Faculty Bibliography

BACKGROUND/UNASSIGNED:Physician review websites are easily accessible resources for patients seeking care. The purpose of our study is to characterize the negative reviews of hand surgeons found on popular review sites using a random sample of members from the American Academy of Orthopaedic Surgeons (AAOS) directory. MATERIALS AND METHODS/UNASSIGNED:We randomly selected 500 hand surgeons from the AAOS Find an Orthopaedist database and searched for reviews on three websites: Healthgrades.com, Vitals.com, and RateMDs.com. All one-star written reviews were categorized based on the primary complaint in the review. These complaints were analyzed to determine the factors most frequently associated with negative reviews. RESULTS/UNASSIGNED:A total of 1,848 written one-star reviews were included in the analysis. Of all included reviews, 18.1% directly referenced having surgery with the reviewed surgeon while 81.9% did not. Nonclinical complaints comprised the majority of reviews (73.6%). Of the nonclinical complaints, bedside manner was the most frequently cited complaint (53.8%), while wait time (11.0%), time spent with the provider (10.4%), and staff complaints (8.5%) were the next most common. Among the clinical complaints, unfavorable surgical outcomes (40.4%) were most common, while disagreement with or unclear treatment plans (23.6%), misdiagnosis (12.3%), and uncontrolled pain (11.9%) were next. CONCLUSION/UNASSIGNED:While there are several potential sources of patient dissatisfaction, we have demonstrated that nonclinical aspects of care, such as surgeon bedside manner and office wait times, are disproportionately cited as reasons for negative ratings on physician review websites. It is essential for hand surgeons to understand the motivations behind the reviews that they receive.

BACKGROUND:Wide-awake local anesthesia no tourniquet (WALANT) surgery offers a unique clinical and economic approach to delivering high-quality upper extremity care.Purpose:This article explores the evoluation, techniques, clinical efficancy, financial advantages, and future directions of WALANT as it establishes is growing role in value-based orthopedic care. In doing so, it outlines the value proposition of WALANT for patients, providers, and the hospital system. METHODS:The authors conducted a comprehensive PubMed search to identify studies evaluating the clinical and economic outcomes of WALANT surgery in upper extremity procedures. Eligible studies included prospective and retrospective research, as well as case studies and case series, comparing WALANT with traditional anesthesia. The studies examined focused on metrics such as functional outcomes, patient satisfaction, and cost savings for the patient and the hospital system. RESULTS:Current literature shows that hand and upper extremity surgery performed under WALANT yields similar functional outcomes and even demonstrates equal or higher patient satisfaction compared with traditional anesthesia. Regarding cost savings, WALANT's minimalist approach to procedures can lead to significant waste reduction and notable financial benefits for the patient, the provider, the hospital, and the wider healthcare system. CONCLUSIONS:WALANT surgery offers a compelling value proposition for the patient, the provider, and the healthcare system at large. Through efficient use of resources focused on minimizing waste and optimizing patient experience and outcomes, WALANT offers an opportunity for value-based surgical care. Further research into more sophisticated clinical uses and large-scale cost-savings analyses is necessary for WALANT procedures to be further validated and more broadly adopted. LEVEL OF EVIDENCE/METHODS:Level V.Key Words: wide-awake surgery, WALANT, upper extremity surgery, hand surgery.

This case is a 37-year-old man with diffuse primary synovial chondromatosis of the elbow, with associated ulnar nerve compression and flexion contracture at the elbow. An open synovectomy with removal of loose bodies and an ulnar nerve decompression with anterior subcutaneous transposition were performed. Postoperatively, the patient's elbow mobility and nerve compression symptoms improved steadily, which significantly improved his function. Primary synovial chondromatosis of the elbow is a rare disease that can result in pain, swelling, decreased range of motion, and mechanical symptoms. Treatment usually involves synovectomy and removal of loose bodies to address patients' pain and joint motion.

The scapholunate ligament (SLL) is a critical stabilizer of the wrist joint. Disruption of the SLL leads to altered wrist kinematics, including scaphoid flexion, lunate extension, and increased stress on surrounding cartilage and ligaments, which can progress to dorsal intercalated segment instability and scapholunate advanced collapse. Despite predictable biomechanical changes, clinical outcomes vary widely because some patients develop significant functional limitations, whereas others remain asymptomatic. Nonoperative management, including immobilization, therapy, and bracing, remains the first-line treatment for partial tears or stable injuries. Surgical intervention, such as SLL repair with capsulodesis or reconstruction, is indicated for cases with persistent pain, instability, or functional deficits. Capsulodesis is a commonly used adjunct to SLL repair. Multiple surgical techniques exist for SLL repair in the acute setting and for reconstruction in the chronic setting when SLL is deemed irreparable. Although several surgical techniques are available for chronic injuries, a gold standard has not yet been established.

Since the beginning of documented medical history, amputation procedures, limb loss, and the myriad creative solutions attempted to care for these individuals have been reported. With the coalescence of multiple World Wars resulting in an ever-increasing number of individuals with limb loss and advancing medical technology, a need to innovate in this field has always been present. The complexity of the hand and upper extremity in self-care, communication, vocation, and exercise results in more demands of prostheses to mimic or replace these functions as opposed to the lower extremity, which is focused mostly on weight bearing and ambulation. As such, this need has pushed technological advances past the simpler passive or body-powered prostheses alone, now with externally powered and hybrid devices revolutionizing the way these appliances were implemented in everyday life. Despite the ever-advancing field of prosthetic technology, upper and lower extremity amputees alike still battle common challenges of pain, phantom limb sensation, and lack of prosthetic control and sensation. Targeted muscle reinnervation and regenerative peripheral nerve interface offer new surgical solutions to some of these challenges and are proving invaluable. As technology and surgical options continue to advance at an ever-rapid pace, a more thoughtful and individualized approach to the care of upper extremity limb loss is available. In this study, we review the history and evolution of upper extremity prostheses and discuss considerations in making optimal surgical and prosthetic decisions for upper extremity amputees.

PURPOSE/UNASSIGNED:The anatomy of the "critical corner" in volar lunate facet fractures makes achieving fixation difficult, and standard precontoured volar locking plates may be limited in certain fracture patterns. The purpose of this review was to identify various fixation techniques for the volar lunate facet and review the outcomes data associated with each fixation method. METHODS/UNASSIGNED:A review of the literature was performed by first screening the PubMed database for relevant articles using key terms: "volar lunate facet," "critical corner," and "distal radius fractures." Two reviewers independently assessed all 87 articles for relevance. Articles were included if both reviewers agreed on their inclusion and if they described an alternative fixation method for treating volar lunate facet fractures. The reviewers then extracted as much data as possible regarding the fixation methods, including technique, sample size, follow-up period, and various outcomes such as range of motion, grip strength, return to work, and rates of union. RESULTS/UNASSIGNED:Of the 28 articles that were included, the fixation methods reviewed were categorized into direct Kirschner wire fixation, compression fixation-"spring wire fixation," tension fixation-"wire-loop fixation," and containment fixation with the use of a buttress pin in various configurations. These alternative fixation methods had high rates of union, few complications, and good to excellent clinical outcomes. CONCLUSIONS/UNASSIGNED:The limitations of using a single volar locking plate for volar lunate facet fractures have led to the development of novel fixation techniques. Although these alternative fixation methods have demonstrated promising outcomes, the existing studies have small sample sizes. CLINICAL RELEVANCE/UNASSIGNED:Distal radius fractures involving the volar lunate facet present a challenge in operative fixation due to the various anatomical features described. Each unique fracture pattern must be thoroughly evaluated to determine the most appropriate fixation method.

The diagnosis and treatment of fast-flow arteriovenous malformations with or without dynamic arteriovenous fistulae in the upper limb can be both frustrating and daunting for the hand surgeon. The clinical presentation can vary from an incidental finding to a pulsating mass, threatening the entirety of the upper extremity and precipitating cardiac failure secondary to diverging vasculature. Non-operative treatment is appropriate for the small, minimally symptomatic mass. However, considerable controversy remains regarding the management of symptomatic lesions, specifically regarding the utility of embolization or sclerotherapy and the aggressiveness of surgical resection, concepts that are dependent primarily on both the size and location of the lesion. Although classification schemes exist, which attempt to stratify the severity of the lesion encountered by the upper-extremity surgeon, they make no attempt to categorize its location based on clinical relevance. Therefore, our purpose was to review the etiology, clinical presentation, and management of arteriovenous malformations in the upper limb and to refine the present classification to include present treatment options for this uncommonly encountered pathology.

BACKGROUND:Corticosteroid injections are a first-line treatment of trigger finger and de Quervain's tenosynovitis. Little research has evaluated preinjection patient-reported outcomes as a predictive factor for treatment success following corticosteroid injection. We hypothesized that patients with less pretreatment impairment would demonstrate greater post-treatment improvement than patients whose function was more severely impaired. METHODS:We retrospectively reviewed prospectively collected Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) scores in patients undergoing corticosteroid injection for trigger finger or de Quervain's tenosynovitis from 2017 to 2023. Independent variables were patient baseline characteristics, comorbidities, and baseline PROMIS UE. The primary outcome was treatment success between 30 days and 12 weeks, defined as achieving the minimal clinically important difference for PROMIS UE without undergoing surgery. RESULTS:= .44). CONCLUSION/CONCLUSIONS:Corticosteroid injection provides meaningful improvement for a subset of trigger finger and de Quervain's tenosynovitis patients. Corticosteroid injection remains a first-line treatment for trigger finger and de Quervain's tenosynovitis patients, especially for those with more severe functional impairment.

INTRODUCTION/BACKGROUND:Frailty, a physiological decline in functional capacity, may influence nonunion risk. This study aimed to investigate the association between frailty, as measured by the modified Frailty Index-5 (mFI-5), and the likelihood of nonunion fractures of the upper extremity. METHODS:This retrospective cohort study utilized the national inpatient sample (NIS) from 2015 to 2019. Patients aged 18 and older with upper extremity fractures, identified by ICD-10-CM codes, were included. Patients were categorized into routine healing and nonunion groups. Frailty was assessed using the mFI-5, classifying patients as robust, prefrail, frail, or severely frail. Multivariate logistic regression, controlling for age, sex, and Injury Severity Score (ISS), was performed to determine the association between frailty and nonunion. RESULTS:The study included 21,618 patients, with 3782 presenting with nonunion fractures. The median age was 69 years, and 60.5% were female. The most common fracture types in the routine healing group were forearm (40.1%), clavicle (18.4%), and humerus (16.9%), while in the nonunion group, humerus (30.4%) and scapula (32.1%) were most common. Multivariate logistic regression showed that frail and severely frail patients had a decreased risk of nonunion (OR 0.751 and 0.705, respectively, p < 0.001). Each unit increase in mFI-5 score was associated with a decreased risk of nonunion (OR 0.868, p < 0.001). Sub-analysis revealed a decreased risk of nonunion with increasing frailty for humerus, clavicle, scapula, and phalanx fractures, but no significant association for wrist, forearm, or metacarpal fractures. CONCLUSION/CONCLUSIONS:Contrary to expectations, increasing frailty, as measured by the mFI-5, was associated with a decreased risk of nonunion fractures in the upper extremity. This paradoxical finding may be due to closer medical supervision and improved treatment compliance in frail patients. Further prospective studies are needed to explore the complex interplay between frailty, treatment adherence, and fracture healing.