Faculty Bibliography

Background: The purpose of this study was to determine the factors that affect hand surgeon operating room (OR) turnover time. We hypothesized that surgeon presence in the OR, decreased American Society of Anesthesiologists (ASA) class, smaller case type, and earlier case time, as well as other factors, decreased OR turnover time. Methods: A total of 685 hand surgery cases performed by 5 attending hand surgeons between September 2013 and December 2014 were identified. Turnover time, patient comorbidities (ASA class), surgeon, prior OR surgical procedure, current OR surgical procedure, location of the surgery (ambulatory surgical center [ASC] vs orthopedic specialty hospital [OSH]), time of surgery, and order of OR cases were recorded. The effect of surgeon routine variables, OR case factors, and patient health status on OR turnover was analyzed. Results: Turnover time was significantly shorter in cases where the surgeon remained in the OR during turnover (27.5 minutes vs 30.4 minutes) and when the surgeon incentivized OR staff (24 minutes vs 29 minutes). The ASC was found to have shorter turnover times than the OSH (27.9 minutes vs 36.4 minutes). In addition, ASA class, type of prior OR procedure, type of current OR procedure, and case order all significantly affected turnover time. Comparison of OR turnover time among the 5 surgeons revealed a statistically significant difference at the OSH but not at the ASC. Conclusion: OR turnover time is significantly affected by surgeon routine, location of surgery, patient ASA class, procedure type, and case order. Interestingly, the effect of hand surgeon routine on OR turnover time may be amplified at an academic OSH versus an ASC.

PURPOSE: To assess the risk of injury to the dorsal sensory branch of the ulnar nerve (DSBUN) with percutaneous pinning of commonly stabilized ulnar-sided structures. METHODS: Eleven fresh-frozen cadaveric upper extremities were assessed. Percutaneous pinning of the fifth metacarpal base and neck, lunotriquetral joint, ulnar styloid, and distal radioulnar joint (DRUJ) with 1.4-mm Kirschner wires was performed under fluoroscopic guidance. Each specimen was then carefully dissected and the distance from each pin to the DSBUN was measured using a digital caliper. Direct injury to the DSBUN and pins found immediately adjacent to the nerve were recorded. RESULTS: Mean distance from the pin to the DSBUN at the fifth metacarpal neck was 5.0 +/- 1.5 mm; fifth metacarpal base, 2.3 +/- 2.2 mm; lunotriquetral joint, 1.8 +/- 1.6 mm; ulnar styloid, 0.8 +/- 1.1 mm; and DRUJ, 3.1 +/- 0.9 mm. Two of 11 ulnar styloid pins and 1 of 11 lunotriquetral pin directly penetrated the DSBUN, whereas 4 of 11 ulnar styloid pins, 3 of 11 fifth metacarpal base pins, and 2 of 11 lunotriquetral pins were directly adjacent to the DSBUN. There was an increased overall risk of DSBUN injury (risk of direct injury and risk of adjacent pin) with pinning of the ulnar styloid compared with fifth metacarpal neck and DRUJ pinning. CONCLUSIONS: The current study demonstrates the risk of iatrogenic injury to the DSBUN with percutaneous pinning of the ulnar styloid, lunotriquetral joint, and fifth metacarpal base. CLINICAL RELEVANCE: We recommend identifying and protecting the nerve to mitigate the risk of iatrogenic injury when performing ulnar-sided pinning of structures from the ulnar styloid to the fifth metacarpal base.

The literature on the effect of ulnar styloid fractures (USFs) on concomitant distal radius fractures (DRFs) is mixed. We conducted a study to determine if associated ipsilateral USFs affect outcomes of DRFs. We retrospectively evaluated 315 DRFs treated (184 operatively, 131 nonoperatively) over a 7-year period. Concomitant USFs were identified. Mean follow-up was 12 months. Disabilities of the Arm, Shoulder, and Hand (DASH) and 36-Item Short Form Health Survey (SF-36) outcome scores, and grip strength and wrist range of motion data, were collected. Statistical analysis was performed with Student t test and analysis of variance. Incidence of concomitant USF and DRF was higher (P < .0002) in the operative group (64.6%) than in the nonoperative group (39.1%). Patients with USFs had worse mean (SD) pain score, 1.80 (2.43) versus 0.80 (1.55) (P = .0001), DASH score, 17.03 (18.94) versus 9.21 (14.06) (P = .001), and SF-36 score, 77.16 (17.69) versus 82.68 (16.10) (P = .022). In the operative group, patients with USFs had more pain and poorer DASH Functional scores than patients without USFs. Results were similar in the nonoperative group. There was no difference in healing time between intra-articular and extra-articular fractures or between presence and absence of USFs. Concomitant occurrence of USFs and DRFs-which is associated with worse pain scores and lower functioning compared with USFs without DRFs-should prompt clinicians to counsel patients about delayed recovery.

BACKGROUND: The purpose of this study is to evaluate patient's perceptions of physician reimbursement for the most commonly performed surgery on the hand, a carpal tunnel release (CTR). METHODS: Anonymous physician reimbursement surveys were given to patients and non-patients in the waiting rooms of orthopaedic hand physicians' offices and certified hand therapist's offices. The survey consisted of 13 questions. Respondents were asked (1) what they thought a surgeon should be paid to perform a carpal tunnel release, (2) to estimate how much Medicare reimburses the surgeon, and (3) about how health care dollars should be divided among the surgeon, the anesthesiologist, and the hospital or surgery center. Descriptive subject data included age, gender, income, educational background, and insurance type. RESULTS: Patients thought that hand surgeons should receive $5030 for performing a CTR and the percentage of health care funds should be distributed primarily to the hand surgeon (56 %), followed by the anesthesiologist (23 %) and then the hospital/surgery center (21 %). They estimated that Medicare reimburses the hand surgeon $2685 for a CTR. Most patients (86 %) stated that Medicare reimbursement was "lower" or "much lower" than what it should be. CONCLUSION: Respondents believed that hand surgeons should be reimbursed greater than 12 times the Medicare reimbursement rate of approximately $412 and that the physicians (surgeons and anesthesiologist) should command most of the health care funds allocated to this treatment. This study highlights the discrepancy between patient's perceptions and actual physician reimbursement as it relates to federal health care. Efforts should be made to educate patients on this discrepancy.

PURPOSE: To determine whether specific anatomic lesions of the scapholunate supporting structures are associated with the grades of scapholunate instability according to the Geissler classification. METHODS: Six fresh frozen cadaveric limbs underwent serial arthroscopic sectioning of the scapholunate supporting ligaments. To simulate a progressive scapholunate injury based on the current literature, sectioning occurred as follows: volar scapholunate interosseous ligament (SLIL), membranous SLIL, dorsal SLIL, radioscaphocapitate, long radiolunate, dorsal radiocarpal, dorsal intercarpal, and scaphotrapeziotrapezoid ligaments. We performed arthroscopic examination of the radiocarpal and midcarpal joints after each ligamentous sectioning and recorded the appearance of the scapholunate interval. RESULTS: There was a progressive increase in Geissler grade with sequential sectioning of the scapholunate supporting ligaments. In all specimens, Geissler grade 2 injury was associated with sectioning of intrinsic ligaments only. Geissler grade 3 injury first appeared with sectioning through the dorsal SLIL and continued through sectioning of the volar extrinsic ligaments. Geissler grade 4 injury did not occur until the dorsal extrinsic ligaments were sectioned. Statistical analysis indicated a linear relationship between ligament sectioned and Geissler grade, with deeper sections associated with a higher Geissler grade. CONCLUSIONS: In this cadaveric model, arthroscopically determined Geissler grade was associated with specific anatomic lesions of the scapholunate supporting ligaments. Sequential sectioning of the ligaments showed a progressive increase in Geissler grade. CLINICAL RELEVANCE: Knowledge of the association of Geissler grade with pathoanatomy may aid the surgeon in deciding which reconstructive method is best.

Distal radioulnar joint (DRUJ) arthritis presents a challengingproblem. Surgical interventions include resectionarthroplasties, such as the Darrach procedure and hemiresectionarthroplasty, the Sauve-Kapandji procedure, andmore recently prosthetic replacement for either the ulnarhead or the entire DRUJ. Resection arthroplasties have beenassociated with complications, including instability andradioulnar convergence. The prosthetic replacements havebeen designed in an attempt to restore more normal DRUJkinematics. This paper provides a review of the anatomy andbiomechanics of the DRUJ and discusses the outcomes of theavailable surgical options for symptomatic DRUJ arthritis.The arthritic distal radioulnar joint (DRUJ) is a difficultproblem. Many of the surgical interventionsdeveloped for this condition are associated with complications,such as instability and radioulnar convergence.Recently, prosthetic replacement of either the ulnar heador the entire DRUJ has been advocated in order to betterrestore the kinematics of the joint. A review of the anatomyand biomechanics of the DRUJ and a discussion of thenumerous surgical options and their outcomes is provided.

PURPOSE: To describe the features of displaced intra-articular fractures confined to the volar rim of the distal radius and compare outcomes after their operative fixation to complete intra-articular and extra-articular fractures treated with operative fixation. METHODS: A total of 627 distal radius fractures were treated over a 6-year period. Twenty-eight patients had volar rim fractures (type 23-B3, as classified by the Orthopaedic Trauma Association [OTA]), all treated with operative reduction and fixation using a volar buttress plate. Clinical outcome information including radiographs, Short Form-36 health survey, and Disabilities of the Arm, Shoulder, and Hand questionnaire were collected at regular postoperative intervals. Patients with volar rim fractures were compared with patients who sustained other types of operatively managed distal radius fractures (OTA types 23-A, 23-B1/B2, and 23-C). RESULTS: The most common type of volar rim fracture consisted of a single large fragment (OTA 23-B3.2; 46%), followed by comminuted fractures (OTA 23-B3.3; 36%). Restoration of radiographic parameters was similar between groups except for an increased volar tilt in volar rim fractures compared with group 23-B1/B2. Active wrist and finger motion improved in all groups except for wrist extension, which was less in the 23-B1/B2 groups. The 23-B1/B2 group had the greatest pain and worst Short Form-36 scores. Disabilities of the Arm, Shoulder, and Hand questionnaire scores were similar and without differences between groups. CONCLUSIONS: Our data suggest that patients with volar rim distal radius fractures can expect a rapid return to function with minimal risk for complications and have outcomes similar to other types of operatively treated distal radius fractures. Further investigation of type 23-B fractures (23-B1/B2) is warranted owing to evidence of diminished outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

BACKGROUND: Socioeconomic factors have been found to be predictors of outcome for other ailments. The purpose of this study was to evaluate the association of patient education level on pain and disability after distal radius fracture. METHODS: A series of patients with distal radius fractures (n = 335) were enrolled into a prospective research registry. Standard demographic information was obtained from patients, including a five-value categorical education variable. After treatment with closed reduction, external fixation, or internal fixation patients were evaluated for pain, function (Disability of the Arm, Shoulder, and Hand score [DASH]), range of motion (ROM), and grip strength at standard intervals until 12 months post-injury. A series of linear mixed effects models were developed to evaluate the relationship between time from injury and education level with each of the outcomes measured. RESULTS: Complete demographic and 12-month follow-up data were available on 227 patients (75 %). There were neither group differences in mode of injury, severity, nor treatment modality after stratification by education level. Mixed effects model analyses revealed a significant linear association between level of education and measured outcomes at each follow-up point. Overall, each increase in education level demonstrated a doubling of improvement in pain, ROM, grip strength, and DASH score. CONCLUSIONS: Outcome of distal radius fracture depends on acute care and follow-up rehabilitation; however, patient-related factors indicative of socioeconomic status are becoming increasingly relevant as predictors of outcome and should be considered by the orthopaedist.

PURPOSE: In order to identify predictors for hand stiff- ness following distal radius fractures and understand the consequences of this common clinical finding, we studied 260 patients. Our null hypothesis was that we would find no predictors of post injury hand stiffness. METHODS: Baseline demographics and injury character- istics were obtained at distal radius fracture presentation. Treatment and healing was documented. Stiffness was de- fined as tip to palm distance greater than 1 cm for any one finger. Outcome parameters obtained at regular intervals included wrist and hand range of motion, radiographs, vi- sual analog pain scales, and Disability of the Arm Shoulder and Hand (DASH) questionnaires. RESULTS: Forty-nine of 260 patients (19%) patients were considered to be "stiff" by our criteria. Grip strength was weaker for stiff patients as well. Patient demographics were similar in both groups with the "stiff" cohort having a greater mean age, p = 0.05. There was no significant differ- ence in stiffness seen in operative cases versus nonoperative cases. Injury ulnar variance was 3.1mm (SD = 3.5) in the "stiff" cohort and 1.8 (SD = 2.9) in the "non-stiff" cohort (p= 0.02). Functional disability as measured by the DASH differed (p = 0.001) between stiff and non-stiff patients for both 6 month and 1 year follow-up time points. Stiff patients were more likely than non-stiff patients to have lower grip strength at 12-month post fracture (p = 0.001). CONCLUSION: Older patients who present with significant ulnar variance at injury are more likely to experience hand stiffness at some time during their recovery. The develop- ment of hand stiffness is associated with poorer functional outcome than those who do not develop stiffness.

OBJECTIVES: : The purpose of this study was to evaluate forearm rotation after volar plating of the distal radius fractures with and without pronator quadratus repair. DESIGN: : This was an institutional review board-approved retrospective review of prospectively collected data. SETTING: : The study was conducted at an Academic Medical Center. PATIENTS: : Over a 5-year period, 606 patients with distal radius fractures (OTA classifications 23-A through 23-C) were enrolled in an institutional review board-approved, prospectively collected, distal radius database. One hundred and seventy-five patients underwent open reduction and internal fixation with volar plating. Of these, 112 patients had complete 1-year follow-up (6 weeks, 3, 6, and 12 months) and were included in this study. INTERVENTION: : Volar plating of the distal radius was performed with pronator quadratus repair (group A), versus volar plating without pronator quadratus repair (group B). Surgeries in group A were performed by a fellowship trained hand surgeon utilizing volar plates from Depuy Orthopedics (Warsaw, IN), whereas the surgeries in group B were performed by a fellowship trained orthopedic trauma surgeon utilizing volar plates from Stryker (Mahwah, NJ). MAIN OUTCOME MEASUREMENTS: : Primary outcomes include forearm range of motion. Secondary outcomes include grip strength, pain levels, functional outcomes (DASH scores), radiographs, and complications. RESULTS: : Baseline and demographic characteristics of the patients were similar between the 2 groups. There was no difference in mean pronation (P = 0.08) at 1 year. Among secondary analyses, radial deviation was significantly different (P = 0.03); however, pain (P = 0.13) and DASH scores (P = 0.14) were not. The only patient that requested plate removal had the pronator repaired (group A). CONCLUSIONS: : We conclude that there is no advantage in repairing the pronator quadratus during volar plating of distal radius fractures. LEVEL OF EVIDENCE: : Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.