Publications by authors named "Brandon E Earp"

103 Publications

Implicit and Explicit Factors That Influence Surgeons' Decision-Making for Distal Radius Fractures in Older Patients.

J Hand Surg Am 2022 Aug 2;47(8):719-726. Epub 2022 Jun 2.

Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston MA; Harvard Medical School, Boston, MA.

Purpose: The purpose of this study was to evaluate factors that influence surgeons' decision-making in the treatment of distal radius fractures in older patients.

Methods: Fourteen clinical vignettes of a 72-year-old patient with a distal radius fracture were sent to 185 orthopedic hand and/or trauma surgeons. The surgeons were surveyed regarding the demographic/practice details, treatment decision (surgical or nonsurgical), and factors that influenced management, including the Charlson Comorbidity Index, functional status, radiographic appearance, and handedness. Multivariable regression analyses were used to assess the effect of both surgeon-described (explicit) and given clinical (implicit) factors on the treatment decision and to evaluate for discrepancies.

Results: Sixty-six surgeons completed the survey, and 7 surgeons completed 10-13 vignettes. Surgeons made the explicit determination to pursue nonsurgical treatment based on the presence of comorbidities (odds ratio [OR], 0.02 for surgery; 95% confidence interval [CI], 0.01-0.05), but the observation of the underlying clinical data suggested that the recommendation for surgical treatment was instead based on a higher functional status (OR, 3.54/increase in functional status; 95% CI, 2.52-4.98). Those employed by hospitals/health systems were significantly less likely to recommend surgery than those in private practice (OR, 0.42; 95% CI, 0.23-0.79) CONCLUSIONS: This study demonstrates that the presence of comorbidities, functional status, and practice setting has a significant impact on a surgeon's decision to treat distal radius fractures in older patients. The discrepancy between the surgeon-described factors and underlying clinical data demonstrates cognitive bias.

Clinical Relevance: Surgeons should be aware of cognitive biases in clinical reasoning and should work through consequential patient decisions using an analytical framework that attempts to reconcile all available clinical data.
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http://dx.doi.org/10.1016/j.jhsa.2022.03.013DOI Listing
August 2022

Role of Pronator Quadratus Repair in Volar Locking Plate Treatment of Distal Radius Fractures.

J Am Acad Orthop Surg 2022 Aug 26;30(15):696-702. Epub 2022 Apr 26.

From the Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA (Zhang, Meyer, Earp, and Blazar), and Harvard Medical School, Boston, MA (Zhang, Meyer, Earp, and Blazar).

Distal radius fractures are the most common type of upper extremity fractures, and their incidence is increasing. There has been a rise in the surgical treatment of distal radius fractures, primarily with volar locking plate fixation. Although this procedure is commonly done among orthopaedic surgeons, the role of pronator quadratus repair after fixation remains controversial. The pronator quadratus serves as a secondary forearm pronator and a dynamic stabilizer of the distal radioulnar joint. Aside from a functional role, repair of the pronator quadratus has been proposed to serve as a biologic barrier between the volar locking plate and the flexor tendons to minimize tendon irritation. In this narrative review, we discuss the current treatment trends, the surgical approach for volar locking plate treatment of distal radius fractures, and the anatomy and function of the pronator quadratus. We discuss the case for and against the repair of the pronator quadratus, both for function and prevention of flexor tendon irritation and rupture. The preponderance of high-level evidence demonstrates no benefit to pronator quadratus repair for pain relief or function. The current evidence does not conclusively support or refute pronator quadratus repair as a biologic barrier from the flexor tendons.
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http://dx.doi.org/10.5435/JAAOS-D-22-00083DOI Listing
August 2022

Patient Preferences for Limited Fasciectomy Versus Collagenase Treatment for Dupuytren Contracture.

J Hand Surg Asian Pac Vol 2022 Apr 31;27(2):242-247. Epub 2022 Mar 31.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.

The primary objective of this study was to assess patient preferences for collagenase (CCH) treatment versus limited surgical fasciectomy in a cohort that has undergone both treatments for Dupuytren contracture. We retrospectively identified 68 patients who have undergone both limited surgical fasciectomy and CCH treatment for digital flexion contractures from Dupuytren disease. Patients were contacted by telephone and asked whether they preferred surgery or CCH treatment for their Dupuytren contracture. Multivariable logistic regression was used to determine factors associated with preference for surgery versus CCH treatment. Of the 68 patients who were treated with both CCH and surgery, 37 patients (54.4%) preferred CCH treatment over surgery, 26 (38.2%) preferred surgery over CCH treatment, and 5 (7.4%) were unable to decide. Patients expressed common themes of the perceived ease of recovery following CCH treatment versus the perceived durability of contracture correction with surgery. Preference for surgical fasciectomy over CCH treatment was associated with lower American Society of Anesthesiologists Physical Status Classification (ASA) [odds ratio (OR): 0.32, 95% confidence interval (CI): 0.14-0.75]. The order of treatment was also associated with the treatment preference; treatment with surgery after CCH compared to treatment with CCH after surgery was associated with a preference for surgery (OR: 6.51, 95% CI: 2.15-19.7). In a cohort of patients who have undergone both treatments, patients were divided in their preferences, with a slight majority preferring CCH treatment over surgery. Treatment recommendations should be individualised to each patient's long-term goals and expectations. Level III (Therapeutic).
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http://dx.doi.org/10.1142/S242483552250031XDOI Listing
April 2022

Patterns and Persistence of Perioperative Plasma and Cerebrospinal Fluid Neuroinflammatory Protein Biomarkers After Elective Orthopedic Surgery Using SOMAscan.

Anesth Analg 2022 Apr 7. Epub 2022 Apr 7.

From the Division of Interdisciplinary Medicine and Biotechnology.

Background: The neuroinflammatory response to surgery can be characterized by peripheral acute plasma protein changes in blood, but corresponding, persisting alterations in cerebrospinal fluid (CSF) proteins remain mostly unknown. Using the SOMAscan assay, we define acute and longer-term proteome changes associated with surgery in plasma and CSF. We hypothesized that biological pathways identified by these proteins would be in the categories of neuroinflammation and neuronal function and define neuroinflammatory proteome changes associated with surgery in older patients.

Methods: SOMAscan analyzed 1305 proteins in blood plasma (n = 14) and CSF (n = 15) samples from older patients enrolled in the Role of Inflammation after Surgery for Elders (RISE) study undergoing elective hip and knee replacement surgery with spinal anesthesia. Systems biology analysis identified biological pathways enriched among the surgery-associated differentially expressed proteins in plasma and CSF.

Results: Comparison of postoperative day 1 (POD1) to preoperative (PREOP) plasma protein levels identified 343 proteins with postsurgical changes (P < .05; absolute value of the fold change [|FC|] > 1.2). Comparing postoperative 1-month (PO1MO) plasma and CSF with PREOP identified 67 proteins in plasma and 79 proteins in CSF with altered levels (P < .05; |FC| > 1.2). In plasma, 21 proteins, primarily linked to immune response and inflammation, were similarly changed at POD1 and PO1MO. Comparison of plasma to CSF at PO1MO identified 8 shared proteins. Comparison of plasma at POD1 to CSF at PO1MO identified a larger number, 15 proteins in common, most of which are regulated by interleukin-6 (IL-6) or transforming growth factor beta-1 (TGFB1) and linked to the inflammatory response. Of the 79 CSF PO1MO-specific proteins, many are involved in neuronal function and neuroinflammation.

Conclusions: SOMAscan can characterize both short- and long-term surgery-induced protein alterations in plasma and CSF. Acute plasma protein changes at POD1 parallel changes in PO1MO CSF and suggest 15 potential biomarkers for longer-term neuroinflammation that warrant further investigation.
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http://dx.doi.org/10.1213/ANE.0000000000005991DOI Listing
April 2022

Factors Associated With Implant Removal Following Plate-and-Screw Fixation of Isolated Metacarpal Fractures.

J Hand Surg Am 2022 Mar 16. Epub 2022 Mar 16.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA. Electronic address:

Purpose: The incidence of and associated risk factors for implant removal following the plate-and-screw fixation of metacarpal shaft fractures have not been well described. The primary objective of our study was to identify implant-related radiographic parameters associated with implant removal in patients treated with the plate-and-screw fixation of isolated, displaced metacarpal fractures at 2 years of follow-up. The secondary objective of our study was to identify patient-related factors associated with implant removal.

Methods: A retrospective study of all patients who underwent open treatment of a metacarpal fracture with a plate-and-screw construct from January 1, 2000, to April 30, 2019, at 2 level-1 trauma centers was conducted. After the application of exclusion criteria, we identified 138 patients with a single isolated metacarpal fracture of a nonthumb digit treated with open reduction and internal fixation using a plate-and-screw construct. Our study endpoint was the removal of the plate-and-screw construct or a minimum of 2 years of follow-up without the removal of the hardware. Twenty-three patients achieved our study endpoint as determined using their electronic medical records, and 58 additional patients were reached via telephone to confirm their implant removal status. A bivariate analysis was used to screen for factors associated with implant removal, and variables significant in the bivariate screen were included in a multivariable stepwise logistic regression model.

Results: Twenty-three out of 81 patients (28%) in our final cohort underwent implant removal by the final follow-up visit. In the logistic regression analysis, the distance between the plate and metacarpophalangeal joint, the distance between the plate and carpometacarpal joint, and active smoking were independently associated with implant removal.

Conclusions: The proximity of metacarpal plates to adjacent joints is associated with subsequent implant removal. Patients may be counseled about the higher risk of implant removal when periarticular metacarpal plating is performed.

Type Of Study/level Of Evidence: Prognosis IV.
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http://dx.doi.org/10.1016/j.jhsa.2022.01.026DOI Listing
March 2022

Risk Factors for Implant Removal After Surgical Fixation of Midshaft Clavicle Fractures.

Orthopedics 2022 Jul-Aug;45(4):e201-e206. Epub 2022 Mar 4.

Midshaft clavicle fractures are common injuries that traditionally have been managed nonoperatively. However, recent literature has shown lower rates of nonunion and improved patient-reported outcomes with surgical management. The rate of implant removal after surgical fixation varies across the literature from 5% to 82%, depending on the method of fixation. We performed a retrospective review of all patients who underwent open reduction and internal fixation (ORIF) with plate-and-screw constructs for midshaft fractures of the clavicle at 2 level I trauma centers to determine the rate of implant removal and identify variables associated with implant removal. We collected all patient-, injury-, and treatment-specific factors as well as information on reoperation for removal of implants. Bivariate analysis and multivariable logistic regression analysis were used to assess whether explanatory factors were associated with removal of implants after ORIF for midshaft clavicle fractures. Of the 146 patients who were treated with ORIF for midshaft clavicle fractures with plate-and-screw constructs, 41 (28%) underwent removal of the implant. The median follow-up was 836 days (interquartile range, 457-1567 days). Variables associated with increased risk of implant removal included anterior plate position (odds ratio, 5.32; 95% CI, 2.01-14.1) and number of holes in the plate (odds ratio, 1.28; 95% CI, 1.00-1.63). These results question whether anterior plating results in less implant prominence and less subsequent removal of implants. [. 2022;45(4):e201-e206.].
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http://dx.doi.org/10.3928/01477447-20220225-10DOI Listing
July 2022

Gender Disparity Trends in Authorship of Hand Surgery Research.

J Hand Surg Am 2022 05 25;47(5):420-428. Epub 2022 Feb 25.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA. Electronic address:

Purpose: Despite an overall trend towards gender parity, women continue to remain underrepresented in surgical fields. Until recently, women's representation in hand surgery literature was largely unexplored. The objective of this study was to examine how authorship gender trends among academic hand surgeons have evolved between 2006 and 2019.

Methods: Original research articles published from 2006 to 2019 in 3 leading clinical hand surgery journals were extracted from PubMed. Publications with a full author first name were analyzed, and the gender of each author was assigned with the validated Genderize algorithm. Analyses were performed to evaluate authorship publication trends, unique authors, and research career productivity.

Results: From 2006 to 2019, 4,769 articles met the inclusion criteria, and the genders of 17,102 authors were identified. There were 2,848 (16.6%) female authors and 14,254 (83.4%) male authors. The proportion of female authors increased from 13.4% to 19.9% from 2006 to 2019. Similarly, female representation as first and senior authors increased significantly, from 10.9% to 20.1% and 7.6% to 14.2%, respectively. Of the 8,417 unique authors, 1,775 (21.1%) were women and 6,642 (78.9%) were men. Only 3.3% of these unique female authors published 5 or more papers during the study period. Among the 10 most frequently published authors for each gender, 18 of the 20 authors were surgeons.

Conclusions: There has been substantial progress toward gender parity in academic hand surgery over the last 14 years, and the proportion of women publishing in leadership positions has increased.

Clinical Relevance: Increased gender representation in medicine and research is important for both patients and providers, and these findings suggest that ongoing support and mentorship for women in academic careers should be a priority.
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http://dx.doi.org/10.1016/j.jhsa.2022.01.002DOI Listing
May 2022

Future Fracture Risk in Upper Extremity Fracture and Non-Fracture Patients.

Hand (N Y) 2022 Feb 26:15589447211049521. Epub 2022 Feb 26.

Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Background: Upper extremity (UE) fragility fractures are common and strong predictors of subsequent fractures. To investigate the relative importance of an UE fragility fracture in determining future fracture risk, we conducted a cross-sectional study to compare future fracture risk between patients presenting for osteoporosis evaluation after an UE fragility fracture and a similarly aged cohort of patients without an UE fracture.

Methods: In all, 129 UE fracture patients seen in our bone health clinic (BHC) and 114 non-fracture UE fracture patients seen in an UE clinic completed clinic intake surveys assessing for fracture risk factors. Prefracture fracture risk (PFFR) and fracture risk assessment tool (FRAX) scores estimated the future fracture risks at the timepoint before and after the UE fragility fracture event, respectively. The primary study outcome was the 10-year risk of future fracture.

Results: The 10-year probability of major osteoporotic and hip fractures were significantly higher among the BHC group when estimated with FRAX. When estimated with PFFR score, there was no difference in the 10-year probability of hip fracture between the groups. Prevalence of secondary osteoporosis and glucocorticoid use was higher in the BHC group, and prevalence of rheumatoid arthritis was higher in the UE clinic group.

Conclusions: This study underscores the importance of an UE fragility fracture in determining the risk of future fracture. A fragility fracture of the UE should be considered a sentinel event and physicians who evaluate these patients should recognize them as a high-risk group for future hip fracture.
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http://dx.doi.org/10.1177/15589447211049521DOI Listing
February 2022

SLAMF7 engagement superactivates macrophages in acute and chronic inflammation.

Sci Immunol 2022 02 11;7(68):eabf2846. Epub 2022 Feb 11.

Harvard Medical School, Boston, MA, USA.

Macrophages regulate protective immune responses to infectious microbes, but aberrant macrophage activation frequently drives pathological inflammation. To identify regulators of vigorous macrophage activation, we analyzed RNA-seq data from synovial macrophages and identified SLAMF7 as a receptor associated with a superactivated macrophage state in rheumatoid arthritis. We implicated IFN-γ as a key regulator of SLAMF7 expression and engaging SLAMF7 drove a strong wave of inflammatory cytokine expression. Induction of TNF-α after SLAMF7 engagement amplified inflammation through an autocrine signaling loop. We observed SLAMF7-induced gene programs not only in macrophages from rheumatoid arthritis patients but also in gut macrophages from patients with active Crohn's disease and in lung macrophages from patients with severe COVID-19. This suggests a central role for SLAMF7 in macrophage superactivation with broad implications in human disease pathology.
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http://dx.doi.org/10.1126/sciimmunol.abf2846DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8991457PMC
February 2022

The Environmental Impact of Open Versus Endoscopic Carpal Tunnel Release.

J Hand Surg Am 2022 Feb 2. Epub 2022 Feb 2.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.

Purpose: The environmental impact of common ambulatory hand surgeries has been an area of growing interest in recent years. There were 2 objectives of this study: (1) to quantify the carbon footprint of carpal tunnel surgery and its principal driving components; and (2) to compare the carbon footprints of open carpal tunnel release (oCTR) and endoscopic carpal tunnel release (eCTR).

Methods: We performed a life cycle assessment to quantify the environmental impacts of 2 surgical procedures: oCTR and eCTR. Patients were retrospectively identified by querying the Mass General Brigham institutional billing database. Fourteen oCTR procedures and 14 eCTR procedures in 28 patients were included in the life cycle assessment. The boundaries of the life cycle assessment were the start and end times of the procedures. The environmental impacts were estimated using the carbon footprint, expressed in the equivalent mass of carbon dioxide released into the atmosphere (kgCO-eq). The facility-related, processing-related, solid waste-related, and total kgCO-eq were calculated.

Results: The average carbon footprint of carpal tunnel release was 83.1 kgCO-eq and was dominated by processing-related and facilities-related factors. The average carbon footprint of eCTR (106.5 kgCO-eq) was significantly greater than that of oCTR (59.6 kgCO-eq).

Conclusions: Endoscopic carpal tunnel release leaves a greater carbon footprint than oCTR, and its environmental impact is dominated by facility-related and central processing-related factors.

Type Of Study/level Of Evidence: Economic and Decision Analyses IV.
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http://dx.doi.org/10.1016/j.jhsa.2021.12.003DOI Listing
February 2022

Factors Associated With Severity of Cubital Tunnel Syndrome at Presentation.

Hand (N Y) 2021 Dec 7:15589447211058821. Epub 2021 Dec 7.

Brigham and Women's Hospital, Boston, MA, USA.

Background: The outcomes of cubital tunnel syndrome surgery are affected by preoperative disease severity. The aim of this study was to identify factors associated with clinical and electrodiagnostic severity of cubital tunnel syndrome at presentation.

Methods: We retrospectively identified 213 patients with electrodiagnostically confirmed cubital tunnel syndrome who underwent cubital tunnel surgery from July 2008 to June 2013. Our primary response variable was clinical cubital tunnel syndrome severity assessed by the McGowan grade. Our secondary response variables were sensory nerve action potential (SNAP) recordability, presence of fibrillations, and motor nerve conduction velocities (CVs) in the abductor digiti minimi (ADM) and first dorsal interosseous (FDI). Bivariate analysis was used to screen for factors associated with disease severity; significant variables were selected for multivariable regression analysis.

Results: Older age was associated with higher McGowan grade and diabetes mellitus was associated with unrecordable SNAPs on bivariate analysis. No other variables met inclusion criteria for multivariable regression analysis for McGowan grade or unrecordable SNAPs. Multivariable regression analysis showed older age and higher Distressed Communities Index (DCI) to be associated with decreased motor nerve CVs in ADM. Multivariable regression analysis showed higher body mass index (BMI) and higher DCI to be associated with decreased motor nerve CVs in FDI. No variable was associated with the presence of fibrillations.

Conclusions: A subset of patients with cubital tunnel syndrome may benefit from earlier referral for hand surgery evaluation and earlier surgery. Older patients, with higher BMI, with diabetes mellitus, and with economic distress are at higher risk for presentation with more severe disease.
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http://dx.doi.org/10.1177/15589447211058821DOI Listing
December 2021

Subspecialty Variation in Academic Citations of Orthopedic Surgery Publications.

Clin Orthop Surg 2021 Dec 15;13(4):569-574. Epub 2021 Nov 15.

Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.

Background: The objective of this study was to assess the variation in academic citation and social media mentions across orthopedic subspecialties in general orthopedic surgery journals.

Methods: An internet-based study was performed of 666 articles from four orthopedic journals published from January 2018 to February 2019. Each publication was categorized by its subspecialty within orthopedics: arthroplasty, hand and upper extremity, foot and ankle, orthopedic oncology, pediatric orthopedics, shoulder, spine, sports medicine, orthopedic trauma, basic science, and miscellaneous. For each publication, academic citations were quantified using Google Scholar and Web of Science, and social media mentions were quantified using Twitter. Comparisons of continuous data among various subspecialties were performed using analysis of variance.

Results: The average number of citations per publication was 7.4 ± 9.0 on Google Scholar, 4.5 ± 5.3 on Web of Science, and 2.8 ± 8.7 on Twitter. The number of academic citations differed significantly by subspecialty on Google Scholar ( < 0.001) and Web of Science ( < 0.001). There was no difference in social media mentions on Twitter by subspecialty ( = 0.8). The most highly cited subspecialties, adjusted for number of publications, were arthroplasty, orthopedic oncology, and sports medicine, while the least highly cited subspecialties were hand and upper extremity, pediatric orthopedics, and orthopedic basic science.

Conclusions: There is significant baseline variation in the citation of orthopedic publications among various subspecialties. Our findings argue against the use of a uniform threshold to gauge scholarly success in orthopedic surgery. The variation in citation of orthopedic publications across subspecialties support the use of subspecialty-specific benchmarks to gauge academic productivity.
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http://dx.doi.org/10.4055/cios20263DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8609223PMC
December 2021

The Impact of Coronavirus Disease 2019 Restrictions on an Academic Hand Surgery Practice.

J Hand Surg Glob Online 2022 Mar 15;4(2):84-88. Epub 2021 Nov 15.

Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA.

Purpose: The impact of the severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019) has been felt worldwide. We examined the quantitative impact during the first 4 weeks of hospital system and state-mandated restrictions on an academic, urban hand surgery practice. We hypothesized that the volume of clinic encounters, office procedures, and surgical cases would decrease and that the volume of nonelective care would remain unchanged.

Methods: We retrospectively reviewed all encounters at a hand surgery practice from March 16, 2020, through April 12, 2020 and compared those to two 4-week control time periods. Weekly encounter volumes and work relative value units (RVUs) were obtained for clinic encounters, office procedures, and surgical cases. The type of ambulatory visit was also identified. Surgical cases were categorized into 4 types (fracture or dislocation, acute soft tissue or nerve injury, infection, or elective/nonurgent) for the most recent time periods. We performed  tests to compare weekly volumes and RVUs between time periods.

Results: After the implementation of mandated restrictions on elective health care, ambulatory hand surgery clinic encounters decreased 72% to 73%, clinic procedures decreased by 87% to 90%, and surgical cases decreased by 87% to 88%. The percentage of ambulatory visits performed via telemedicine increased from 0.06% to 74%. Similar impacts on RVUs were seen. Surgeries for fractures and dislocations declined by 58% and those for acute soft tissue or nerve injury declined by 40%; the number of surgical procedures for infection remained unchanged.

Conclusions: The coronavirus restrictions on elective healthcare led to an immediate, substantial impact on hand surgery practice. There were significant decreases in the volumes of ambulatory encounters, office procedures, and surgical cases. The long-term financial impact of this change in practice is still to be determined but, based on the quantitative impacts seen, is likely to be significant.

Type Of Study/level Of Evidence: Economic/Decision Analysis IV.
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http://dx.doi.org/10.1016/j.jhsg.2021.10.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8590933PMC
March 2022

Dupuytren's Contracture: The Readability of Online Information.

J Patient Exp 2021 27;8:23743735211056431. Epub 2021 Oct 27.

Harvard Medical School, Boston, MA, USA.

Dupuytren's contracture is a common hand pathology for which consultation and treatment are largely at the patient's discretion. The objective of this study was to evaluate the readability of current online patient information regarding Dupuytren's contracture. The largest public search engines (Google, Yahoo, and Bing) were queried using the search terms "Dupuytren's contracture," "Dupuytren's disease," "Viking's disease," and "bent finger." The first 30 unique websites by each search were analyzed and readability assessed using five established algorithms: Flesch Reading Ease, Gunning-Fog Index, Flesch-Kincaid Grade level, Coleman-Liau index, and Simple Measure of Gobbledygook grade level. Analysis of 73 websites demonstrated an average Flesch Reading Ease score of 48.6 ± 8.0, which corresponds to college reading level. The readability of websites ranged from 10.5 to 13.3 reading grade level. No article was written at or below the recommended sixth grade reading level. Information on the internet on Dupuytren's contracture is written at higher than recommended reading grade level. There is a need for high-quality patient information on Dupuytren's contracture at appropriate reading grade levels for patients of various health literacy backgrounds. Hospitals, universities, and academic organizations focused on the development of readable online information should consider patients' input and preferences.
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http://dx.doi.org/10.1177/23743735211056431DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8554572PMC
October 2021

Association of Economic Well-Being With Comorbid Conditions in Patients Undergoing Carpal Tunnel Release.

J Hand Surg Am 2021 Oct 26. Epub 2021 Oct 26.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.

Purpose: Medical comorbidities have been associated with the development of carpal tunnel syndrome (CTS), severity at the time of presentation, and outcomes of carpal tunnel release (CTR). Socioeconomic factors have also been associated with worse function in patients with CTS at presentation and after surgery. However, the effects of economic well-being on the prevalence of medical comorbidities in patients with CTS have not been well-described. The objective of this study was to determine whether economic well-being is associated with medical comorbidities in a cohort of patients undergoing CTR.

Methods: Patients (n = 1,297) who underwent CTR at a single tertiary care referral center over a 5-year period from July 2008 to June 2013 were retrospectively identified. The exclusion criteria were acute trauma or infection, revision surgery, incomplete medical records, and neoplasm excision. Additionally, patients were excluded if they lacked documented confirmatory or normal electrodiagnostic study findings prior to CTR. Finally, this study comprised a cohort of 892 patients with electrodiagnostic study-confirmed CTS who underwent CTR. The economic well-being of patients was assessed using the Distressed Communities Index. The comorbidities of diabetes mellitus, chronic kidney disease, hypertension, hypothyroidism, cervical radiculopathy, tobacco use, and body mass index were assessed. Bivariate comparisons were used to determine the associations between the tiers of economic well-being and comorbidities.

Results: Lower economic well-being was associated with body mass index, diabetes mellitus, chronic kidney disease, and tobacco use in these patients. Although hypertension, hypothyroidism, and cervical radiculopathy were not associated with economic well-being, their comparisons were underpowered.

Conclusions: Patients experiencing economic distress have a higher comorbidity burden, and as such, may be at an increased risk of complications or poorer outcomes. The association between economic well-being and comorbidities in this population suggests the need for a multidisciplinary care model that addresses both compressive neuropathy and the associated economic factors.

Type Of Study/level Of Evidence: Prognostic II.
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http://dx.doi.org/10.1016/j.jhsa.2021.09.012DOI Listing
October 2021

Shoulder Arthrodesis versus Upper Trapezius Transfer for Traumatic Brachial Plexus Injury: A Proportional Meta-Analysis.

Adv Orthop 2021 13;2021:4445498. Epub 2021 Oct 13.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, 15 Francis St, Boston, MA 02115, USA.

Shoulder arthrodesis and upper trapezius transfer are two surgical options for secondary shoulder reconstruction for traumatic brachial plexus injury (BPI). There is a lack of comparative evidence to guide the choice for one procedure over the other. The objectives of this study were to compare (1) rates of complications and reoperation and (2) shoulder range of motion and functional outcome scores following shoulder arthrodesis versus upper trapezius transfer for traumatic BPI. A systematic review and meta-analysis were conducted by a search of four databases of studies assessing shoulder arthrodesis and/or upper trapezius transfer for shoulder reconstruction following adult traumatic BPI. A proportional meta-analysis was performed using a random effects model in anticipation of unobserved heterogeneity. The final meta-analysis included 374 patients from 17 studies, including 232 patients from 11 studies on shoulder arthrodesis and 142 patients from 6 studies on upper trapezius transfer. Shoulder arthrodesis had higher rates of complications and reoperations than upper trapezius transfer for traumatic BPI, but these differences did not reach a statistical significance. Due to the limited sample size, variations in reporting, and study heterogeneity in the published literature, we were not able to draw conclusions regarding shoulder range of motion and functional outcome scores between these two procedures. Shoulder arthrodesis and upper trapezius transfer are both viable options for secondary shoulder reconstruction for traumatic BPI, but with different complications and reoperation profiles. Patients should be counseled on the risk of nonunion and humerus fracture following shoulder arthrodesis.
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http://dx.doi.org/10.1155/2021/4445498DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8528632PMC
October 2021

Longitudinal Changes in Serum Markers of Bone Metabolism and Bone Material Strength in Premenopausal Women with Distal Radial Fracture.

J Bone Joint Surg Am 2022 01;104(1):15-23

Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Background: Markers of bone metabolism (MBM) play an important role in fracture evaluation, and changes have been associated with increased fracture risk. The purpose of the present study was to describe changes in MBM in premenopausal women with distal radial fractures.

Methods: Premenopausal women with distal radial fractures (n = 34) and without fractures (controls) (n = 39) were recruited. Serum MBM in patients with distal radial fractures were obtained at the time of the initial presentation, 6 weeks, and 3, 6, and 12 months. MBM included 25(OH) vitamin D, PTH, osteocalcin, P1NP, BSAP, CTX, sclerostin, DKK1, periostin, and TRAP5b. Areal bone mineral density (aBMD) was assessed with dual x-ray absorptiometry, and the bone material strength index (BMSi) was assessed with microindentation.

Results: Most MBM reached peak levels at 6 weeks after the injury, including osteocalcin (+17.7%), sclerostin (+23.5%), and DKK1 (12.6%). Sclerostin was lower (-27.4%) and DKK1 was higher (+22.2%) at 1 year after the fracture. CTX declined below baseline levels at 6 and 12 months, whereas TRAP5b, BSAP, and periostin did not significantly change. At 12 months, sclerostin was lower (p = 0.003) and DKK1 was higher (p = 0.03) in the distal radial fracture group than in the control group. Greater fracture severity was associated with greater increases in P1NP and BSAP. aBMD and BMSi were not associated with fracture.

Conclusions: Distal radial fractures caused increases in several MBM, which typically peaked at 6 weeks after injury and gradually decreased over 6 months. Sclerostin and DKK1 remained below and above baseline at 1 year, respectively. Increasing fracture severity resulted in larger changes in MBM. aBMD and BMSi did not discriminate between patients with distal radial fractures and controls. Continued efforts to identify markers of skeletal fragility in young women are warranted to mitigate future fracture risk.

Level Of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.21.00540DOI Listing
January 2022

Acute Radial Head Resection for Fracture: are We Likely to Miss an Essex-Lopresti Injury?

Ortop Traumatol Rehabil 2021 Aug;23(4):263-270

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, USA.

Background: Given the current available evidence, surgical treatment of radial head fracture with acute resection is controversial. The aim of this study was to determine whether acute resection of the radial head for a radial head fracture leads to longitudinal forearm instability due to a missed Essex-Lopresti injury.

Material And Methods: A retrospective review was conducted of radial head resections performed for acute radial head fractures at two Level I trauma centers from 2000 to 2018. A total of 11 patients met inclusion criteria. Our primary outcome was a missed Essex-Lopresti injury at time of final clinical follow-up. Long-term telephone follow-up was attempted for QuickDASH, pain scores, and satisfaction scores.

Results: Of the 11 radial head fractures in this study, intraoperative radial pull tests were performed and normal in 6 patients. No patient was found to have a missed Essex-Lopresti injury at a mean of 36.2 months' clinical follow-up after radial head resection. At a mean telephone follow-up of 12.6 years in available patients, mean QuickDASH was 3.4, mean satisfaction was 9.75 out of 10, and no further complication or reoperation was reported.

Conclusion: Our findings challenge the dogma that the radial head cannot be safely excised in the setting of acute fracture, even with elbow instability and/or wrist pain, particularly when intraoperative longitudinal stability is assessed by a stress maneuver.
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http://dx.doi.org/10.5604/01.3001.0015.2363DOI Listing
August 2021

The Impact of the Soong Index on Hardware Removal and Overall Reoperation Rates After Volar Locking Plate Fixation of Distal Radius Fractures.

J Hand Surg Am 2022 06 4;47(6):584.e1-584.e9. Epub 2021 Sep 4.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA. Electronic address:

Purpose: This study sought to determine the impact of volar plate prominence on reoperation rates after open reduction and internal fixation of distal radius fractures with volar locking plates and to identify other factors associated with removal of hardware (ROH) or a reoperation.

Methods: A retrospective study of patients who underwent distal radius open reduction and internal fixation between 2012 and 2016 at 2 level I trauma centers was conducted. Plate prominence was evaluated using the Soong index at the first postoperative visit. The details of patient demographics, fracture and plate characteristics, complications, and reoperations were recorded. Bivariate and multivariable regression analyses were used to identify factors associated with increased rates of ROH and overall reoperation.

Results: A total of 732 (70.2%) of 1,042 patients completed follow-up at an average of 38.2 months, including 34 patients with bilateral operations, yielding 766 distal radius fractures. One hundred sixteen (15.1%) patients underwent reoperation at an average of 12.1 ± 13.6 months after the index surgery. Removal of hardware was the most commonly performed reoperation (77 patients, 10%). The multivariable regression analysis revealed significantly higher rates of ROH in Soong grade 1 or 2 patients (odds ratio 16, 95% CI 5.8-47; odds ratio 44, 95% CI 14-140, respectively) than in Soong grade 0 patients. Plate type, younger age, bilateral injuries, and concomitant procedures at the time of the index operation were all associated with increased risk of ROH. There were significant differences between individual surgeons the in rates of ROH (range 2.1%-22%) and overall reoperation (range 5.2%-36%). Compared with other hand surgeons, fellowship-trained hand surgeons had lower rates of ROH (8% vs 14%, respectively) and overall reoperation (12% vs 22%, respectively).

Conclusions: The rates of ROH and overall reoperation increase with increasing Soong grade. Plate type is independently predictive of future ROH. Older patients and those undergoing open reduction and internal fixation experience lower rates of subsequent reoperation.

Type Of Study/level Of Evidence: Prognostic IV.
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http://dx.doi.org/10.1016/j.jhsa.2021.06.021DOI Listing
June 2022

Skin Tenting in Displaced Midshaft Clavicle Fractures.

Arch Bone Jt Surg 2021 Jul;9(4):418-422

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.

Background: The objectives of this study were to (1) identify factors associated with skin tenting in displaced midshaft clavicle fractures and (2) analyze individual surgeon variation in this diagnosis.

Methods: A retrospective cohort study was performed at two Level I trauma centers of 396 patients with displaced midshaft clavicle fractures treated by 47 surgeons with open reduction internal fixation from January 2010 to March 2019. Our main outcome measure was skin tenting, as diagnosed by the treating surgeon and used as an indication for surgical treatment.

Results: Skin tenting was diagnosed by the treating surgeon in 34 out of 396 patients (9%) with displaced midshaft clavicle fractures. Multivariable logistic regression analyses showed that lower BMI () and fracture shortening () were independently associated with skin tenting in displaced midshaft clavicle fractures. There was wide variation among surgeons in the rate of diagnosis of skin tenting, ranging from 0% to 41% prevalence of skin tenting depending on the treating surgeon ().

Conclusion: Although lower BMI and greater fracture shortening were associated with skin tenting, the diagnosis is subjective. We found wide variation in the diagnosis of skin tenting, even among surgeons within a single metropolitan area.
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http://dx.doi.org/10.22038/abjs.2020.45004.2230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8359666PMC
July 2021

Minimum 2-year outcomes of reverse total shoulder arthroplasty for fracture: how does acute arthroplasty compare with salvage?

J Shoulder Elbow Surg 2022 Feb 5;31(2):252-260. Epub 2021 Aug 5.

Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.

Background: The objective of our study was to compare patient-reported outcome measures, range of motion (ROM), complication rates, and reoperation rates after reverse total shoulder arthroplasty (rTSA) for proximal humeral fractures between patients treated acutely (≤30 days after injury), those treated after initial nonoperative treatment (>30 days after injury), and those treated after failed open reduction-internal fixation. Secondarily, we aimed to identify any patient-, injury-, or surgery-related factors independently associated with our response variables.

Methods: We identified 576 patients who sustained a proximal humeral fracture treated with primary or revision shoulder arthroplasty between January 2003 and August 2018. The final cohort included 153 patients. Multivariable analysis was used to assess whether explanatory variables were associated with our response variables.

Results: Initial nonoperative treatment compared with acute rTSA was associated with worse Shoulder Subjective Value (P = .04), Shoulder Pain and Disability Index score (P = .03), and Shoulder Pain and Disability Index disability subscale score (P = .03). Only depression was independently associated with worse visual analog scale pain score (P = .04). There was no significant difference in postoperative ROM between the initial treatment groups. Older age was associated with decreased ROM in all planes. Additionally, ipsilateral upper-extremity injury was associated with decreased active abduction (P = .03), and cemented humeral stems were associated with decreased passive abduction (P = .03). Initial nonoperative treatment was associated with increased complication rates (odds ratio, 3.65; 95% confidence interval, 1.11-12.01), and male sex was associated with higher rates of reoperation (odds ratio, 3.53; 95% confidence interval, 1.31-9.51).

Conclusions: Patients who undergo initial periods of nonoperative management have worse functional outcomes and higher complication rates than those who undergo acute rTSA for proximal humeral fractures. Patients who undergo rTSA after failed open reduction-internal fixation show no difference in patient-reported outcomes compared with those who undergo acute rTSA. In addition, male patients are at higher risk of reoperation, whereas older patients are at risk of decreased ROM. Patients with preoperative depression are at risk of increased pain at 2 years after surgery.
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http://dx.doi.org/10.1016/j.jse.2021.06.020DOI Listing
February 2022

Factors Associated With Surgical Treatment of Isolated, Displaced Midshaft Clavicle Fractures.

Orthopedics 2021 Jul-Aug;44(4):e515-e520. Epub 2021 Jul 1.

Given the current available evidence, surgical treatment of isolated, displaced midshaft clavicle fractures is discretionary. The aim of this study was to determine whether there are identifiable factors associated with the surgical treatment of isolated, displaced midshaft clavicle fractures. A retrospective cohort study of 150 patients who underwent nonoperative treatment and 290 patients who underwent surgical treatment of isolated, displaced midshaft clavicle fractures from January 2010 to March 2019 at 2 level I trauma centers was performed. Multivariable regression analysis demonstrated that younger age (odds ratio [OR], 0.97; 95% CI, 0.95-0.99), absence of diabetes mellitus (OR, 0.045; 95% CI, 0.003-0.79), nonsmoking status (OR, 0.31; 95% CI, 0.13-0.75), higher American Society of Anesthesiologists classification (OR, 5.0; 95% CI, 2.7-9.2), fracture comminution (OR, 2.3; 95% CI, 1.3-3.9), and fracture displacement (OR, 1.1; 95% CI, 1.0-1.1) were associated with surgical treatment of an isolated, displaced midshaft clavicle fracture. Furthermore, lower social deprivation (OR, 0.99; 95% CI, 0.97-0.99) and private insurance compared with Medicare (OR, 6.6; 95% CI, 1.6-27) were associated with surgical treatment. The authors conclude that surgical treatment of discretionary midshaft clavicle fractures is influenced by patient factors, fracture characteristics, and socioeconomic factors. Further study is needed to understand the etiology of social disparities in clavicle surgery and rectify unintended trends in treatment. [. 2021;44(4):e515-e520.].
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http://dx.doi.org/10.3928/01477447-20210618-10DOI Listing
October 2021

Limited Fasciectomy Versus Collagenase Clostridium histolyticum for Dupuytren Contracture: A Propensity Score Matched Study of Single Digit Treatment With Minimum 5 Years of Telephone Follow-Up.

J Hand Surg Am 2021 10 16;46(10):888-895. Epub 2021 Jul 16.

Harvard Medical School, Boston, MA; Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA. Electronic address:

Purpose: The purpose of this study was to compare reintervention and perceived recurrence, with minimum 5 years of telephone follow-up, after limited fasciectomy or collagenase Clostridium histolyticum (CCH) in the treatment of Dupuytren contracture affecting a single digit.

Methods: We performed a retrospective cohort study of 48 patients with single digit treatment who underwent limited surgical fasciectomy at one hospital and 111 patients who underwent CCH treatment at a second hospital from 2010 to 2013. Patients were contacted by telephone about reintervention and perceived recurrence. Average length of telephone follow-up was 7.3 years in the CCH group and 7.4 years in the surgery group. The 2 groups were compared using 2 methods to control for potential confounding bias: (1) propensity score matching and (2) multivariable analysis accounting for potential confounders.

Results: After propensity score matching, there were 44 patients in each group with similar disease and demographic characteristics. Rates of reintervention and perceived recurrence were significantly higher in the CCH group than the surgery group at a minimum of 5 years following treatment.

Conclusions: Long-term overall reintervention and perceived recurrence following treatment of Dupuytren contracture affecting a single digit were higher with CCH treatment than surgical fasciectomy when comparing groups with similar baseline characteristics. Our findings may be used to counsel patients on the durability of the outcomes of treatment when considering treatment options for Dupuytren contractures.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2021.05.022DOI Listing
October 2021

Three-Dimensional Printing in Hand Surgery.

J Hand Surg Am 2021 11 15;46(11):1016-1022. Epub 2021 Jul 15.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.

The medical application of 3-dimensional printing technology has evolved in the last decade, with an increasing variety of uses in hand surgery. The ability for patient-specific design, rapid prototyping, and low cost of production of 3-dimensional printed materials has led to this rise in clinical applications, both for common procedures and complex reconstructions. Within hand surgery, 3-dimensional printing can be applied in several broad categories: to construct patient-specific models for preoperative planning, to design orthotics and prosthetics to meet specific patient demands, to create patient-specific aids for intraoperative use, to generate patient-specific hardware and prostheses for implantation, and for applications for trainee education.
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http://dx.doi.org/10.1016/j.jhsa.2021.05.028DOI Listing
November 2021

Patient Perception and Preferences for Virtual Telemedicine Visits for Hand and Upper Extremity Surgery.

Telemed J E Health 2022 04 12;28(4):509-516. Epub 2021 Jul 12.

Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Telemedicine in upper extremity surgery is an evolving modality that provides a viable alternative to the traditional in-person visit for achieving convenient, safe, and cost-effective health care. Our study aimed to identify patient preferences for virtual visits for hand and upper extremity surgery. An institutional review board approved survey was prospectively administered to all patients >18 years of age, presenting for any complaint to an orthopedic hand and upper extremity clinic at a Level I academic trauma center from September to December 2019. This survey included questions about access and literacy of technology as well as patient preferences regarding virtual visits. The medical record was reviewed to collect demographics, insurance type, and reasons for their visit. Bivariate and multivariate analyses were performed according to survey responses. Two hundred consecutive patients () completed surveys. Surveys revealed that >88% of patients own a computer or smartphone, have WiFi access at home, and own a device capable of video chat. In total, 75% of patients reported that they would be moderately or highly comfortable in their ability to use a device for a virtual visit. In bivariate and multivariate analyses, technological literacy and access to a private space to conduct a visit were associated with high interest in virtual visits. Telemedicine is a viable alternative to in-person patient visits. Our study demonstrates that most patients are willing and able to participate in a virtual visit for a hand or upper extremity issue.
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http://dx.doi.org/10.1089/tmj.2021.0146DOI Listing
April 2022

Correlation and responsiveness of global health, upper extremity-specific, and shoulder-specific functional outcome measures following reverse total shoulder arthroplasty for proximal humerus fracture.

BMC Musculoskelet Disord 2021 Jun 23;22(1):574. Epub 2021 Jun 23.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, 55 Fruit Street, MA, 02115, Boston, USA.

Purpose: Reverse total shoulder arthroplasty (rTSA) is effective and increasingly utilized for the management of proximal humerus fracture (PHF). However, the optimal patient-reported outcome metrics (PROMs) for the evaluation of patient outcomes after this surgery are unclear. We investigated the correlation among global, upper extremity-specific, and shoulder-specific PROMs in patients undergoing rTSA for PHF as well as the responsiveness of these PROMs as assessed by floor and ceiling effects. We hypothesized that patients' post-operative outcome would be best reflected by a combination of these metrics.

Methods: Thirty patients with a history of rTSA for ipsilateral PHF filled out the following outcomes questionnaires at a minimum of 3 years post-op: EQ-5D, EQ-5D VAS, PROMIS physical function, DASH, SSV, SPADI, and ASES. Correlation between metrics was assessed using the Spearman correlation coefficient. Responsiveness was assessed by comparing the proportion of patients reaching floor or ceiling values using McNemar's test.

Results: Global health metrics (EQ-5D and PROMIS physical function) were strongly correlated with the upper extremity-specific metric (DASH). Shoulder-specific outcomes (SPADI, ASES, and ASES) were moderately correlated with both the global metrics and DASH. There was no significant difference between PROMs with regards to floor and ceiling effects.

Conclusions: The DASH score has been shown to be valid and responsive for shoulder interventions, and our data demonstrate that it correlates strongly with overall quality of life. Shoulder-specific metrics are valid and responsive for shoulder interventions but correlate less with global quality of life. An optimal PROM strategy in rTSA for PHF might involve both DASH and a shoulder-specific score. Based on our assessment of floor and ceiling effects, none of these metrics should be excluded for poor responsiveness.
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http://dx.doi.org/10.1186/s12891-021-04450-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8223380PMC
June 2021

Pronator Quadratus Repair Does Not Affect Reoperation Rates Following Volar Locking Plate Fixation of Distal Radius Fractures.

Hand (N Y) 2021 Jun 9:15589447211017239. Epub 2021 Jun 9.

Brigham and Women's Hospital, Boston, MA, USA.

Background: The purpose of this study was to evaluate the impact of pronator quadratus (PQ) repair on reoperation rates after distal radius open reduction internal fixation (ORIF) using a volar locking plate.

Methods: A retrospective study of all patients undergoing distal radius ORIF with a volar locking plate between January 2012 and December 2016 at 2 urban, academic level I trauma centers was performed. Patient demographics, fracture and procedure characteristics, surgeon subspecialty, PQ repair, and reoperations were recorded. Descriptive statistics were used to determine whether patient-related or injury-related characteristics were associated with PQ repair. Bivariate and multivariable regression analyses were used to assess the effect of PQ repair on subsequent reoperations.

Results: In total, 509 patients were included, including 31 patients with bilateral injuries. The average follow-up time was 3.7 ± 2.8 years. Patients undergoing PQ repair were younger (57 ± 17 years vs 61 ± 17 years) and were more likely to have a lower Soong grade (53% vs 44% with Soong grade 0) than patients without PQ repair. Pronator quadratus repair was not found to have a significant impact on hardware removal, reoperations for flexor tendon pathology, or overall reoperations.

Conclusions: Pronator quadratus repair was more commonly performed in younger patients and in patients with a lower Soong grade. Hand-subspecialized surgeons are more likely to pursue PQ repair than trauma-subspecialized surgeons. This study did not detect statistically significant differences in hardware removal, flexor tendon pathology, or overall reoperations between groups.
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http://dx.doi.org/10.1177/15589447211017239DOI Listing
June 2021

Clavicle Fractures With Associated Acute Neurovascular Injury.

Orthopedics 2021 May-Jun;44(3):e390-e394. Epub 2021 May 1.

Descriptions of acute neurovascular injury after clavicle fracture are limited to case reports. The objectives of this study were to assess both the prevalence of acute neurovascular injury after midshaft clavicle fracture and the outcomes of early fracture stabilization. A retrospective chart review was conducted of all adult patients with midshaft clavicle fracture who were treated surgically at 2 tertiary care referral centers from January 2010 to March 2019. The records of patients who were identified as having clinical or radiographic evidence of neurovascular compromise were reviewed to assess for deficits on physical examination on presentation, relevant radiographic and electro-diagnostic findings, timing and type of fixation, and time until resolution of symptoms and radiographic union postoperatively. Of the 443 adult patients undergoing surgical treatment for displaced midshaft clavicle fracture, 3 (1%) experienced acute neurovascular compromise and underwent early fixation. In all cases, fracture displacement caused compression of adjacent neurovascular structures in the costoclavicular space. No lacerations of underlying neurovascular structures were encountered intraoperatively, suggesting a pattern of nerve contusion or vascular compression from the initial injury and fracture displacement. Postoperatively, 2 patients had full recovery of preoperative neurologic deficits and 1 patient experienced partial recovery of motor deficits with persistent neuropathic pain. There were no instances of symptomatic vascular insufficiency at final follow-up. Acute neurovascular injury as a result of compression of underlying structures in the costoclavicular space is a rare complication of displaced midshaft clavicle fracture. Early surgical decompression of compressed neurovascular structures and rigid clavicle osteosynthesis can lead to significant postoperative functional improvement. [. 2021;44(3):e390-e394.].
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http://dx.doi.org/10.3928/01477447-20210414-11DOI Listing
July 2021

The Efficacy of Orthopedic Telemedicine Encounters During the COVID-19 Crisis.

Orthopedics 2021 Mar-Apr;44(2):e211-e214. Epub 2021 Mar 1.

Telemedicine technology was rapidly and widely adopted during the early phase of the coronavirus disease 2019 (COVID-19) response, and its efficacy in orthopedic surgery is still undetermined. The objective of this study was to determine the efficacy of new patient orthopedic surgery ambulatory encounters performed using telemedicine during the early phase of the COVID-19 crisis. Failure of the telemedicine encounter was assessed in this study by 2 separate criteria: (1) an unplanned visit to the emergency department (ED) within 6 weeks of the telemedicine encounter and (2) a planned subsequent in-person encounter for inability to formulate a complete diagnosis virtually. The authors retrospectively identified all new patient orthopedic surgery ambulatory encounters performed using telemedicine in the orthopedic surgery department of an academic tertiary care center during the first 6 weeks of the COVID-19 response, from March 16, 2020, to April 26, 2020. The study cohort included 298 new patients treated by 41 providers. The mean age of the 298 patients was 48 years, and 59% were women. Two hundred encounters were performed with video, and 98 were performed with telephone only. Three (1%) patients presented to the ED within 6 weeks of their new patient telemedicine encounter, and 8 (3%) patients presented for a planned in-person encounter. The authors concluded that new patient orthopedic surgery ambulatory encounters performed using telemedicine were able to effectively direct patients to a variety of treatments and dispositions, with a low rate of unplanned presentation to the ED or need for supplementary in-person assessment. [. 2021;44(2):e211-e214.].
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http://dx.doi.org/10.3928/01477447-20210216-01DOI Listing
June 2021

Long-Term Outcomes and Mortality Following Carpal Tunnel Release in Patients Older Than 80 Years of Age.

World Neurosurg 2021 07 21;151:e1002-e1006. Epub 2021 May 21.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA.

Objective: The objectives of this study were 1) to assess the long-term patient-reported outcomes of carpal tunnel release (CTR) in patients 80 years of age or older, and 2) to determine the long-term mortality rate of this population after CTR.

Methods: We performed a retrospective study of 96 patients who underwent CTR at 80 years of age or older from July 2008 to June 2013. Mortality was assessed by medical records, the Social Security Death Index, and telephone contact. Living patients were contacted for long-term follow-up, and functional outcomes and patient satisfaction were assessed.

Results: The mean age of the 96 patients at time of CTR was 84.1 years, including 89 octogenarian patients and 7 nonagenarian patients, and 67% were female. At an average of 9 years from surgery, the mortality rate of our cohort was 53% (51 of 96 patients). Five patients died within 1 year after CTR; no factor associated with early mortality after CTR was identified in the bivariate analysis. Telephone follow-up at an average of 9 years after CTR was available for 15 patients. Mean Boston Carpal Tunnel Syndrome Questionnaire symptom severity score was 1.6 points, mean Boston Carpal Tunnel Syndrome Questionnaire functional status score was 1.8 points, mean Quick Disabilities of the Arm, Shoulder and Hand score was 27.9, and mean satisfaction was 7.1. Eighty percent of patients reported that they would rechoose CTR.

Conclusions: There are long-term benefits from CTR in patients 80 years of age or older. The mortality rate of this cohort mirrors that of the general population, and CTR is justified in this elderly age group both for the magnitude and duration of treatment effect.
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http://dx.doi.org/10.1016/j.wneu.2021.05.031DOI Listing
July 2021
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