Penlight versus Smartphone: Diagnostic Efficacy of Transillumination
The Effect of Corticosteroid Injections on Postoperative Infections in Trigger Finger Release
BACKGROUND:Corticosteroid injections have proven benefit in the treatment of symptomatic trigger finger; however, the immune system and tissue repair modulating properties of corticosteroids justify further consideration in surgical candidates. The aim of this study was to assess the relationship between corticosteroid injections and postoperative infection in trigger finger release. METHODS:A single-center retrospective review was conducted of patients seen from 2010 to 2019 to identify those who underwent trigger finger release with subsequent antibiotic prescription for chart-documented wound infection. A demographic matched cohort of 100 patients was identified for comparison. Preoperative corticosteroid injection history including timing, frequency, and dose was collected for all patients. Patient demographics, comorbidities, and presence of postoperative infection were collected from patient medical records. Superficial infection was defined as those requiring antibiotics for resolution without return to the operating room; deep infection was defined as infections that required irrigation and debridement. RESULTS:= .04). CONCLUSIONS:While corticosteroid injection in the preoperative period is associated with a higher rate of postoperative infection, the time before surgery and the corticosteroid dose do not appear to have an effect.
Coding Practices in Hand Surgery and Their Relationship to Surgeon Compensation Structure
Purpose/UNASSIGNED:To evaluate the coding practices of hand surgeons in the American Society for Surgery of the Hand with respect to practice compensation structure using common, representative hand surgery cases. Methods/UNASSIGNED:We developed a survey of demographic factors and 4 commonly encountered hypothetical hand surgery cases. This survey was emailed to the members of the American Society for Surgery of the Hand. Respondents were asked to code these cases using prepopulated applicable Current Procedural Terminology codes or any other codes of their choosing. The membership responses were then compared with those of 3 independent orthopedic coders. Results/UNASSIGNED:< .05). The 3 independent coders all chose a single Current Procedural Terminology code for the carpal tunnel release, distal radius fracture, and scaphoid nonunion cases. The percentages of physician responses that selected only these codes were 84.6% (carpal tunnel release), 61.0% (distal radius fracture), and 73.6% (scaphoid nonunion). Physicians were less likely to code in line with the independent coders for the distal radius fracture case compared with other cases, particularly those physicians with a collections-based model. Conclusions/UNASSIGNED:The compensation model may be associated with coding practices for more complicated hand cases. The additional work-related value units potentially billed can quickly accumulate for frequently performed procedures. This wide variation supports a need for more frequent and accessible communication and education on coding practices in hand surgery. Clinical relevance/UNASSIGNED:Improved communication and education regarding appropriate coding practices as well as easily accessible reference material may assist in minimizing coding discrepancies for surgical hand procedures.
Thumb Disability Examination (TDX) as a New Reliable Tool for Basal Joint Arthritis
Background â€ƒThe general assessment of basal joint arthritis (BJA) is limited using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. This has been shown to be insensitive to pain and disability levels, leading to the development and validation of the thumb disability examination (TDX) as a specific tool for BJA in 2014. Objective â€ƒThe goal of this study was to evaluate the reliability, sensitivity, and specificity of the TDX score for BJA. Methods â€ƒA multicenter BJA database was established in 2007 to collect prospective data. We evaluated the correlation between the TDX score, visual analog pain scale with activity (A-VAS), Eaton-Littler score, and grip strength using a Pearson test. Additionally, we evaluated the pre- and postintervention scores to assess their predictive values. Results â€ƒA total of 109 thumbs of 74 patients with TDX scores were evaluated. Females were more commonly affected (75.2%), and the mean age was 65.39 years (standard deviation: 10.04). The majority of participants were white (90.8%). A high correlation between TDX and A-VAS score (Pearson's correlationâ€‰=â€‰0.520; p â€‰<â€‰0.001) and between grip strength (Pearson's correlationâ€‰=â€‰-0.336; p â€‰<â€‰0.005) and Eaton-Littler score (Pearson's correlationâ€‰=â€‰0.353' p â€‰<â€‰0.01) was identified. Additionally, when comparing pre- and post-intervention for all treatment groups and for operative intervention, significant differences in TDX scores were observed (both p â‰¤ 0.01). No significant differences could be identified for DASH score or A-VAS when assessing these same groups. Conclusion â€ƒThe TDX score correlates to high Pearson's correlation values and p -values, especially in grip strength, Eaton-Littler score, A-VAS score, and pre-/postintervention for all treatment groups combined and when specifically assessing the surgical intervention group. As a result, it can be concluded that the TDX score is a specific tool for the assessment of BJA. Level of Evidence â€ƒThis is a Level II, prospective comparative study.
Surgical Management of Scaphotrapeziotrapezoid Arthritis
Scaphotrapeziotrapezoid (STT) arthritis occurs commonly with basal joint arthritis, but can also occur in isolation or in conjunction with other patterns of wrist arthritis, such as scapholunate advanced collapse. Surgical options depend on the specific clinical scenario encountered. Isolated STT arthritis was classically managed with arthrodesis, but is now often addressed with distal scaphoid resection (open or arthroscopic), trapeziectomy (partial or complete) and partial trapezoid resection, or implant arthroplasty. Development of postoperative dorsal intercalary segment instability is a notable concern with any of these techniques. STT arthritis in conjunction with basal joint arthritis can be managed effectively with trapeziectomy and either partial trapezoid excision or distal scaphoid excision. STT arthritis with scapholunate advanced collapse is uncommon, but can be managed with proximal row carpectomy or scaphoidectomy and four-corner fusion. If basal joint arthritis is also present, trapeziectomy can additionally be performed, but grip strength is likely to be substantially diminished.
Etiology, Evaluation, and Management Options for the Stiff Digit
The stiff digit may be a consequence of trauma or surgery to the hand and fingers and can markedly affect a patient's level of function and quality of life. Stiffness and contractures may be caused by one or a combination of factors including joint, intrinsic, extensor, and flexor tendon pathology, and the patient's individual biology. A thorough understanding of the anatomy, function, and relationship of these structures on finger joint range of motion is crucial for interpreting physical examination findings and preoperative planning. For most cases, nonsurgical management is the initial step and consists of hand therapy, static and dynamic splinting, and/or serial casting, whereas surgical management is considered for those with more extensive contractures or for those that fail to improve with conservative management. Assuming no bony block to motion, surgery consists of open joint release, tenolysis of flexor and/or extensor tendons, and external fixation devices. Outcomes after treatment vary depending on the joint involved along with the severity of contracture and the patient's compliance with formal hand therapy and a home exercise program.
Failure of Adjustably Aligned Modular Radial Head Arthroplasty With Head-Neck Dissociation and Metallosis
Radial head arthroplasty was introduced in 1941 and the literature supports satisfactory overall midterm patient outcomes and acceptable complication profiles with several models. There are several previously described mechanisms by which radial head complications typically occur. We present the case of a rarely described mechanism of radial head implant failure: elbow synovitis and pain from partial dissociation and metallosis in an adjustably aligned, modular, monopolar, mixed metal, press-fit radial head arthroplasty.
Preparatory Time-Related Hand Surgery Operating Room Inefficiency: A Systems Analysis
BACKGROUND:No study exists on preparatory time-from patient's entrance into the operating room to skin incision-and its role in hand surgery operating room inefficiency. The purpose of this study was to investigate the length and variability of preparatory time and assess the relationship between several variables and preparatory time. METHODS:Consecutive upper extremity cases performed for a period of 1 month by hand surgeons were reviewed at 3 surgical sites. Preparatory time was compared across locations. Cases at one location were further analyzed to assess the relationship between preparatory time and several variables. Both traditional statistical methods and Shewhart control charts, a quality control tool, were used for data analysis. RESULTS:A total of 288 cases were performed. The mean preparatory times at the 3 sites were 25.1, 25.7, and 20.7 minutes, respectivley. Aggregated preparatory time averaged 24.4 (range 7-61) minutes, was 75% the length of the surgical time, and accounted for 34% of total operating room time. Control charts confirmed substantial variability at all locations, signifying a poorly defined process. At a single site, where 189 cases were performed by 14 different surgeons, there was no difference in preparatory time by case type, American Society of Anesthesiologists status, or case start time. Preparatory time varied by surgeon and anesthesia type. CONCLUSIONS:Preparatory time was found to be a source of inefficiency, independent of the surgical site. Control charts reinforced large variations, signifying a poorly designed process. Surgeon seemingly plays an important, albeit likely indirect, role. Efforts to improve operating room workflow should include preparatory time.
Anomalous Courses of the Palmar Cutaneous Branch of the Median Nerve in Relation to the Flexor Carpi Radialis Tendon for ORIF of Distal Radius Fractures
BACKGROUND:The purpose of this study was to prospectively document the incidence of variations in the course of palmar cutaneous branch of the median nerve (PCBMN) that may increase the risk of injury to the nerve during the flexor carpi radialis (FCR) approach. We hypothesize that the incidence of anomalous branching of the PCBMN around the FCR sheath will be approximately 5%. METHODS:All cases that met inclusion criteria between November 2013 and March 2018 were included. The operating surgeon made the final decision for operative intervention using the FCR approach. Each surgeon performed the standard FCR approach to the distal radius. The branching location from the median nerve, the relationship to the FCR sheath, and the course of the PCBMN were recorded. RESULTS:In total, 101 distal radius fractures were included. The average branching point of PCBMN was 5.2 cm from the distal wrist crease (range = 3.3-9.0). There were 26 anomalous branching patterns of PCBMN. Nineteen (18.8%) crossed volar, dorsal, or ran within the FCR sheath. Six PCBMN were found within the FCR sheath, 1 penetrated the FCR sheath, 6 crossed volar to the FCR sheath, and 6 were dorsal to the FCR tendon sheath. When comparing the branching patterns of the PCBMN from the median nerve, 4 branched from the volar aspect, 2 branched from the dorsal aspect, and 1 branched from the ulnar aspect of the median nerve. CONCLUSIONS:Variation in the course of the PCBMN relative to the FCR sheath is more than previously thought and can be expected in approximately 18.8% of patients.
Accuracy and Reliability of Radiographic Estimation of Volar Lip Fragment Size in PIP Dorsal Fracture-Dislocations
BACKGROUND:A cadaveric study was performed to evaluate the accuracy and reliability of radiographic estimation of the volar lip fragment size in proximal interphalangeal joint fracture-dislocations. METHODS:Middle phalangeal base volar lip fractures of varying size and morphology were simulated in 18 digits. Radiographs and digital photographs of the middle phalangeal joint surface were obtained pre- and postinjury. Ten orthopedic surgeons of varying levels of training estimated the fracture size based on radiographs. The estimated joint involvement on radiograph was compared with the digitally measured joint involvement. RESULTS:Radiographic estimation underestimated the volar lip fragment size by 9.02%. Estimations possessed high intraobserver (0.76-0.98) and interobserver (0.88-0.97) reliabilities. No differences were detected between levels of surgeon training. CONCLUSIONS:The significant underestimation of the volar lip fragment size demonstrates the lack of radiographic estimation accuracy and suggests that surgeons should be mindful of these results when making treatment plans.