver patient record program, we used Current Procedural Terminology coding to identify 48,815 patients within the Humana database from 2007 to 2015 who sustained a distal radius fracture. Rates of osteotomy after both nonsurgical treatment and open reduction internal fixation (ORIF) of distal radius fractures were evaluated and stratified by age and gender. We analyzed the cost of treatment for each group. Osteotomy rates were compared between groups using chi-square test of significance.ResultsThe rates of osteotomy with nonsurgical treatment compared with ORIF were significantly different (0.5% vs 0.3%). The rate of osteotomy for patients aged more than 50 years was significantly higher than that for patients aged less than 50 years regardless of treatment (0.3% vs 0.1%). In men, the rate of osteotomy for nonsurgical treatment compared with ORIF was not significantly different. However, in women, the rate of osteotomy for nonsurgical treatment compared with ORIF was significantly different (0.59% vs 0.30%). The average cost per patient (regardless of outcome) for nonsurgical treatment was $477 and the average cost for ORIF was $1,309. If an osteotomy was required after nonsurgical treatment, the average overall cost was $4,152. If an osteotomy was required after ORIF, the average overall cost was $5,965.ConclusionsOsteotomy after distal radius fracture infrequently occurs but is seen more frequently in fractures treated nonsurgically. Female patients are more likely to undergo an osteotomy after nonsurgical treatment of a distal radius fracture than are males. This information can be used to counsel patients when making shared decisions regarding treatment.Type of study/level of evidenceTherapeutic III.
       
  • Distal Biceps Repair Using a Unicortical Intramedullary Button Technique:
           A Case Series

    • Abstract: Publication date: July 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 3Author(s): Nathan A. Monaco, Alexander J. Duke, Meghan W. Richardson, David E. Komatsu, Edward D. WangPurposeAlthough surgical repair of distal biceps tendon rupture improves functional outcomes compared with nonsurgical treatments, the choice of operative technique remains a matter of preference. This study retrospectively examined outcomes from a repair technique using a volar distal biceps reinsertion secured with a unicortical intramedullary button in the proximal radial tuberosity to determine its safety and functional outcomes.MethodsA single fellowship-trained shoulder and elbow surgeon treated 27 men, average age 48 years (range, 25–66 years), between 2012 and 2016. Patient-reported outcomes included the Disabilities of the Arm, Shoulder, and Hand and American Shoulder and Elbow Surgeons (ASES) satisfaction scores and the Mayo Elbow Performance Score. Average patient follow-up was 24 months.ResultsThis series had an overall complication rate of 39.3% (11 of 28): 9 lateral antebrachial cutaneous neuropraxias, one radial sensory nerve irritation, and one superficial infection. No complications of peripheral nerve injury, proximal radioulnar synostosis, or rerupture were observed. Results (mean ± SD) demonstrated low disability (Disabilities of the Arm, Shoulder, and Hand score = 2.9 ± 5.3), high satisfaction (American Shoulder and Elbow Surgeons score = 9.3 ± 1.4), and acceptable performance (Mayo Elbow Performance Score = 97.7 ± 6.3). Subcategory analysis identified a correlation between time to surgery and complications. Disability scores were higher in patients with workers’ compensation claims versus private insurance (mean, 11.0 vs 1.1).ConclusionsFurther trials are required to compare the results and complication rates of this unicortical intramedullary button procedure with other established methods.Type of study/level of evidenceTherapeutic IV.
       
  • Arthroscopically Assisted Transosseous Triangular Fibrocartilage Complex
           Foveal Tear Repair in the United States Military

    • Abstract: Publication date: April 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 2Author(s): John Dunn, Michael Polmear, Christopher Daniels, Emily Shin, Leon NestiPurposeTo compare subjective and objective midterm functional clinical outcomes of knotless arthroscopic assisted transosseous (AAT) triangular fibrocartilage complex (TFCC) repairs specifically in a cohort of military service members.MethodsPatient charts were reviewed to identify all cases of TFCC repair by a single surgeon from 2012 to 2016. Primary outcome variables were the Quick–Disabilities of the Arm, Shoulder, and Hand score and return to full military duty. Secondary outcome variables were visual analog scale for pain, Mayo Modified Wrist Score, Single-Assessment Numeric Evaluation, and the number of push-ups in 2 minutes during a record physical fitness test. Inclusion criteria were adult active duty service members who underwent AAT TFCC repair with a minimum of 2 years’ follow-up. Terminal follow-up was determined by a telephone interview. Exclusion criteria were distal radioulnar joint instability, revision procedures, cases involving other ligamentous repair procedures, and those with an incomplete medical record or who could not be reached for the survey.ResultsFifteen patients, average age 21 years (range, 18–29 years), met inclusion and exclusion criteria with mean follow-up of 3.8 years (range, 2–5.9 years). Average Quick–Disabilities of the Arm, Shoulder, and Hand score was 9.7 (range, 0–29.5) and 93% were able to remain on active duty. Average secondary outcomes scores were: visual analog scale = 1.3 (range, 0–4); Single-Assessment Numeric Evaluation = 87.3 (range, 30–100); Mayo Modified Wrist Score = 84.3 (range, 55–100); and push-ups = 72 (range, 42–90) in 2 minutes. One patient required a secondary surgery.ConclusionsKnotless AAT TFCC repair may be a safe and effective procedure that may return military service members to a preinjury level of activity.Type of study/level of evidenceTherapeutic IV.
       
  • Cost per Episode of Care With Collagenase Clostridium histolyticum Versus
           Fasciectomy for Dupuytren Contracture: A Real-World Claims Database
           Analysis

    • Abstract: Publication date: April 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 2Author(s): Stephen B. Camper, Victoria Divino, David Hurley, Mitch DeKovenPurposeTo quantify the total cost for a 3-month episode of care after treatment with collagenase Clostridium histolyticum (CCH) (Xiaflex) versus fasciectomy for Dupuytren contracture (DC) in the United States.MethodsAdult patients treated for DC (single finger only) with either CCH or fasciectomy from January, 2012 to June, 2016 were identified (the first treatment was the index date) from the IQVIA Real-World Data Adjudicated Claims-US Database. Patients had continuous health plan enrollment 360 days or more pre-index (pre-index) and 90 days or more post-index (follow-up), and one or more pre-index medical claims with a DC diagnosis (International Classification of Diseases, Ninth Revision, Clinical Modification 728.6; International Classification of Diseases, 10th Revision, Clinical Modification M72.0). Patients with pre-index treatment for DC were excluded. The primary outcome was the comparison of all-cause and DC-specific health care costs paid by the health plan over the 3-month follow-up. We defined DC-specific as claims with a DC diagnosis, DC-related therapies, and all claims associated with the index date and day after. Generalized linear models compared adjusted all-cause and disease-specific total costs.ResultsA total of 1,654 CCH and 2,745 fasciectomy patients were identified (mean age, 59.7 and 58.0 years; 81.8% and 74.4% male; respectively). Fasciectomy patients had higher mean total all-cause costs compared with CCH patients in the follow-up ($8,519 vs $7,657). Fasciectomy patients had higher mean costs related to outpatient surgical visits ($3,592 vs $826), physician office visits, and laboratory and pathology tests, but lower mean costs for all other services (outpatient ancillary and Healthcare Common Procedure Coding System drugs) ($2,901 vs $4,748) and inpatient care. Similarly, fasciectomy patients had higher mean total DC-specific costs ($6,204 vs $5,038). In adjusted analyses, CCH patients were associated with reductions in total all-cause (11.5%) and DC-specific (20.0%) health care costs.ConclusionsCollagenase C histolyticum for the treatment of DC was associated with a 12% reduction in the total cost of care compared with that for fasciectomy. The higher costs associated with fasciectomy were primarily driven by outpatient surgery costs.Type of study/level of evidenceEconomic/Decision Analysis II.
       
  • Epidemiology of Finger Amputations in the United States From 1997 to 2016

    • Abstract: Publication date: April 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 2Author(s): Daniel B.C. Reid, Kalpit N. Shah, Adam E.M. Eltorai, Christopher C. Got, Alan H. DanielsPurposeThere are minimal long-term epidemiological data focused on finger amputations in the United States (US). We sought to quantify the incidence and trends in finger amputations over a 20-year period, describe mechanisms of injury by age groups, and examine trends in emergency department (ED) disposition.MethodsThe National Electronic Injury Surveillance System was queried over a 20-year period (1997–2016) for finger amputations presenting to US EDs. Using US Census data, national incidence rates were estimated. We evaluated specific mechanisms of injury and ranked common mechanisms for each age group. Trends in hospital admission rates were evaluated and predictors of admission were examined using logistical regression.ResultsFrom 1997 to 2016, a weighted estimate of 464,026 patients sustained finger amputations in the US with an estimated yearly incidence of 7.5/100,000 person-years. A bimodal age distribution was seen, with the greatest incidence in children aged less than 5 years and adults over 65 years. Doors were the most common injury mechanism in children (aged less than 5 years), whereas power saws were most common in teens and adults (aged more than 15 years). Over the study period, there was a significant increase in patients admitted to the hospital; however, this increase was not seen among African Americans. Significant predictors of hospital admission included male gender, age less than 18 years, high-energy mechanisms, non–African American race, and very large hospital size, as defined by the National Electronic Injury Surveillance System.ConclusionsThe incidence of finger amputations is bimodal; young children (aged less than 5 years) and the elderly (aged greater than 65 years) are at greatest risk. There is a widening disparity between African Americans and non–African Americans in relation to ED disposition. Doors and power saws are the most common mechanisms of injury; however, these affect different age ranges. This study’s results highlight the need for improved age-specific safety guidelines and device safety features.Type of study/level of evidencePrognostic IV.
       
  • K-Wire Fixation of Metacarpal and Phalangeal Fractures: Association
           Between Superficial Landmarks and Penetration of Structures Surrounding
           the Metacarpophalangeal Joint

    • Abstract: Publication date: Available online 16 August 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Joshua Gordon, Nicholas Andring, Nicholas P. IannuzziPurposeThere is little information regarding the starting points for intramedullary K-wires and their effect on the soft tissues surrounding the metacarpophalangeal (MCP) joint. This study attempted to identify starting points for intramedullary K-wire fixation and determine the effect of these K-wires on soft tissues surrounding the MCP joint.MethodsWe placed intramedullary K-wires in the index, middle, and little finger metacarpals and proximal phalanges in 6 cadaveric specimens. We measured the starting points of the K-wires and performed dissection to evaluate which structures were penetrated. A Fisher exact test determined statistical significance between K-wire penetration of soft tissue structures and the starting point for K-wires.ResultsMetacarpal K-wires started 8.5 ± 1.5 mm volar to the dorsal aspect of the metacarpal head, 19.1 ± 4.6 mm proximal to the digital palmar crease, and 8.6 ± 1.2 mm from the metacarpal head midline. All MCP K-wires crossed at least one soft tissue structure about the MCP joint; the most commonly the sagittal band. Proximal phalanx K-wires started 8.9 ± 2.9 mm proximal to the distal aspect of the metacarpal head, 25.5 ± 5.9 mm proximal to the digital palmar crease, and 9.9 ± 1.5 mm from metacarpal head midline. All proximal phalanx K-wires crossed at least one soft tissue structure about the MCP, most commonly the joint capsule. No relation was established between K-wire start point and penetration of soft tissue structures.ConclusionsUse of these measurements may aid the physician in placing intramedullary K-wires into the proximal phalanges and metacarpals. Starting points that decrease the rate of penetration of soft tissue structures around the MCP joint have not been described, and all pins crossed at least one soft tissue structure adjacent to the MCP joint.Type of study/level of evidenceTherapeutic IV
       
  • Retrograde Intramedullary Absorbable Pin Fixation for Intraarticular
           Fracture of the Metacarpal Head

    • Abstract: Publication date: Available online 16 August 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Atsushi Okazaki, Hiroaki Sakano, Yutaka InabaPurposeTo review retrospectively the outcome of retrograde intramedullary absorbable pin fixation for intra-articular fractures of the metacarpal head.MethodsNine patients with intra-articular fractures of the metacarpal head were treated surgically with 1.5-mm-diameter unsintered hydroxyapatite particles and a poly-l-lactide pin. There were 2 women and 7 men, mean age 28.9 years. Patients were observed for a mean of 13.1 months after surgery. The metacarpophalangeal joint was exposed through a dorsal skin incision. After reduction of the fracture, 2 unsintered hydroxyapatite particles and poly-l-lactide pins were inserted from the articular surface of the distal bone fragment into the medullary canal of the metacarpal. A volar aluminum orthosis was applied in the intrinsic plus position for a mean of 1.8 weeks (range, 0–4 weeks), and range of motion exercises were started after the orthosis was removed.ResultsAnatomical reduction and bony union were achieved in all patients. Mean period required to achieve bone union was 4.6 weeks. No patients experienced pain after healing; all resumed normal activities at the time of follow-up, when mean flexion and extension of the metacarpophalangeal joint were 82.8° and –2.2°, respectively. There were no malunions or osteoarthritic changes, no breakage of the pin, aseptic inflammation, or avascular necrosis of the metacarpal head, and no foreign body reactions.ConclusionsWe performed a retrograde intramedullary absorbable pin fixation for intra-articular fracture of the metacarpal head. Using this method, damage to the articular cartilage and surrounding soft tissue was minimized, range of motion exercise could be started early after surgery, and hardware removal surgery was not necessary.Type of study/level of evidenceTherapeutic IV.
       
  • Outcomes After Wrist Arthroscopy for the Treatment of Scapholunate
           Predynamic Instability in the Young Active Patient

    • Abstract: Publication date: July 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 3Author(s): Christopher M. Belyea, Kevin P. Krul, Emily H. Shin, Rey D.L. GumbocPurposePredynamic instability in scapholunate (SL) ligament tears is a source of wrist pain. Despite this, identifying the proper treatment remains elusive. The purpose of this study was to evaluate return to activity after wrist arthroscopic electrothermal shrinkage for treatment of SL predynamic instability.MethodsPatients enrolled in an ongoing quality assurance project of wrist arthroscopic electrothermal shrinkage surgery for treatment of SL predynamic instability in an active duty military patient cohort were included in this retrospective review. Primary outcomes at a 2-year minimum follow-up were the rate of return to full duty and the rate of return to push-up activities.ResultsThis study identified 14 active duty patients who met inclusion criteria, mean age 29 years. Six were male and 9 of 14 had concomitant arthroscopic occult dorsal ganglion cyst removal at the time of the index surgery. The severity of SL instability was staged using the Geissler classification; the cohort distribution for stages I, II, and III was 3 patients, 10 patients, and 1 patient, respectively. At 2-year follow-up, the return to duty rate was 12 out of 14 and the return to push-ups activity rate was 11 out of 14. Pain with activities by visual analog scale was reduced from 7.1 to 1.4.ConclusionsPrior studies demonstrated SL ligament electrothermal shrinkage as a useful modality for pain relief. Our study suggests that this treatment may also aid in return to duty and push-up activities for young active patients.Type of study/level of evidenceTherapeutic IV.
       
  • Morphometric Variations of Scaphoid and Safety of Screw Fixation for Its
           Waist Zone Fractures in Indian Population: A Preliminary Report

    • Abstract: Publication date: July 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 3Author(s): Vivek Trikha, Arvind Kumar, Samarth Mittal, Jigyasa Passey, Sahil Gaba, Rizwan Khan, Aditya Jain, Atin KumarPurposeSurgeons fixing scaphoid fractures need to be familiar with their morphological variations and their implications for safe screw placement during fixation. The purpose of this computed tomography (CT)-based study was to analyze the anatomical limits of safe screw placement for scaphoid waist fractures in the Indian population.MethodsWe measured the coronal and sagittal dimensions of the scaphoid in 3 zones: proximal, waist, and distal, in CT scans of wrists with intact scaphoids obtained from 50 live subjects. In addition, we studied the curvature of the scaphoid, its longitudinal extent, and the safe placement of trajectories for different screw diameters.ResultsThe proximal segment had the narrowest mean coronal width of 6.39 mm, whereas the waist region had the narrowest mean sagittal width of 9.02 mm. Mean scaphoid curvature was 132.23°. Maximal bony extent of the scaphoid was significantly higher than the mean length of screw placed centrally in the mid-waist region.ConclusionsThis study showed that there is a considerable amount of variation in scaphoid morphometry in Indian patients. All scaphoids capable of safely containing a single 4-mm screw or 2 parallel 1.7-mm screws coplanar in the sagittal plane. Surgeons treating these fractures should consider a CT-based analysis to plan the screw direction and length and need to be familiar with the morphometric variations of the scaphoid.Clinical relevanceThe measurements and techniques in this study may be helpful in understanding morphometric variations of the scaphoid and in planning surgery for fixation of fractures around its waist region.
       
  • Clinical Outcomes of Collagenase Injections During a Surgeon’s
           Initial Learning Phase

    • Abstract: Publication date: July 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 3Author(s): John Z. Zhao, Philip E. Blazar, Ariana Mora, Tamara D. Rozental, Brandon E. Earp, Lauren Adey, Brandon Earp, Jason Fanuele, Michael Garcia, Alfred Hess, Tamara Rozental, David Ruchelsman, Eon Shin, Barry Simmons, Jeffrey StonePurposeCollagenase Clostridium histolyticum (CCH) has increasingly been used to treat Dupuytren contracture since its Food and Drug Administration approval in 2010. One concern among practitioners is the learning curve of this new technique. This study characterizes success and complication rates for surgeons with no prior experience with CCH treatment.MethodsWe recruited 10 hand and upper-extremity surgeons for this study. Retrospective clinical records were reviewed for the first 10 CCH injections by each surgeon. Preinjection, postmanipulation, and 30- to 90-day follow-up measurements were recorded, along with any complications. Finally, provider opinions regarding CCH for Dupuytren contracture were collected.ResultsThere were 100 CCH injections in 100 fingers: 42 with isolated metacarpophalangeal contractures, 24 with isolated proximal interphalangeal contractures, and 34 with both metacarpophalangeal and proximal interphalangeal contractures. At 30- to 90-day follow-up, 61.4% of primary joints demonstrated improvement of contracture to within 0° to 5° degrees from full extension, 85.2% showed greater than 50% reduction in contracture, and 12 patients were lost to follow-up. Trend analysis suggested a flat initial learning curve. Complications occurred in 33 cases and included skin tears (31) and lymphadenopathy (4). No tendon ruptures were observed. All surgeons were either satisfied or extremely satisfied with CCH and continued using it in their practices.ConclusionsClinical results achieved from practitioners’ early injections mirrored success and surgeon satisfaction rates previously reported in the literature. However, complication rates were higher than those in initial clinical trials but similar to later studies that used local anesthesia during manipulation. Trends in clinical outcomes among the first 10 injections suggest an initially flat learning curve for CCH. Practitioners’ opinions of CCH remained favorable after early use.Type of study/level of evidenceTherapeutic III.
       
  • The Effect of Wrist Position on Finger Tendon Loads Following Pulley
           Sectioning and Operative Reconstruction

    • Abstract: Publication date: July 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 3Author(s): Mohammad M. Haddara, Brett Byers, Shrikant Chinchalkar, Louis M. Ferreira, Nina SuhPurposePostoperative rehabilitation is important for maximizing patient outcomes after surgical pulley reconstruction. The purpose of this study was to identify the optimal wrist position in which rehabilitation should be undertaken to decrease the load on surgically reconstructed pulleys.MethodsWe tested 14 digits composed of the index, middle, and ring fingers from 5 cadaveric specimens in a novel in vitro finger motion simulator designed to achieve full finger flexion and extension actively. Servo-motors were used to generate motion through tendons under load or position control while measuring tendon forces, joint range of motion, and tendon excursion. Flexor digitorum profundus (FDP) and flexor digitorum superficialis loads were measured sequentially with native intact pulleys and A2 and A4 pulleys sectioned, and with reconstructed A2 and A4 pulleys. Each condition was tested with the wrist neutral and with 30° wrist flexion or extension. The effect of wrist position on FDP and flexor digitorum superficialis loads under each condition was analyzed using repeated-measures analysis of variance.ResultsWith pulleys reconstructed, the wrist position had a significant effect on tendon load. The flexed wrist position resulted in a 31% reduction of FDP load compared with the neutral wrist position. Wrist extension also produced an apparent reduction of 14%, although not statistically significant.ConclusionsAfter pulley repair, placing the wrist in 30° flexion decreased tension in the FDP tendon compared with a neutral wrist.Clinical relevanceThis study suggests that rehabilitation should be carried out with the wrist flexed to reduce the load on pulley reconstructions.
       
  • Feasibility and Reliability of Open Reduction Internal Fixation in Delayed
           Distal Radius Fracture Management

    • Abstract: Publication date: July 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 3Author(s): Christopher Lee, Clifford Pereira, Stephen Zoller, Jason Ghodasra, Kent Yamaguchi, James Rough, Mark Sugi, Prosper BenhaimPurposeCurrent guidelines recommend that open reduction internal fixation (ORIF) for distal radius fractures (DRFs) be performed within 4 weeks of injury. Delayed DRF management (4 weeks or more) is traditionally subject to corrective osteotomy. We report a 5-year single-surgeon series of delayed DRFs that were treated by ORIF rather than osteotomy.MethodsWe performed a retrospective review on all patients admitted to a single tertiary care center with a DRF requiring ORIF (2007–2012). Institutional review board approval was obtained. Patients were divided into an early group (EG) (surgery less than 4 weeks after injury) and delayed group (DG) (surgery after 4 or more weeks). Data collected included demographics, injury pattern, intraoperative parameters, and pre- and postoperative x-ray findings. Subjective and objective functional data were determined using a Disabilities of the Arm, Shoulder, and Hand questionnaire score and Mayo Wrist Score.ResultsA total of 171 patients (EG = 54; DG = 117) underwent ORIF from 2007 to 2012 and met inclusion criteria. Both groups had similar age, gender, and racial demographics. Of these, 117 patients in the delayed group underwent ORIFs at 40 ± 13.9 days (range, 28–146 days) after injury. Preoperative fracture patterns were radiographically equivalent. A dorsal approach was required more frequently in the EG (7.4%) compared with DG (1.1%). The Orbay maneuver was performed at a significantly higher rate in the DG (55.8%) compared with the EG (38.8%). Blood loss, tourniquet times, intraoperative complications, radiographic parameters, articular incongruency rates, and Disabilities of the Arm, Shoulder, and Hand score, and Mayo Wrist Score were not statistically significant between groups.ConclusionsNo significant differences were found in intraoperative technique, operative time, postoperative radiographs, and subjective outcome measures in patients treated with early versus late ORIF. Despite the current belief that primary ORIF in delayed DRF is technically impossible and warrants an osteotomy, our series indicates that ORIF is indeed a viable option in DRFs as late as 5 months after injury.Type of study/level of evidenceTherapeutic IV
       
  • Restoration of Sensation and Thumb Opposition Using Nerve Transfers
           Following Resection of a Synovial Sarcoma of the Median Nerve

    • Abstract: Publication date: July 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 3Author(s): Hollie A. Power, Ida K. Fox, Lorna C. Kahn, Susan E. MackinnonSynovial sarcomas of peripheral nerves are rare and often leave major functional deficits after wide excision. We present a case of median nerve reconstruction using nerve transfers after resection of a synovial sarcoma of the median nerve. Sensation was restored by transferring the fourth common digital nerve to the first and second common digital nerves. Thumb opposition was restored by transferring the abductor digiti minimi branch to the recurrent motor branch. The soft tissue defect was reconstructed with a free gracilis muscle flap. Fifteen months after surgery, there was Medical Research Council grade 4+ opposition strength with co-contraction of the abductor digiti minimi. Sensation recovered slowly over time. The Disabilities of the Arm, Shoulder, and Hand score decreased from 47.4 before surgery to 13.3 afterward. The patient was able to use the right hand for writing and crafting pottery. Distal nerve transfers are a reliable option for reconstruction of complete median nerve defects.
       
  • Prevalence of Bifid Median Nerve and the Cross-Sectional Area as Assessed
           by Ultrasonography in Healthy Japanese Subjects

    • Abstract: Publication date: April 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 2Author(s): Satoshi Shinagawa, Tsuyoshi Tajika, Noboru Oya, Fumitaka Endo, Takuro Kuboi, Noritaka Hamano, Tsuyoshi Sasaki, Tsuyoshi Ichinose, Hitoshi Shitara, Kenji Takagishi, Hirotaka ChikudaPurposeUltrasonography is useful for evaluating anatomical variations of the median nerve and aids in diagnosing carpal tunnel syndrome by assessing the cross-sectional area (CSA) at the carpal tunnel inlet. The purposes of this study were to investigate the prevalence of the bifid median nerve and to establish reference values for the CSA at the carpal tunnel inlet in healthy participants.MethodsA total of 349 Japanese participants were included (121 men and 228 women, mean age 66.3 years). Study participants underwent ultrasonography to assess the CSA of the median nerve at the carpal tunnel inlet of the bilateral wrist. First, we investigated the prevalence of the bifid median nerve in 349 participants. Then, we assessed the relation between the CSA and clinical factors (age, height, weight, body mass index, fat mass, fat-free mass, bilateral grip strength, and key pinch strength) in healthy participants.ResultsAmong the 349 participants, 59 (16.9%) had a bifid median nerve. Mean CSA in healthy participants (no bifid median nerve) was 9.7 ± 2.9 mm2 in women and 9.0 ± 1.8 mm2 in men (both: 9.4 ± 2.6 mm2). In women, mean CSA in subjects in their sixties was significantly higher than in younger subjects, and we found a significant positive correlation between the CSA and the fat-free mass.ConclusionsIn this observational study of healthy Japanese, the prevalence of the bifid median nerve was 16.9%; the mean CSA was 9.7 ± 2.9 mm2 in women and 9.0 ± 1.8 mm2 in men. Older women had a larger CSA than did younger women.Clinical relevanceThis study describes the prevalence of the bifid median nerve and normative values for the CSA of the median nerve precisely diagnose carpal tunnel syndrome to more by ultrasonography.
       
  • Treatment of Osteomyelitis of the Distal Interphalangeal Joint With
           Antibiotic-Impregnated Calcium Phosphate Paste Granules

    • Abstract: Publication date: April 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 2Author(s): Ryoichi Shibuya, Hisayuki Tabuse, Tsutomu Yamaji, Kenzo Kiso, Hideki YoshikawaSeptic arthritis of small joints with associated osteomyelitis is difficult to treat and repeated surgical debridement and prolonged antibiotic administration are often needed. We report on the surgical technique and outcome of 3 patients with chronic arthritis and superimposed osteomyelitis at a distal interphalangeal joint of the right index finger. All patients were treated in a single surgical stage consisting of irrigating and debriding the tendon and tendon sheath, and filling the distal phalanx and middle phalangeal bone marrow with granules of calcium phosphate cement impregnated with vancomycin. No patients showed signs of recurrence of infection at 1 year or longer after operation although all progressed to autofusion of the distal interphalangeal joint.
       
  • Airbag-Associated Bilateral Thumb Metacarpophalangeal Joint Ulnar
           Collateral Ligament Injury

    • Abstract: Publication date: April 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 2Author(s): Nicole H. Goldhaber, Christian E. SampsonWe report a case of simultaneous bilateral thumb metacarpophalangeal ulnar collateral ligament avulsions resulting from airbag deployment during a motor vehicle crash. Upper-extremity airbag injuries are common, but it is rare to sustain bilateral thumb metacarpophalangeal joint ulnar collateral ligament avulsions. In addition, the location of the avulsions was unusual because they occurred proximally rather than the more common distal ulnar collateral ligament injuries. It is possible that injury caused by airbag deployment favors symmetrical proximal injury of the ulnar collateral ligament.
       
  • Arthroscopic-Assisted Suspensionplasty Using the Palmaris Longus Tendon
           for Osteoarthritis of the Thumb Carpometacarpal Joint

    • Abstract: Publication date: April 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 2Author(s): Taku Hatta, Kiyotsugu Shinagawa, Eiji ItoiOsteoarthritis of the thumb carpometacarpal joint is common, especially in postmenopausal women. Numerous surgical techniques, including ligament reconstruction, partial or complete trapeziectomy, arthrodesis, and arthroplasty have been introduced. Suspensionplasty combined with trapeziectomy has been introduced to prevent proximal subsidence of the first metacarpal. To prevent excessive release of periarticular capsuloligamentous tissues, resection of the proximal part of the trapezium, and the cosmetically unappealing bump, arthroscopic partial trapeziectomy has been used as a less-invasive treatment option. With advanced techniques and devices, arthroscopic suspensionplasty with the autograft can be performed; thus far, there have been no series reporting on arthroscopic treatment options for this common condition. The purpose of this article is to present a technique for arthroscopic-assisted suspensionplasty using the palmaris longus tendon to reinforce the graft–bone interface, based on the concept of the tension slide technique to treat thumb carpometacarpal osteoarthritis.
       
  • Volar Buttress Plating for Dorsal Fracture-Dislocation of the Proximal
           Interphalangeal Joint With a Central Depressed Fragment: A Preliminary
           Report of 12 Cases

    • Abstract: Publication date: April 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 2Author(s): Kentaro WatanabeA preliminary report is presented of 12 patients with dorsal fracture-dislocations of the proximal interphalangeal joint with a central depressed fragment treated by volar buttress plating, with good results.
       
  • Trapezium Bone Resection Arthroplasty and Suspension With Suture Button
           for the Treatment of Trapeziometacarpal Osteoarthritis: Long-Term
           Follow-Up in a Colombian Cohort

    • Abstract: Publication date: April 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 2Author(s): Carlos González, David Suarez, Daniel Vanegas, Camilo Restrepo, Ana Milena HerreraPurposeOsteoarthritis of the trapeziometacarpal (TMC) thumb joint is one of the most common and debilitating degenerative osteoarthritic conditions of the hand. Two available surgical options include arthrodesis versus arthroplasty; the latter uses complete or partial trapeziectomy. Suspension with a suture button avoids the use of tendon grafts and favors early rehabilitation. Our purpose was to evaluate the long-term results of suspension arthroplasty using the suture button technique in a Colombian cohort.MethodsThis was a retrospective study of clinical results of a cohort of patients with osteoarthritis of the TMC joint of the thumb, who were treated with trapezium resection arthroplasty plus suspension with a suture button. We included 15 patients (16 thumbs). Functional recovery and pain level were assessed through the grip and pinch strength tests, range of motion, Quick–Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Kapandji scores, and visual analog scale score of pain. Trapezial space was measured on preoperative and postoperative x-rays.ResultsAverage age of patients was 62.4 years; there were 14 women. One patient had bilateral involvement. Preoperative QuickDASH score was 70.45 and Eaton–Littler classification of the 16 cases was II in 1, III in 6, and IV in 9 thumbs. Average follow-up was 33.75 months (range, 24–48 months) and average QuickDASH score was 24.7. Grip and pinch strengths were 96.9% and 108.3%, respectively, of the nonsurgical side. Average palmar and radial abduction was 92.8% and 101.1%, respectively of the nonsurgical thumb. Average Kapandji score was 9.33. During the last follow-up, the visual analog scale score was 2 or lower in 83.3% of cases. There was one complication of regional pain syndrome.ConclusionsIn our population, TMC arthroplasty with suture button provided good functional results for patients with osteoarthritis of the TMC thumb joint, primarily related to pain relief, satisfaction, and early reincorporation into daily activities.Type of study/level of evidenceTherapeutic IV.
       
  • Needle Aponeurotomy Versus Collagenase Injections for Dupuytren Disease: A
           Review of the Literature and Survey of Patient-Reported Satisfaction,
           Recurrence, and Complications After Needle Aponeurotomy

    • Abstract: Publication date: April 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 2Author(s): Joseph A. Buckwalter V, Spencer Kitchin, Charles A. Goldfarb, Martin I. BoyerNeedle aponeurotomy (NA) and collagenase injections (CI) for treatment of Dupuytren disease are practical and clinically efficient techniques. The purpose of this report is to review the comparative literature and present postprocedure survey data on NA. We reviewed the current literature on treatment of Dupuytren disease with NA and report on direct and indirect comparisons of the 2 treatment options. We also retrospectively identified patients treated with NA for Dupuytren disease, reviewed the demographic details of treatment in the medical records, and solicited patients’ feedback on satisfaction, recurrence, and complications using a phone survey. The results of the survey are discussed in the context of current literature. A total of 250 completed the survey an average of 34 months after treatment. Of those, 178 (71%) were very satisfied or satisfied, 187 (75%) reported some recurrence, and 5% reported a complication. Patients less than 2 years from the procedure were statistically significantly more likely to be satisfied with the procedure and more likely to have it again, and reported less recurrence of disease. Current literature does not clearly suggest a best treatment option for Dupuytren disease. Recent analyses suggest that there is a cost difference, with NA presenting as a more cost-effective option. Survey results demonstrated a low complication rate although the rate of recurrence was high, which was consistent with other studies. Needle aponeurotomy is safe and effective, and results in high patient satisfaction despite a high recurrence rate.
       
  • Comparison of the Visible Articular Surface between the Lateral
           Para-Olecranon Approach and Two Other Common Posterior Approaches for
           Distal Humeral Fracture: an Anatomical Study

    • Abstract: Publication date: April 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 2Author(s): Tsuyoshi Amemiya, Takuji Iwamoto, Taku Suzuki, Satoshi Oki, Noboru Matsumura, Kazuki SatoPurposeTo quantify the visible area of the articular surface of the distal humerus exposed by the lateral para-olecranon (LPO) approach and to compare this with the bilaterotricipital (BT) and olecranon osteotomy (OO) approaches.MethodsWe examined 12 elbows from 6 fresh cadavers (mean age, 93.5 years; range, 90–99 years; 3 men and 3 women). Elbows on one side of the cadavers underwent the LPO approach. The opposite elbows underwent the BT approach followed by the OO approach. Macroscopically observable articular cartilage was coated with synthetic silicone resin paint under direct vision. The dissected bone was fixed on the table and photographs of the distal humerus were taken from anteriorly and posteriorly. The color-coded areas projected on 2 planes were quantified using digital photography and computer analysis software.ResultsProportions of the total visible area, summation of the anterior and posterior visible articular areas, were 25.3% ± 2.2% for the BT procedure, 46.4% ± 8.4% for the LPO procedure, and 58.5% ± 5.7% for the OO procedure, showing significant differences among the 3 procedures. The LPO procedure achieves better exposure of the posterior articular surface than the BT procedure, but the LPO procedure had limitations in the anterior visible area compared with the OO procedure. In particular, direct vision of the humeral trochlea was restricted by the presence of the olecranon.ConclusionsThe LPO approach has improved visualization of the distal humeral articular surface compared with the BT approach but not as good as that achieved with the OO approach.Clinical relevanceThe LPO approach is applicable to cases of AO type C1 and C2 distal humeral fractures and some cases of type C3 fracture, excluding those accompanied by complex fractures in the trochlea of the humerus. It is important to evaluate the fracture line of the humeral trochlea in preoperative computed tomography to determine whether to use the LPO or OO approach for AO type C3 fracture.
       
  • One-Stage Use of Integra in the Management of a Complex Dorsal Hand Wound
           in a Patient with Acquired Hemophilia A

    • Abstract: Publication date: April 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 2Author(s): Eric D. Wicks, Nima Rezaie, Kurt A. GasnerThis case report presents a unique clinical dilemma in the treatment of a large full-thickness dorsal hand wound in a 64-year-old Caucasian woman with recently diagnosed acquired hemophilia A. The wound was instigated by nominal blunt force trauma to the dorsal hand and progressed to a large desquamating bulla. Treatment was initiated by careful evacuation of the bulla and daily dressing changes. The resulting necrosis of the skin produced a loose eschar. Subsequent removal of the eschar left the extensor tendons with minimal hypodermis covering the paratenon. The potential for life-threatening hemorrhage limited treatment options. The wound was treated with Integra Dermal Regeneration Template and planned for delayed definitive coverage. Continued concern for hemorrhage and comorbid conditions delayed skin grafting. Wound surveillance demonstrated notable interval healing ultimately resulting in complete regeneration of the skin, providing full coverage of the wound and no functional deficits without surgical intervention or skin grafting.
       
  • A Cadaveric Study of the Posterior Interosseous Nerve and Its Branches at
           the Level of the Distal Radius

    • Abstract: Publication date: April 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 2Author(s): Thomas M. Gregory, Marion Goutard, Jules Gregory, Simon A. Hurst, Lorenzo Merlini, Jérome PierrartPurposePosterior interosseous nerve (PIN) damage has been cited as a cause of wrist pain syndrome after distal radius fractures. The goal of this cadaveric study was to examine this hypothesis by looking for branches between the PIN and the periosteum of the distal radius.MethodsThe PIN was dissected in 10 adult specimens (8 fresh and 2 embalmed) under ×2.5 magnification. All of the dissections started from the last motor branch of the PIN, innervating the extensor indicis proprius, and proceeded from proximal to distal.ResultsThe PIN was divided into 3 terminal segments in the dorsal wrist joint (proximal, middle, and distal segments). We were able to observe that branches to the distal radial periosteum were constant and emerged from the middle segment where the nerve is enclosed in a sturdy fibro-fatty sheath adhered to the dorsal periosteum of the distal radius. No collateral bundle was identified in the proximal segment. In the distal segment, every specimen had branches to the radiocarpal joint; 9 of 10 had a midcarpal innervation. Terminal branches to the carpometacarpal joints were identified in 2 cadaveric wrists.ConclusionsThe radial periosteum PIN branches consistently identified in these specimens may contribute to dorsal wrist pain seen at the time of late follow-up in patients after distal radius fractures.Clinical relevanceThe benefit of PIN denervation as an adjuvant procedure should be evaluated further in the surgical management of wrist injuries.
       
  • Radiographic Thresholds With Increased Odds of a Poor Outcome Following
           Distal Radius Fractures in Patients Over 65 Years Old

    • Abstract: Publication date: April 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 2Author(s): Caitlin J. Symonette, Joy C. MacDermid, Ruby GrewalPurposeOlder patients (aged older than 65 years) appear to tolerate a great degree of anatomic deformity after DRFs; however, the threshold beyond which the deformity becomes unacceptable is unknown. The purposes of this study were to identify the acceptable threshold for radiographic parameters after DRFs in patients aged over 65 years according to a patient-rated pain and disability outcome measure and to determine whether baseline activity levels influenced these parameters.MethodsA cohort of 190 older adults (aged 65 years and older) with DRF were selected from an existing prospectively collected database. The influence of specific radiographic parameters (ulnar variance, radial inclination [RI], and volar-dorsal tilt) and baseline activity levels on 1-year Patient-Rated Wrist Evaluation (PRWE) scores was investigated. The odds ratio (OR) of a poor outcome according to a 1-year PRWE (cutoff score of ≥25) at various alignment thresholds was calculated with 95% confidence intervals (CIs). Activity level (underactive vs active) was determined using the Rapid Assessment of Physical Activity survey.ResultsRadiographic parameters for the cohort varied widely (mean ulnar variance, 1.9 ± 0.9 mm, range –2.4 to 8.0 mm; mean RI, 18.7°± 5.9°, range, 0.1° to 38°; and mean dorsal tilt, 4.5° ±11.9°, range –24.0° to 33.6°). Most of the cohort (n = 158, 83%) had a good outcome (mean PRWE, 14.4 ± 19.5). The OR of a poor outcome was significant for RI less than 20° (OR = 3.6; 95% CI 1.5–8.7) and dorsal tilt greater than 15° (OR = 5.3; 95% CI, 1.0–27.8). Malalignment on radiographs and a poor outcome according to PRWE were not significantly different in the underactive versus active subpopulations.ConclusionsThis study provides alignment cutoffs that best discriminate adverse pain and disability patient outcomes after DRF in a cohort aged more than 65 years. This information can be used to counsel older patients about their increased likelihood of a poor outcome with RI less than 20˚ or a dorsal tilt greater than 15°. Further research is required to examine outcomes after applying these thresholds in a prospective manner to management decision algorithms for DRF in patients aged over 65 years.Type of study/level of evidencePrognostic II.
       
  • Carpal Instability Reconstruction and Wrist Procedures in the Medicare
           Population

    • Abstract: Publication date: April 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 2Author(s): Daniel Reinhardt, Michael Bokempber, Jacob Brubacher, E. Bruce TobyPurposeWe conducted a retrospective study to determine the annual number of patients undergoing various wrist procedures in the Medicare population as well as the revision rate and common revision procedures after carpal instability reconstruction surgeries (Current Procedural Terminology [CPT] billing code 25320).MethodsWe examined the Medicare orthopedic datasets using the PearlDiver application to identify patients who underwent 12 different common wrist procedures, including carpal instability reconstruction procedures, from 2005 to 2014. Carpal instability reconstruction procedures were those identified by CPT 25320, which includes various methods of reconstruction such as capsulodesis, ligament repair, and tendon transfer or graft. Medicare covers approximately 51 million Americans and consists of those aged 65 years and older as well as younger patients enrolled in Social Security disability or with end-stage renal disease. Demographic and payment data were determined for the entire cohort. Patients with less than 3 months of active insurance records after the wrist procedure were excluded.ResultsA total of 29,898 wrist procedures were performed over the study period. The most commonly performed procedure was wrist arthroscopy with joint debridement or triangular fibrocartilage complex repair (6,557 patients). A total of 2,949 patients underwent carpal instability reconstruction procedures, 174 of whom underwent revision or salvage surgeries (5.9%). The most common revision procedure was an additional reconstruction operation whereas the most common salvage procedure was proximal row carpectomy. Average Medicare payment was $4,107.67 for the index procedure and $3,760.95 for revision procedures. The number of wrist procedures increased 43% over the study period.ConclusionsCarpal instability reconstruction procedures and wrist arthroscopies with joint debridement or TFCC repair are performed more commonly in elderly patients than anticipated or indicated. Procedures such as these, without quality evidence supporting their use in elderly patients, are going to be scrutinized as the United States moves toward value-based health care. Although it appears that carpal reconstruction procedures have a low revision rate in the short to medium term in the Medicare population, the wide variety of procedures captured by CPT 25320 makes outcome measurements challenging. A more specific coding system should be created to reflect the surgeon’s effort more accurately, as well as better track revision rates.Type of study/level of evidenceTherapeutic III.
       
  • Painful Locking Elbow in a Child with Congenital Proximal Radioulnar
           Synostosis

    • Abstract: Publication date: April 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 2Author(s): Nezar B. Hamdi, Abdulmuhsen N. Alshammari, Abdullah Y. Almarshad, Faisal M. AlFayyadhPainful snapping or locking in the elbow is an uncommon presentation that has been observed in children with proximal radioulnar synostosis. Only a few cases have been reported in the English language literature. In this report, we present the case of a painful locking elbow in a 12-year-old boy with a congenital proximal radioulnar synostosis. We describe its symptoms, signs, radiographic appearance, surgical treatment, and outcome, and review the relevant literature.
       
  • Acute Atraumatic Compartment Syndrome of the Hand Due to Acquired
           Hemophilia A

    • Abstract: Publication date: April 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 2Author(s): Daniel Walder, Thuan Ly, Claudia Meuli-Simmen, Mario Bargetzi, Flavien MaulerAcquired hemophilia A (factor VIII inhibitor) is a rare idiopathic disease with a high rate of morbidity and mortality. We report the case of an 83-year-old woman who presented with atraumatic compartment syndrome of the right hand resulting from spontaneous bleeding. Urgent fasciotomy was performed. Only after several revision surgeries and a complicated course could the resulting defects be closed by secondary intention and skin grafting. The patient needed interdisciplinary care involving early initiation of clotting factor replacement and immunosuppressive therapy to control the bleeding. Acquired hemophilia A must be considered as an important life-threating differential diagnosis in cases of atraumatic compartment syndrome. Primary treatment differs from the traumatic compartment syndrome. Early diagnosis with immediate start of replacement therapy to correct coagulation and initialization of immunosuppressive therapy are crucial for successful treatment.
       
 
 
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