Faculty Bibliography

PURPOSE: The availability of tendon grafts is an important consideration for successful upper extremity reconstructive surgery, including flexor or extensor tendon reconstructions, tendon transfers, and ligament reconstructions. Graft selection is based on availability, expendability, ease of harvest, and length. Given variations in patient height and extremity length, existing average values may provide suboptimal insight into actual tendon lengths available. The purpose of this study is, therefore, to pursue a method of estimating available donor tendon lengths based on easily measured anatomical surface landmarks. METHODS: Thirty cadaveric upper and lower extremity limbs were dissected and the length of commonly harvested tendon grafts including the palmaris longus, extensor indicis proprius, extensor digiti minimi, plantaris, and second long toe extensor was measured. Surface forearm length (from finger tip to cubital fossa) and surface fibular length (from lateral malleolus to fibular head) were also measured. Correlations between surface measurements and underlying tendon lengths were analyzed, and linear models were generated that predicted tendon length as a function of surface measurements. RESULTS: Surface measurements were correlated with underlying tendon length (R = 0.46 - 0.66). Linear models could predict tendon lengths based on surface measurements (P < .05). A ratio of donor tendon length compared with the limb segment measured was established for each tendon and can be applied to estimate donor tendon length. For the upper extremity tendons, the multipliers for the palmaris longus, extensor indicis proprius, and extensor digiti minimi were 0.51, 0.20, and 0.18, respectively. Lower extremity tendon ratios for the plantaris and extensor digitorum longus were 0.69 and 0.60, respectively. CONCLUSIONS: Although length of available donor tendon can be a limiting variable at the time of surgery, surgeons may be better able to estimate underlying tendon lengths using easily obtained superficial measurements. CLINICAL RELEVANCE: Information obtained from these cadaveric measurements may aid in preoperative planning in hand and upper extremity surgery.

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.

The Internet is a common resource for applicants of hand surgery fellowships, however, the quality and accessibility of fellowship online information is unknown. The objectives of this study were to evaluate the accessibility of hand surgery fellowship Web sites and to assess the quality of information provided via program Web sites. Hand fellowship Web site accessibility was evaluated by reviewing the American Society for Surgery of the Hand (ASSH) on November 16, 2014 and the National Resident Matching Program (NRMP) fellowship directories on February 12, 2015, and performing an independent Google search on November 25, 2014. Accessible Web sites were then assessed for quality of the presented information. A total of 81 programs were identified with the ASSH directory featuring direct links to 32% of program Web sites and the NRMP directory directly linking to 0%. A Google search yielded direct links to 86% of program Web sites. The quality of presented information varied greatly among the 72 accessible Web sites. Program description (100%), fellowship application requirements (97%), program contact email address (85%), and research requirements (75%) were the most commonly presented components of fellowship information. Hand fellowship program Web sites can be accessed from the ASSH directory and, to a lesser extent, the NRMP directory. However, a Google search is the most reliable method to access online fellowship information. Of assessable programs, all featured a program description though the quality of the remaining information was variable. Hand surgery fellowship applicants may face some difficulties when attempting to gather program information online. Future efforts should focus on improving the accessibility and content quality on hand surgery fellowship program Web sites.

BACKGROUND: Distal radius fractures are very common injuries and surgical treatment for them can be painful. Achieving early pain control may help improve patient satisfaction and improve functional outcomes. Little is known about which anesthesia technique (general anesthesia versus brachial plexus blockade) is most beneficial for pain control after distal radius fixation which could significantly affect patients' postoperative course and experience. QUESTIONS/PURPOSES: We asked: (1) Did patients receiving general anesthesia or brachial plexus blockade have worse pain scores at 2, 12, and 24 hours after surgery? (2) Was there a difference in operative suite time between patients who had general anesthesia or brachial plexus blockade, and was there a difference in recovery room time? (3) Did patients receiving general anesthesia or brachial plexus blockade have higher narcotic use after surgery? (4) Do patients receiving general anesthesia or brachial plexus blockade have higher functional assessment scores after distal radius fracture repair at 6 weeks and 12 weeks after surgery? METHODS: A randomized controlled study was performed between February, 2013 and April, 2014 at a multicenter metropolitan tertiary-care referral center. Patients who presented with acute closed distal radius fractures (Orthopaedic Trauma Association 23A-C) were potentially eligible for inclusion. During the study period, 40 patients with closed, displaced, and unstable distal radius fractures were identified as meeting inclusion criteria and offered enrollment and randomization. Three patients (7.5%), all with concomitant injuries, declined to participate at the time of randomization as did one additional patient (2.5%) who chose not to participate, leaving a final sample of 36 participants. There were no dropouts after randomization, and analyses were performed according to an intention-to-treat model. Patients were randomly assigned to one of two groups, general anesthesia or brachial plexus blockade, and among the 36 patients included, 18 were randomized to each group. Medications administered in the postanesthesia care unit were recorded. Patients were discharged receiving oxycodone and acetaminophen 5/325 mg for pain control, and VAS forms were provided. Patients were called at predetermined intervals postoperatively (2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, and 72 hours) to gather pain scores, using the VAS, and to document the doses of analgesics consumed. In addition, patients had regular followups at 2 weeks, 6 weeks, and 12 weeks. Pain scores were again recorded using the VAS at these visits. RESULTS: Patients who received general anesthesia had worse pain scores at 2 hours postoperatively (general anesthesia 6.7 +/- 2.3 vs brachial plexus blockade 1.4 +/- 2.3; mean difference, 5.381; 95% CI, 3.850-6.913; p < 0.001); whereas reported pain was worse for patients who received a brachial plexus blockade at 12 hours (general anesthesia 3.8 +/- 1.9 vs brachial plexus blockade 6.3 +/- 2.4; mean difference, -2.535; 95% CI, -4.028 to -1.040; p = 0.002) and 24 hours (general anesthesia 3.8 +/- 2.2 vs brachial plexus blockade 5.3 +/- 2.5; mean difference, -1.492; 95% CI, -3.105 to 0.120; p = 0.031).There was no difference in operative suite time (general anesthesia 119 +/- 16 minutes vs brachial plexus blockade 125 +/- 23 minutes; p = 0.432), but time in the recovery room was greater for patients who received general anesthesia (284 +/- 137 minutes vs 197 +/- 90; p = 0.0398). Patients who received general anesthesia consumed more fentanyl (64 mug +/- 93 mug vs 6.9 mug +/- 14 mug; p < 0.001) and morphine (2.9 mug +/- 3.6 mug vs 0.0 mug; p < 0.001) than patients who received brachial plexus blockade. Functional outcome scores did not differ at 6 weeks (data, with mean and SD for both groups, and p value) or 12 weeks postoperatively (data, with mean and SD for both groups, and p value). CONCLUSIONS: Brachial plexus blockade pain control during the immediate perioperative period was not significantly different from that of general anesthesia in patients undergoing operative fixation of distal radius fractures. However, patients who received a brachial plexus blockade experienced an increase in pain between 12 to 24 hours after surgery. Acknowledging "rebound pain" after the use of regional anesthesia coupled with patient counseling regarding early narcotic administration may allow patients to have more effective postoperative pain control. It is important to have a conversation with patients preoperatively about what to expect regarding rebound pain, postoperative pain control, and to advise them about being aggressive with taking pain medication before the waning of regional anesthesia to keep one step ahead in their pain control management. LEVEL OF EVIDENCE: Level 1, therapeutic study.

Nonunion can occur relatively frequently after scaphoid fracture and appears to be associated with severity of injury. There have been a number of techniques described for bone grafting with or without screw fixation to facilitate fracture healing. However, even with operative fixation of scaphoid fractures with bone grafting nonunion or malunion rates of 5 to 10 percent are still reported. This is the first report of an anatomic locking plate for scaphoid fracture repair in a 25-year-old right hand dominant healthy male.

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: A 2-part biomechanical study was constructed to test the hypothesis that coronal morphology of the thumb metacarpophalangeal joint impacts the assessment of instability in the context of radial collateral ligament (RCL) injury. METHODS: Fourteen cadaveric thumbs were disarticulated at the carpometacarpal joint. Four observers measured the radius of curvature of the metacarpal (MC) heads. In a custom jig, a micrometer was used to measure the RCL length as each thumb was put through a flexion and/or extension arc under a 200 g ulnar deviation load. Strain was calculated at maximal hyperextension, 0 degrees , 15 degrees , 30 degrees , 45 degrees , and maximal flexion. Radial instability was measured with a goniometer under 45 N stress. The RCL was then divided and measurements were repeated. Analysis of variance and Pearson correlation metrics were used. RESULTS: The RCL strain notably increased from 0 degrees to 30 degrees and 45 degrees of flexion. With an intact RCL, the radial deviation was 15 degrees at 0 degrees of flexion, 18 degrees at 15 degrees , 17 degrees at 30 degrees , 16 degrees at 45 degrees , and 14 degrees at maximal flexion. With a divided RCL, instability was greatest at 30 degrees of flexion with 31 degrees of deviation. The mean radius of curvature of the MC head was 19 +/- 4 mm. Radial instability was inversely correlated with the radius of curvature to a considerable degree only in divided RCL specimens, and only at 0 degrees and 15 degrees of flexion. CONCLUSIONS: The RCL contributes most to the radial stability of the joint at flexion positions greater than 30 degrees . The results suggest that flatter MC heads contribute to stability when the RCL is ruptured and the joint is tested at 0 degrees to 15 degrees of metacarpophalangeal flexion. CLINICAL RELEVANCE: The thumb MC joint should be examined for RCL instability in at least 30 degrees of flexion.

Hand bites from domestic animals are extremely common.Though many may initially appear benign, it is importantfor treating physicians to be aware of the factors that placepatients sustaining animal bites at additional risk for infection.As clinicians, we must be able to efficiently diagnoseand treat these patients properly to avoid the morbiditythat animal bites can provoke. The current paper reviewsthe evaluation and management of domestic animal bitesto the hand.

PURPOSE: To determine the radial head arthroplasty length that best replicates the native radiocapitellar contact pressure. METHODS: Eight cadaveric elbows (4 matched pairs) with an average age of 73 years were tested. All specimens were ligamentously stable and without visible cartilage wear. Radiocapitellar contact pressures were digitally analyzed during simulated joint loading at 0 degrees , 45 degrees , and 90 degrees of elbow flexion and neutral rotation in the intact specimens and after ligament-preserving radial head arthroplasty at -2 mm, 0 mm, and +2 mm of the native length. The results were analyzed using 1-way analysis of variance and post hoc Tukey pairwise comparison tests. RESULTS: Paired analysis demonstrated significantly decreased mean contact pressures when comparing the native versus the minus 2 groups. Significantly decreased maximum contact pressures were also noted between the native and the minus 2 groups. Examining the mean contact pressures showed no significant difference between the native and the zero group and the native and the plus 2 groups. As for the maximum contact pressures, there was also no significant difference between the native and the zero group and the native and the plus 2 group. CONCLUSIONS: Up to 2 mm of overlengthening may be tolerated under simulated loading conditions without significantly increasing contact pressures of the radiocapitellar joint. Surgeons can use this knowledge along with radiographic parameters and intraoperative examination of elbow stability to gauge the appropriate size of the radial head implant to be used in order to decrease the risk of overstuffing the joint and minimizing radiocapitellar chondral wear. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.