Publications by authors named "Charles A Goldfarb"

175 Publications

Strategies for Deficit Recovery for the Orthopaedic Service Line: Lessons Learned from the COVID-19 Pandemic: AOA Critical Issues Symposium.

J Bone Joint Surg Am 2022 Aug 10. Epub 2022 Aug 10.

Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.

Abstract: The COVID-19 pandemic and the mandated cessation of surgical procedures for a substantial portion of the 2020 year placed tremendous strain, both clinically and financially, on the health-care system in the United States. As a surgical specialty that accounts for nearly a quarter of all hospital net income, the revenue recovery of orthopaedic service lines (OSLs) is of particular importance to the financial recovery of their broader health-care institutions. In this American Orthopaedic Association (AOA) symposium report, the OSL leaders from 4 major academic medical institutions explain and reflect on their approaches to address their revenue deficits. Cost-reduction strategies, such as tightening budgets, adopting remote-work models, and limiting costs of human capital, were vital to stabilizing departmental finances at the onset of the pandemic, while strategies that focused on expanding surgical volume, such as those that improve efficiency in clinical and surgical settings, were important in growing revenue once elective procedures resumed. Institutional policy, payer administrative procedures, and the overall context of an ongoing public health crisis all placed limitations on recovery efforts, but engaging relevant stakeholders and working with available resources helped OSLs overcome these limitations. Due to clear strategic actions that were taken to address their deficits, each OSL represented in this AOA symposium saw substantial improvement in its year-end financial performance compared with its financial status at the end of the period of mandatory cessation of elective surgical cases.
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http://dx.doi.org/10.2106/JBJS.21.01409DOI Listing
August 2022

The Utility of the Carpal Tunnel Syndrome-6 for Predicting the Outcomes of Carpal Tunnel Release.

J Hand Surg Am 2022 Aug 5. Epub 2022 Aug 5.

Department of Orthopedic Surgery, Washington University in St. Louis, School of Medicine, St. Louis, MO. Electronic address:

Purpose: Considering the cost of, discomfort with, and time required for nerve conduction testing, the Carpal Tunnel Syndrome-6 (CTS-6) is often used to determine the likelihood of the presence of carpal tunnel syndrome. We sought to determine whether the CTS-6, designed as a diagnostic instrument, could serve a dual purpose and predict the outcome of carpal tunnel release (CTR) based on postoperative changes in the Boston Carpal Tunnel Questionnaire (BCTQ) score.

Methods: This prospective observational study enrolled 118 adults before they underwent open CTR at a tertiary center. A primary regression analysis was used to determine the association between preoperative CTS-6 scores and changes in the BCTQ score at ≥6 months after surgery. Additional demographic, social, electrodiagnostic, and mental health variables were assessed for associations with changes in the BCTQ score. The secondary outcomes included single questions rating satisfaction with the result of CTR as well as symptom changes and the Decision Regret Scale. Noneffective CTR was defined as a BCTQ score change of <1.0 point or reported dissatisfaction.

Results: Postoperatively, the BCTQ score improvement averaged 1.38 ± 0.77. Although 102 of 109 patients (94%) noted symptom improvement, 94 of 109 (86%) were satisfied with the result of CTR, and 78 of 109 patients (72%) demonstrated a meaningful change in the BCTQ score. Preoperative CTS-6 scores were not correlated with changes in BCTQ scores. CTS-6 scores were not associated with Decision Regret Scale scores, reported satisfaction, or the single-question assessment of symptom changes. Satisfaction, decision regret, and the single symptom change question were correlated with changes in the BCTQ score and each other. Dissatisfied patients were distinguished by a differential improvement in the BCTQ score (1.5 vs 0.7), but no preoperative variable consistently predicted noneffective CTR.

Conclusions: The CTS-6 score does not predict changes in BCTQ scores after CTR. Patient satisfaction with surgical results is associated with postoperative changes in carpal tunnel symptoms but is not predictable using preoperative information. A single question of symptom change may offer an efficient assessment of CTR outcomes.

Type Of Study/level Of Evidence: Prognostic II.
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http://dx.doi.org/10.1016/j.jhsa.2022.06.017DOI Listing
August 2022

An Analysis of Associated Conditions and the Relationship Between the Severity of Hand Manifestations With That of the Forearm in Ulnar Longitudinal Deficiency.

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

Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO. Electronic address:

Purpose: A deeper investigation of medical and musculoskeletal conditions in patients with ulnar longitudinal deficiency (ULD) is needed. The association between the severity of the manifestations of ULD in the hands and forearms has not been firmly established. The purpose of this study was to describe the medical and musculoskeletal conditions associated with ULD and examine the relationship between hand and forearm anomalies.

Methods: The Congenital Upper Limb Differences registry was queried for all patients with a diagnosis of ULD, as defined by the Oberg-Manske-Tonkin classification system, between 2014 and 2020. The patients' demographic information, medical and musculoskeletal comorbidities, radiographs, and clinical images were reviewed. The participants were classified using the Bayne, Cole and Manske, and Ogino classification systems.

Results: Of 2,821 patients from the Congenital Upper Limb Differences registry, 75 patients (2.7%) with ULD (14 bilateral), with 89 affected extremities, were included. Hand anomalies were present in 93% of the patients. Approximately 19% of the patients had an associated medical comorbidity, and 20% of the patients had an associated musculoskeletal condition. Cardiac anomalies were present in 8.0% of the patients, and 12% of the patients had a lower extremity abnormality. Radial head dislocation was observed in 13 of 18 patients with Bayne type II or III ULD compared with 8 of 43 patients with other types of unilateral ULD. There was a significant positive association among the Bayne and Ogino, Bayne and Cole/Manske, and Ogino and Cole/Manske classification systems in patients with unilateral ULD.

Conclusions: Associated medical and musculoskeletal conditions are common in patients with ULD, of which cardiac and lower extremity abnormalities are most frequently observed. There is a significant positive association between the severity of forearm anomalies and that of hand anomalies in patients with unilateral ULD. All patients with ULD should undergo a thorough cardiac evaluation by their pediatrician or a pediatric cardiologist.

Type Of Study/level Of Evidence: Symptom prevalence study III.
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http://dx.doi.org/10.1016/j.jhsa.2022.05.021DOI Listing
August 2022

The Responsiveness of the Patient-Reported Outcomes Measurement Information System Upper Extremity and Physical Function in Patients With Cubital Tunnel Syndrome.

J Hand Surg Am 2022 Jun 24. Epub 2022 Jun 24.

Department of Orthopedics, Washington University, St. Louis, MO. Electronic address:

Purpose: The Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) and PROMIS Physical Function (PF) are increasingly referenced patient-reported outcomes. To interpret treatment effects with these patient-reported outcomes, investigators must understand magnitudes of change that represent clinically relevant improvement. This study assessed the responsiveness of PROMIS UE and PF in patients with cubital tunnel syndrome.

Methods: A retrospective analysis of PROMIS UE and PROMIS PF computer adaptive test scores was performed for patients treated nonoperatively for cubital tunnel syndrome over 3 years at a tertiary institution. The Patient-Reported Outcomes Measurement Information System UE and PROMIS PF outcome scores were collected at initial and return clinic visits. At follow-up appointments, patients completed clinical anchor questions evaluating their degree of interval clinical improvement. Anchor questions allowed categorization of patients into groups that had experienced "no change," "minimal change," and "much change." Minimal clinically important difference (MCID) values were calculated for the PROMIS assessments with anchor-based and distribution-based methods.

Results: A total of 304 patients with PROMIS PF scores and 111 with PROMIS UE scores were analyzed. The MCID for the PROMIS UE was 3.1 (95% confidence interval, 1.4-4.8) using the anchor-based method and 3.7 (95% confidence interval, 2.9-4.4) using the distribution-based method. These point estimates exceeded the minimal detectable change of 2.3. The MCID for the PROMIS PF was unable to be determined in this patient sample because patients reporting mild change did not have score changes exceeding measurement error.

Conclusions: The PROMIS UE v2.0 computer adaptive test detected minimal change in patients managed nonoperatively for cubital tunnel syndrome with an estimated MCID range of 3.1-3.7. While PROMIS PF has demonstrated acceptable performance in patients with a variety of upper extremity conditions, for cubital tunnel syndrome, it was less able to detect subtle change. PROMIS UE appears more responsive to subtle changes in cubital tunnel syndrome symptoms.

Clinical Relevance: Patient-reported outcomes may have varied responsiveness depending on the condition studied.
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http://dx.doi.org/10.1016/j.jhsa.2021.11.029DOI Listing
June 2022

The Impact of Isolated Versus Multiple Osteochondromas: Analysis of the CoULD Registry.

J Pediatr Orthop 2022 Aug 24;42(7):387-392. Epub 2022 Jun 24.

Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO.

Purpose: The burden of upper extremity (UE) osteochondromas on function and self-perception among pediatric patients is unclear. The purpose of our study was to study the impact of osteochondromas in comparison to population norms and to evaluate solitary versus multiple osteochondromas on subjective UE function as measured by patient rated outcomes.

Methods: We utilized the CoULD (Congenital Upper Limb Differences) Registry to review all pediatric patients presenting with osteochondromas between January 2014 and February 2021. Demographic information was collected and patients were classified as having either single or multiple osteochondromas. Patient-Reported Outcome Measurement Information System (PROMIS) and Pediatric Outcomes Data Collection Instrument (PODCI) tools were utilized for assessment. Scores for PODCI subscales of UE function, Pain/comfort, and Happiness and PROMIS domains of UE Function, Pain, Depression, Anxiety, and Peer Relations were reviewed. Differences between groups were analyzed using the Student t test.

Results: Ninety-nine patients met inclusion criteria for the study with an average age of presentation of 9.3 years and 61 patients (62%) were male. Overall, patients demonstrated worse UE Function as well as greater Anxiety and Depression in comparison to the population normals on PROMIS assessment. Patients also demonstrated worse patient and parent reported PODCI UE, Sports and Physical Functioning, Pain/Comfort and Global Functioning scores compared with population norms but demonstrated better than average happiness scores. Patients with multiple osteochondromas demonstrated greater PROMIS pain interference and more disability in PODCI Sports and Physical Functioning, Pain/Comfort and Global Functioning compared with those with solitary osteochondromas.

Conclusion: Patients with UE osteochondromas have worse overall function in comparison to population norms, exceeding established minimally clinically important difference values. In addition, patients with multiple osteochondromas reported more pain and poorer physical function than those with solitary osteochondromas. Physicians should be alert to the physical and psychosocial burden of this disease.

Level Of Evidence: Level II-prognostic.
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http://dx.doi.org/10.1097/BPO.0000000000002167DOI Listing
August 2022

The Impact of Social Deprivation and Hand Therapy Attendance on Range of Motion After Flexor Tendon Repair.

J Hand Surg Am 2022 07 25;47(7):655-661. Epub 2022 May 25.

Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO.

Purpose: To examine the influence of social deprivation and hand therapy attendance on active range of motion (AROM) outcomes following flexor tendon repair.

Methods: We performed a retrospective analysis of patients who underwent primary zone I-III flexor tendon repair between November 2016 and November 2020. Area deprivation index (ADI) was used to quantify social deprivation. Medical record review determined each patient's demographic characteristics, injury details, total hand therapy visits, and final AROM outcome. Active range of motion was converted to Strickland's percentage for analysis. Spearman correlation and simple and multivariable linear regression models were used to assess relationships between explanatory variables and outcomes.

Results: There were a total of 109 patients, with a mean ADI of 53 and mean therapy attendance of 13 visits. Higher ADI and lower therapy attendance were correlated, and each was associated with significantly decreased Strickland's percentage. In the multivariable model, therapy attendance, ADI, zone 2 injury, and age maintained significant associations with Strickland's percentage.

Conclusions: Socially deprived patients attend fewer therapy sessions and obtain poorer AROM after flexor tendon repair. Social deprivation is likely to contribute to poor outcomes both by its association with decreased therapy attendance and by other potential pathways that make it difficult for deprived patients to achieve good surgical outcomes.

Type Of Study/level Of Evidence: Prognostic IV.
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http://dx.doi.org/10.1016/j.jhsa.2022.03.018DOI Listing
July 2022

The Iliac Crest Top Hat Bone Graft for Challenging Metacarpal Nonunion.

J Hand Surg Am 2022 07 18;47(7):694.e1-694.e4. Epub 2022 May 18.

Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO. Electronic address:

Metacarpal nonunion is a rare outcome of metacarpal injury, and little has been published about its management. Care typically includes open reduction and internal fixation with a possible bone graft, similar to the treatment of other nonunions. However, there is no literature guidance if traditional methods do not lead to union. To improve the treatment of these recalcitrant metacarpal diaphyseal nonunions, we proposed a new surgical technique using a "top hat" bone graft harvested from the iliac crest. The graft is carefully shaped to create a cancellous "crown," which is inserted into the nonunion site, and cortical "brims," which are used to secure the graft to the metacarpal. This has been successful in treating 2 cases of metacarpal nonunion that failed to heal with first-line intervention.
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http://dx.doi.org/10.1016/j.jhsa.2022.03.020DOI Listing
July 2022

Media Depiction of Birth Differences of the Upper Extremity: Accuracy of Shared Diagnoses.

J Pediatr Orthop 2022 Aug 17;42(7):e753-e755. Epub 2022 May 17.

Washington University School of Medicine, St Louis, MO.

Background: To assess the diagnostic accuracy of public representation of congenital differences of the upper extremities. We hypothesized that there is an over-diagnosis of certain diagnoses such as amniotic constriction band and under-diagnosis of others such as symbrachydactyly and radial deficiency.

Methods: Publicly shared images and associated diagnoses were searched on publicly available news media and social media accounts published from October 2018 through November 2021 using key terms such as "amniotic band syndrome," "congenital arm amputation," and "3D prosthetic arm" as well as The Lucky Fin Project account on Instagram. The images were collected and reviewed by 2 congenital hand surgeons. The surgeons' diagnoses were then compared to the reported diagnoses associated with each image to assess accuracy.

Results: A total of 100 images were collected with the reported diagnosis associated with each image. Two images were removed due to evidence of prior surgery. The hand surgeons' diagnosis disagreed with the reported diagnosis in 60 of 98 (61%) images. Of those 60 inaccurate diagnoses, 2/3 were reported as amniotic constriction band.

Conclusions: Media and social media depictions of congenital upper extremity differences are frequently inaccurate, and our search demonstrated that the amniotic constriction band is the most commonly reported, inaccurate diagnosis. Accuracy of diagnosis in public media is important given the impact a diagnosis has on those viewing and sharing the images.

Level Of Evidence: Level IV, diagnostic.
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http://dx.doi.org/10.1097/BPO.0000000000002185DOI Listing
August 2022

Metacarpal Fractures in the National Football League: Injury Characteristics, Management, and Return to Play.

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

Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX. Electronic address:

Purpose: This study investigated metacarpal fracture occurrences, characteristics, treatments, and return-to-play times for National Football League (NFL) athletes.

Methods: NFL players who sustained metacarpal fractures during the 2012 to 2018 seasons were reviewed. All players on the 32 NFL team active rosters with metacarpal fractures recorded through the NFL Injury Database were included. Player age, time in the league, player position, injury setting, injury mechanism, fractured ray, management, and return-to-play were recorded.

Results: There were 208 injury occurrences resulting in 1 or more metacarpal fractures, identified in 205 players. Of these, 81 (39%) injuries were operated. Return-to-play data were available for 173 (83%) injured players. The median return-to-play time for all athletes was 15 days (interquartile range, 1-55 days). Of the injured players, 130 (71%) missed time but returned the same season. Within this 130-player subset, 69 (53%) were treated nonsurgically and 61 (47%) operatively with median return-to-play times of 16 days (interquartile range, 6-30 days) and 20 days (interquartile range, 16-42 days) respectively. Eighteen individuals in this 130-player subgroup sustained a thumb metacarpal fracture. The return-to-play time was slower for patients sustaining thumb metacarpal fractures compared to other metacarpal fractures, and was significantly longer (median, 55 days) following nonsurgical treatment of thumb fractures compared with operative intervention (median, 24 days). A regression analysis revealed no trend or difference in return to football with respect to player age, time in the league, injury setting (practice vs game), injury mechanism, articular involvement, multiple concomitant injuries, or player position.

Conclusions: Most NFL players who sustain metacarpal fractures miss less than 3 weeks and return to play the same season. The only variables that lessen the return-to-play time are involvement of lesser digit metacarpals and operative intervention for treatment of thumb metacarpal fractures.

Type Of Study/level Of Evidence: Prognostic IV.
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http://dx.doi.org/10.1016/j.jhsa.2022.01.011DOI Listing
April 2022

Long-Term Outcomes of Operatively Treated Medial Epicondyle Fractures in Pediatric and Adolescent Patients.

J Hand Surg Glob Online 2021 May 5;3(3):124-128. Epub 2021 Apr 5.

Department of Orthopaedic Surgery, Washington University School of Medicine & St Louis Children's Hospital, St Louis, MO.

Purpose: Medial epicondyle fractures are among the most common pediatric elbow injuries. The management of these fractures continues to be debated. To better understand patient results with operative fixation, we reviewed the outcomes of operatively treated medial epicondyle fractures.

Methods: A retrospective review was performed to identify all patients less than 18 years of age at the time of injury who were treated surgically for medial epicondyle fractures. Outcomes were assessed based on the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity and Pain Interference domains, Visual Analog Scale for pain, subjective range of motion, ulnar nerve function, and requirement for secondary surgery.

Results: We identified a cohort of 95 patients treated for a medial epicondyle fracture with open reduction and screw fixation. Of these, 39 patients with a mean age of 12.2 years (SD, 2.2 years; range, 7.6-16.0 years) at surgery were assessed for an average follow-up of 6.3 years (SD, 3.2 years; range, 2.2-13.9 years). Outcome measures and pain scores were excellent. The mean PROMIS Upper Extremity score was 56.9, the mean Pain Interference score was 38.5, and the mean Visual Analog Scale score was 0.4.Sixteen patients (41%) required secondary surgery for symptomatic hardware removal. Seven patients (18%) developed sensory complaints and 2 (5%) developed motor complaints consistent with ulnar nerve irritability. Three patients (8%) reported dissatisfaction with elbow range of motion. Patients who required secondary surgeries had higher (worse) PROMIS Pain Interference scores.

Conclusions: At an average of 6.3 years after surgery, the clinical outcomes for medial epicondyle fracture were excellent. While operative treatment for medial epicondyle fractures in children leads to excellent clinical outcomes, patients and surgeons should be aware of high rates of hardware removal.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsg.2021.02.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8991540PMC
May 2021

Outcomes of Acute Repair Versus Nonrepair of Zone I Flexor Digitorum Profundus Tendon Injuries.

J Hand Surg Am 2022 Apr 9. Epub 2022 Apr 9.

Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO. Electronic address:

Purpose: The aim of this study was to determine whether the clinical results of zone I flexor digitorum profundus (FDP) tendon injuries managed with acute surgical repair are comparable to the clinical results of those managed without repair (eg, primary FDP excision or observation).

Methods: Patients aged ≥18 years presenting to a level 1 trauma center between 2015 and 2020 with zone I FDP tendon injury were identified with retrospective chart review. We assessed the following data: age, sex, physical therapy visits, surgical intervention, surgical complications (including infection, repeat surgery after the primary intervention, and rupture of repair), and patient-reported outcomes measurement information system scores.

Results: Twenty-six patients met the inclusion criteria. Group 1 (N = 15 patients, 23 fingers) patients were treated with acute surgical repair. Group 2 (N = 11 patients, 11 fingers) patients were managed without surgical repair, including FDP excision (N = 7) or observation alone (N = 4). In group 1, the average distance from the distal palmar crease to fingertip at the final follow-up was 1.6 cm (range, 0-4 cm). Fourteen of the 15 patients participated in >3 therapy visits. The following complications occurred: 4 fingers with rerupture (2 patients), 4 fingers with surgical wound dehiscence (2 patients), 3 infections (2 patients), and 4 repeat surgeries for these complications. In group 2, the average distance from the distal palmar crease to fingertip at the final follow-up was 1.1 cm (range, 0.5-3 cm). There were no infections, episodes of wound dehiscence, or repeat surgeries. At the final follow-up, both groups showed clinically meaningful improvement on Patient Reported Outcomes Measurement Information System (PROMIS) upper extremity, pain interference, and physical function scores, with similar PROMIS domain scores between groups.

Conclusions: Patients treated without FDP tendon repair had similar outcomes to, and fewer complications than, patients treated with acute tendon repair. Our data suggest that the notable commitment of health care costs, time, and adherence to protocols/restrictions after surgical repair may not confer functional benefit.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2022.02.005DOI Listing
April 2022

Magnetic Resonance Imaging Assessment of Cartilage Appearance Following Marrow Stimulation of Osteochondritis Dissecans of the Humeral Capitellum.

J Hand Surg Am 2022 Jan 4. Epub 2022 Jan 4.

Department of Orthopaedic Surgery. Electronic address:

Purpose: Osteochondritis dissecans (OCD) of the capitellum is often treated by marrow stimulation techniques with good long-term outcomes. Magnetic resonance imaging (MRI) can be used to characterize the healing of cartilage repair tissue. However, no formal system exists for assessment of cartilage healing after marrow stimulation in capitellar OCD. The aims of this study were to describe the postoperative MRI appearance of capitellar repair cartilage after debridement and marrow stimulation for capitellar OCD and assess differences between symptomatic and asymptomatic patients.

Methods: This was a retrospective study of patients with capitellar OCD who underwent arthroscopic debridement and marrow stimulation and had a postoperative MRI to assess healing. The classification system developed by Marlovits and colleagues (Magnetic Resonance Observation of Cartilage Repair Tissue) was used to quantitatively profile the cartilage repair tissue in comparison to adjacent "normal" cartilage. Study participants completed an online survey to correlate outcomes with cartilage appearance.

Results: Eleven patients who underwent MRI for routine evaluation (asymptomatic), and 18 who underwent MRI for symptoms were identified. Overall, 59% of defects were completely filled, and in 83%, the cartilage surface had ulcerations or fibrillations. The cartilage variables were similar between symptomatic and asymptomatic patients. Capitellar subchondral bone edema was observed on the MRI of every patient who underwent a reoperation and was present in only 62% of those who did not. Clinical scores did not correlate with MRI cartilage findings, but the small sample size limited conclusions regarding clinical outcomes related to postoperative cartilage features seen on MRI.

Conclusions: This detailed assessment of cartilage appearance by MRI after marrow stimulation for capitellar OCD demonstrated that incomplete cartilage fill was common in both symptomatic and asymptomatic patients. Those requiring a second surgery were more likely to demonstrate subchondral bone edema.

Type Of Study/level Of Evidence: Diagnostic IV.
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http://dx.doi.org/10.1016/j.jhsa.2021.11.016DOI Listing
January 2022

Hook of Hamate Fractures.

Hand Clin 2021 11;37(4):545-552

Department of Orthopaedic Surgery, Washington University, 660 South Euclid Avenue, Campus Box 8233, St Louis, MO 63110, USA. Electronic address:

Hook of hamate fractures are uncommon injuries with unclear prevalence. Classic presenting symptoms include volar-ulnar hand/wrist pain and weakness in grip, with possible ulnar nerve paresthesias. Patient factors, such as activity level and desired return to work/sport, shape the most appropriate treatment regimen although excision of the hook has been adopted by most surgeons. Overall, once patients receive the correct diagnosis and are treated, good outcomes with high satisfaction rates are expected.
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http://dx.doi.org/10.1016/j.hcl.2021.06.013DOI Listing
November 2021

Paul R. Manske 2020 Award for the Best Upper-Extremity Congenital Research Manuscript.

J Hand Surg Am 2021 08 18;46(8):e11. Epub 2021 Jun 18.

University of California Davis, Sacramento, CA; Shriners Hospitals for Children - Northern California, Sacramento, CA.

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http://dx.doi.org/10.1016/j.jhsa.2021.04.035DOI Listing
August 2021

The Effect of Adoption on Functioning and Psychosocial Well-Being in Patients With Congenital Upper-Extremity Differences.

J Hand Surg Am 2021 10 24;46(10):856-861. Epub 2021 May 24.

Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO.

Purpose: Adoption status has been investigated in numerous populations, identifying negative and positive effects on patient outcomes. This study compared parent-reported outcomes in adopted and nonadopted individuals with congenital upper-extremity (UE) anomalies to determine whether there was a measurable difference in parent perceptions of psychosocial health and functioning.

Methods: The Congenital Upper Limb Differences registry identified adopted individuals from a large cohort of patients. Each adopted patient was matched to 2 nonadopted patients by sex, age, and diagnosis of UE difference using the Oberg-Manske-Tonkin classification. Parent-reported scores on functional and psychosocial subjective outcomes were compared between the 2 cohorts using the Pediatric Outcome Data Collection Instrument.

Results: Ninety-one adopted pediatric patients with congenital UE differences were identified. Sixty had complete matches for comparison, and the remaining 31 patients were not able to be matched and were excluded from the analysis. Pediatric Outcome Data Collection Instrument scores for the UE function domain were worse in the adopted cohort as judged by minimally clinically important difference. In contrast, scores for Pediatric Outcome Data Collection Instrument domains of transfer and mobility, sports and physical function, pain and comfort, and happiness did not exceed the minimally clinically important difference, although the adopted cohort scores were all relatively lower than the nonadopted cohort scores.

Conclusions: In pediatric patients with UE differences, adoption status is seen to affect only the parent-reported domain of UE function. While differences by specific congenital diagnosis call for additional investigation, overall, these findings should be reassuring to families planning to adopt children with UE differences, and they should be supported in their expectations of UE functioning.

Type Of Study/level Of Evidence: Prognostic III.
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http://dx.doi.org/10.1016/j.jhsa.2021.04.013DOI Listing
October 2021

Pediatric Hand Fractures and Congenital Differences: An Analysis of Data From the American Board of Orthopaedic Surgery and the American Board of Plastic Surgery.

J Hand Surg Am 2022 02 22;47(2):191.e1-191.e7. Epub 2021 May 22.

Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, MO.

Purpose: Pediatric patients with hand trauma and congenital differences are treated across multiple surgical subspecialties. The purpose of this study was to assess operative trends over an 11-year period using the American Board of Orthopaedic Surgery and the American Board of Plastic Surgery databases to better understand which surgeons were caring for pediatric hand fractures and birth differences in the first 2 years of their practice.

Methods: We queried the American Board of Orthopaedic Surgery and the American Board of Plastic Surgery databases for surgical procedures performed by applicants for the oral examinations between 2004 and 2014. Candidates self-identified as general orthopedic surgeon, pediatric orthopedic surgeon, hand surgeon (orthopedic and plastic), and general plastic surgeon. This included a total of 2,453 Board applicants. A total of 6,835 surgeries for birth differences or hand trauma were identified and reviewed for patients <18 years of age.

Results: There were 5,759 trauma and 1,076 congenital difference surgeries. A total of 4,786 (70%) surgeries were performed by orthopedic surgeons. Fellowship-trained hand surgeons (orthopedic and plastic) performed 3,809 (56%) surgeries. Pediatric orthopedic surgeons performed 608 (9%) surgeries. Over the 11 years, general orthopedic surgeons performed 4.2 fewer surgeries per year, whereas surgeons in hand orthopedics and pediatric orthopedics performed 10.8 and 4.7 additional surgeries per year. There were 3.1 fewer general orthopedic surgeons per year, whereas there were 3.6 and 1.4 additional surgeons in hand orthopedics and pediatric orthopedics each year, respectively. The number of surgeries and the number of surgeons submitting surgeries did not significantly change for those in general plastics or hand plastics.

Conclusions: This analysis of early practice patterns over 11 years demonstrates that the increasing numbers of surgeons in pediatric orthopedics and hand orthopedics are performing more surgeries compared with other fields.

Clinical Relevance: The care of children with hand injuries and congenital differences is evolving, with direct implications for residency and fellowship education.
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http://dx.doi.org/10.1016/j.jhsa.2021.04.014DOI Listing
February 2022

Paul R. Manske 2020 Award for the best upper extremity congenital research manuscript.

J Hand Surg Eur Vol 2021 09 20;46(7):792-793. Epub 2021 May 20.

University of California Davis, Sacramento, CA, USA.

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http://dx.doi.org/10.1177/17531934211017028DOI Listing
September 2021

Early Improvement in Patient-Reported Outcome Scores After Operative Treatment of Osteochondritis Dissecans of the Humeral Capitellum.

J Hand Surg Am 2021 12 28;46(12):1120.e1-1120.e7. Epub 2021 Apr 28.

Department of Orthopedic Surgery, Washington University, St. Louis, MO. Electronic address:

Purpose: Outcome measures that lack sensitivity for the detection of clinical changes early after surgery for capitellar osteochondritis dissecans (OCD) make it difficult to determine the optimal treatment for these defects. We sought to evaluate the early responsiveness of patient-reported outcomes measurement information system (PROMIS) scores in a cohort of patients operatively treated for capitellar OCD.

Methods: Four PROMIS questionnaires (mobility, upper extremity [UE], pain interference, and peer relations) were electronically administered to patients treated for capitellar OCD at a single tertiary academic medical center between January 1, 2015, and July 1, 2018. The questionnaires were administered at the initial preoperative outpatient clinic visit as well as at the 2-week, 6-week, and final return-to-play (RTP) visits.

Results: Twenty-nine patients (31 elbows, mean age 12.9 years) with available preoperative and postoperative PROMIS data were included. The mean final follow-up period was 26 weeks. Compared with that before surgery, there was a significant improvement in the mobility, pain interference, and UE scores at 6 weeks following surgery. The scores improved most significantly by 6 weeks, reached a relative plateau, and remained significantly improved through the RTP visit thereafter. Patients with preoperative, intra-articular loose bodies scored significantly better than those without them during the 6-week and RTP visits. Patients with lesions >1 cm, compared with those with lesions ≤1 cm, demonstrated greater improvement in the UE scores during the RTP visit.

Conclusions: In patients undergoing operative treatment for capitellar OCD, a significant improvement in the PROMIS domains of mobility, pain interference, and UE can be expected early in the postoperative period, with majority of patients reaching their greatest improvement in scores by 6 weeks following surgery.

Clinical Relevance: This is important information for preoperative counseling. In addition, this information is helpful in confirming that PROMIS scores are responsive in the detection of changes in outcomes during the early postoperative period in this population.
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December 2021

Magnetic Resonance Imaging in Osteochondritis Dissecans of the Humeral Capitellum: Preoperative Assessment of Lesion Size and Lateral Wall Integrity.

J Hand Surg Am 2021 06 29;46(6):454-461. Epub 2021 Mar 29.

Department of Orthopedic Surgery, Washington University School of Medicine, St Louis, MO. Electronic address:

Purpose: Magnetic resonance imaging (MRI) is a helpful tool in the evaluation of osteochondritis dissecans (OCD) of the humeral capitellum. The relationship between MRI appearance and clinically relevant intraoperative findings is incompletely understood. The goal of this study was to evaluate capitellar OCD lesions via preoperative MRI and to determine its accuracy in predicting lesion characteristics including lesion size and capitellar lateral wall integrity.

Methods: Patients surgically treated for capitellar OCD between January 2010 and June 2018 were reviewed. Preoperative MRI images were assessed by a musculoskeletal radiologist with documentation of lesion size, location, violation of the lateral wall, and stage, in accordance with previously established criteria. These data were compared with intraoperative findings. Involvement of the lateral wall of the capitellum was defined using 2 methods: (1) subchondral edema or articular cartilage disruption in the lateral third of the capitellum (lateral third method) or (2) disruption of the proximal-distal subchondral line along the lateral border of the capitellum descending vertically before the subchondral bone turns horizontally to form the radiocapitellar articulation (capitellar lateral wall sign method). Diagnostic test characteristics were compared for both methods.

Results: We reviewed the preoperative MRIs of 33 elbows with capitellar OCD and found no significant difference in mean lesion size between preoperative MRI (1.12 cm) and intraoperative measurement (1.08 cm). For detection of lateral wall integrity, preoperative MRI evaluation using the capitellar lateral wall sign method had an accuracy of 93%, sensitivity of 80%, specificity of 96%, positive predictive value of 80%, and negative predictive value of 96%.

Conclusions: Preoperative MRI is a valid predictor of lesion size. The capitellar lateral wall sign method is highly accurate in the identification of lateral wall involvement, which may influence preoperative planning.

Type Of Study/level Of Evidence: Diagnostic II.
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http://dx.doi.org/10.1016/j.jhsa.2021.01.024DOI Listing
June 2021

Cost Comparison of Botulinum Toxin Injections Versus Surgical Treatment in Pediatric Patients With Cerebral Palsy: A Markov Model.

J Hand Surg Am 2021 05 19;46(5):359-367. Epub 2021 Mar 19.

Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, MO. Electronic address:

Purpose: The purpose of this study was to compare the cost-effectiveness of surgical release to botulinum toxin injections in the treatment of upper-extremity (UE) cerebral palsy (CP).

Methods: A Markov transition-state model was developed to assess the direct and indirect costs as well as accumulated quality-adjusted life-years associated with surgery (surgery group) and continuous botulinum toxin injections (botulinum group) for the treatment of UE CP in children aged 7 to 12 years. Direct medical costs were obtained from institutional billing departments. The number of parental missed workdays associated with each treatment was estimated and previously published regressions were used to calculate indirect costs associated with missed work. Total costs, cost-effectiveness, and incremental cost-effectiveness ratios were calculated. Incremental cost-effectiveness ratios and willingness to pay thresholds were used to make decisions regarding society's willingness to pay for the incremental cost of each treatment given the incremental benefit.

Results: The surgery group demonstrated lower direct, indirect, and total costs compared with the botulinum group. Direct costs were $29,250.50 for the surgery group and $50,596.00 for the botulinum group. Indirect costs were $9,467.46 for the surgery group and $44,428.60 for the botulinum group. Total costs were $38,717.96 for the surgery group and $95,024.60 for the botulinum group, a difference of $56,306.64. The incremental cost-effectiveness ratio was -$42,019.88, indicating that surgery is a less costly and more effective treatment and that botulinum injections fall outside the societal willingness to pay threshold. Excluding indirect costs associated with parental missed work during home occupational therapy did not have a significant impact on the model.

Conclusions: Surgery is associated with lower direct, indirect, and total costs, as well as a greater number of accumulated quality-adjusted life-years. Surgery provides a greater benefit at a lower cost, which suggests that botulinum injections should be used sparingly in this population. Treatment with surgery could represent savings of $5.6 to $11.3 billion annually in the United States.

Type Of Study/level Of Evidence: Economic/Decision Analysis II.
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http://dx.doi.org/10.1016/j.jhsa.2021.01.018DOI Listing
May 2021

Applying the Delphi Method to Define a Focus for the National Outcomes Registry for Tracking the Hand (NORTH).

J Hand Surg Am 2021 05 12;46(5):417-420. Epub 2021 Mar 12.

Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI.

Surgical registries have provided reliable, generalizable, and applicable clinical data that have shaped many fields. Broad collection of defined data can answer clinical questions with greater numbers of patients and more ability to generalize to routine clinical care than randomized trials. National hand surgical registries exist outside the United States. Before the pursuit of a registry, the focus of such an effort must be defined to ensure that registry goals are feasible. This article presents the consensus process conducted by the American Society for Surgery of the Hand's Registry Task Force exploring potential diagnoses for a hand registry.
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http://dx.doi.org/10.1016/j.jhsa.2021.01.007DOI Listing
May 2021

Performance of Patient-Reported Outcomes Measurement Information System (PROMIS) scores compared with legacy metrics in evaluating outcomes after surgical treatment for osteochondritis dissecans of the humeral capitellum.

J Shoulder Elbow Surg 2021 Jul 21;30(7):1511-1518. Epub 2021 Jan 21.

Department of Orthopedics, Washington University in St. Louis, St. Louis, MO, USA. Electronic address:

Background: Patient-Reported Outcomes Measurement Information System (PROMIS) scores have not previously been used to measure long-term outcomes in operatively treated capitellar osteochondritis dissecans (OCD) patients. The aims of our study were to (1) assess patients' long-term outcomes using PROMIS scores, (2) compare the performance of PROMIS with other validated elbow legacy metrics, and (3) evaluate ceiling and floor effects in these outcome measures in patients undergoing surgical treatment for capitellar OCD.

Methods: We evaluated demographic characteristics, procedure details, preoperative PROMIS scores, and associated sports information in surgically treated pediatric capitellar OCD patients. An online survey was sent to the study participants, including the Kerlan-Jobe Orthopaedic Clinic (KJOC) shoulder and elbow score, the quick Disabilities of the Arm, Shoulder and Hand questionnaire, and the Liverpool Elbow Score patient-answered questionnaire, as well as the Mobility, Pain Interference, and Upper Extremity questionnaires from the PROMIS pediatrics bank. Correlations were evaluated between outcome measures. Ceiling and floor effects were evaluated for each outcome measure.

Results: Completed surveys were obtained for 57 patients (59 elbows). The mean patient age at surgery was 14 years (range, 10-18 years). The mean follow-up time was 6 years (standard deviation, 5 years; range, 1-18 years). The mean PROMIS Mobility score improved from 41.2 preoperatively to 55.2 postoperatively (P < .001). The mean Pain Interference score decreased from 46.9 preoperatively to 38 postoperatively (P < .001). The mean Upper Extremity score improved from 42.7 preoperatively to 53.2 postoperatively (P < .001). Significant correlations were observed between all legacy metrics and postoperative PROMIS scores (|r| > 0.54, P < .001). Ceiling or floor effects were seen in all legacy metrics and PROMIS scores. The KJOC score was least affected by ceiling or floor effects.

Conclusion: There is a strong correlation between PROMIS scores and legacy measures evaluating outcomes after surgical management of capitellar OCD. However, large ceiling and floor effects were present in all measures, likely owing to the favorable clinical results. The KJOC score was limited the least by ceiling and floor effects.
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http://dx.doi.org/10.1016/j.jse.2020.11.032DOI Listing
July 2021

Congenital Upper Limb Differences Registry (CoULD): Registry Inclusion Effect.

J Hand Surg Am 2021 06 8;46(6):515.e1-515.e11. Epub 2021 Jan 8.

Washington University School of Medicine, Department of Orthopedic Surgery, St. Louis Children's Hospital, St. Louis, MO; Department of Orthopedic Surgery, Shriners Hospitals for Children-St. Louis, St. Louis, MO.

Purpose: To advance the understanding of the epidemiology and treatment outcomes of congenital upper limb differences, a multicenter registry for Congenital Upper Limb Differences (CoULD) was established. After 4 years of recruitment, we sought to examine whether the relative frequency of congenital conditions compares with prior cross-sectional research and how the data have matured over time by (1) comparing our registry population with previous studies in similar populations and (2) evaluating the change over time of relative frequencies of selected conditions within the CoULD registry cohort, specifically to investigate for registry inclusion effects.

Methods: Data from the 2 founding centers in the CoULD registry were analyzed over a 4-year period. We compared patients included in the CoULD registry against 2 prior studies by matching each condition according to the Oberg-Manske-Tonkin classification system. The relative frequency of 4 representative conditions was calculated to evaluate change over time and to determine when the inception cohort effect diminished.

Results: The CoULD cohort of 1,381 patients was found to have notable differences compared with a 1-year cross-sectional cohort from the U.S. Midwest and a Swedish birth registry. Each of these registries had differences from the CoULD population in prevalence for approximately 33% of the diagnosis categories. The CoULD registry identified and included more pathologies of late presentation and those that do not commonly require surgical care. Changes in relative frequencies of incident and prevalent conditions, the registry inclusion effect, occurred early and stabilized by the third year.

Conclusions: The CoULD registry captures a different relative frequency of conditions than prior studies in similar populations. The findings highlight the CoULD registry may be a more accurate representation of clinical practice in tertiary referral centers; however, it is important to note that there was a registry inclusion effect identified.

Clinical Relevance: Inclusion criteria are an important consideration with any longitudinal data collection method and data should display stability prior to registry reporting.
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http://dx.doi.org/10.1016/j.jhsa.2020.11.006DOI Listing
June 2021

The 2020 Oberg-Manske-Tonkin classification of congenital upper limb differences: updates and challenges.

J Hand Surg Eur Vol 2020 Dec;45(10):1117-1119

Department of Orthopaedic Surgery, Washington University, St. Louis, MO, USA.

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http://dx.doi.org/10.1177/1753193420964335DOI Listing
December 2020

Defining Features of Hand Anomalies in Severe Thumb Hypoplasia: A Classification Modification.

J Hand Surg Am 2021 05 12;46(5):422.e1-422.e5. Epub 2020 Nov 12.

Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO. Electronic address:

Purpose: To investigate morphologic hand anomalies in children with severe but unclassifiable forms of thumb hypoplasia and radial-sided hand deficiency.

Methods: We identified 15 extremities in 13 patients with severe thumb hypoplasia and associated absent radial-sided digits through the Congenital Upper Limb Differences registry. All patients had forearm involvement. Medical records, clinical photographs, and radiographs were evaluated. Radial longitudinal deficiency (RLD) and thumb hypoplasia were classified according to the Bayne and Klug classification and modified Blauth classification, respectively. Unusual or defining associated hand characteristics were identified and categorized.

Results: The most common type of forearm abnormality was absence of the radius (Bayne and Klug type IV), which was present in 10 extremities in the cohort. All 15 extremities had absent thumbs with loss of additional digits. In 6 patients, RLD was part of a syndrome (46%).

Conclusions: Severe forms of thumb hypoplasia in RLD are uncommon. We propose a further modification of the Blauth classification of thumb hypoplasia, type VI, for improved communication regarding this severe type of radial deficiency involving the hand.

Type Of Study/level Of Evidence: Diagnostic IV.
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http://dx.doi.org/10.1016/j.jhsa.2020.10.005DOI Listing
May 2021

Outcomes of Pediatric and Adolescent Carpal Tunnel Release.

J Hand Surg Am 2021 03 1;46(3):178-186. Epub 2020 Nov 1.

Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO. Electronic address:

Purpose: To investigate carpal tunnel syndrome (CTS) presentation and long-term outcomes of carpal tunnel release (CTR) in children and adolescents.

Methods: All pediatric and adolescent patients who underwent CTR between February 2003 and June 2018 were identified. Patients were grouped by etiology: lysosomal storage disease (11 hands), idiopathic (6 hands), acute traumatic (7 hands), delayed traumatic (5 hands) and tumorous (2 hands). Medical records were reviewed for presenting symptoms and preoperative treatments. Final outcomes were assessed via phone interviews, chart review, the Boston Carpal Tunnel Questionnaire (BCTQ), and Patient-Reported Outcomes Measurement Information System (PROMIS) scores.

Results: All 25 patients (31 hands) identified were included in the study; median age at surgery was 12.7 years (range, 2.5-23.3 years). Eighteen patients completed surveys at a median of 4.7 years after surgery (range, 8 months-16 years). Common presenting symptoms in lysosomal storage disease were numbness/tingling (7 hands); pain was only reported in 1 hand. The most frequent indication for acute traumatic CTR (7 hands) was palmar hand swelling at the carpal tunnel (4 hands). Delayed traumatic and idiopathic CTS most often presented with numbness/tingling (4 hands and 6 hands, respectively) and pain (3 hands, 4 hands, respectively). Of the original 4 lysosomal storage disease surgeries included in long-term follow-up, all experienced gradual recurrence of symptoms after years of relief (range, 3-14 years). Two patients underwent revision CTR and were symptom-free at follow-up. All patients with acute traumatic and tumorous etiologies had full resolution of symptoms. Delayed traumatic and idiopathic etiologies frequently experienced recurrent or recalcitrant symptoms (4 of 5 and 3 of 6 surgeries, respectively).

Conclusions: Carpal tunnel release often alleviates symptoms in children with lysosomal storage disease for years to decades. Carpal tunnel release successfully relieves symptoms in acute traumatic cases, but is not always sufficient to relieve symptoms associated with delayed traumatic etiologies. Approximately half of patients with idiopathic CTS experience recalcitrant or recurrent symptoms.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2020.09.009DOI Listing
March 2021

Social Deprivation and Congenital Upper Extremity Differences-An Assessment Using PROMIS.

J Hand Surg Am 2021 02 21;46(2):114-118. Epub 2020 Oct 21.

Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO.

Purpose: Social deprivation, a measure of socioeconomic status, has been shown to negatively affect perceptions of orthopedic conditions and outcomes of treatment. The objective of this study was to assess whether social deprivation correlates with subjective assessment of function in pediatric patients with congenital hand differences.

Methods: Patients enrolled in the Congenital Upper Limb Differences (CoULD) registry were assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS). The PROMIS scores for Pain Interference, Peer Relations, Anxiety, Depression, and Upper Extremity (UE) function were obtained for all patients 5 years and older at initial presentation. Social deprivation was determined by the Area Deprivation Index (ADI); the index ranges from 0 to 100 with higher scores being the most deprived. The PROMIS scores were correlated with the ADI for all patients.

Results: Three hundred seventy-five pediatric patients with congenital UE differences were evaluated. Average age was 11 years, 56% were female, and 55% had bilateral involvement. Overall, PROMIS scores were within 1 SD of normal for Peer Relations, Pain, Depression, and Anxiety. However, child-reported scores for UE function (39) were more than 1 SD below the national average (50). The mean ADI for the cohort was lower than the national average, indicative of less deprivation, with 14% of patients in the most deprived national quartile. Children in the highest ADI quartile reported PROMIS scores that reflected higher Pain Interference (41 vs 45), lower Peer Relations (55 vs 50), higher Anxiety (44 vs 49), and higher Depression (43 vs 47) than children in the lowest ADI quartile.

Conclusions: The PROMIS scores were normal for psychosocial measures in children with congenital hand differences when evaluated as an entire cohort. However, child self-reported PROMIS scores for Pain Interference, Peer Relations, Anxiety, and Depression were worse in more socially deprived areas, suggesting more psychosocial challenges in these children.

Clinical Relevance: Pediatric patients with congenital upper extremity differences in areas of higher social deprivation report lower psychosocial well-being. The care of these individuals must be considered within the context of their environment because they may be more at risk for negative outcomes secondary to environmental and societal stressors.
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http://dx.doi.org/10.1016/j.jhsa.2020.08.017DOI Listing
February 2021

Congenital Upper-Extremity Differences: A Thematic Analysis of On-Line Discussion Boards.

J Hand Surg Am 2021 04 3;46(4):337.e1-337.e10. Epub 2020 Oct 3.

Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO. Electronic address:

Purpose: On-line discussion boards (DBs) are used by patients and family members to pose questions and share experiences with a broader community. Systematic analysis of the text posted to DBs about congenital upper-extremity (UE) differences may allow physicians to identify and address patients' questions and concerns better.

Methods: We used Google and Yahoo! Internet search engines to identify on-line DBs pertaining to congenital UE differences. Posts written between January 1, 2009 and January 1, 2019 were collected and analyzed. Each on-line post was coded by 2 researchers using 3 rounds of grounded theory: open coding, axial coding, and selective coding. This allowed comprehensive, central themes of the DBs to emerge.

Results: We collected 521 posts and analyzed 420 posts from 152 threads. A total of 163 unique users contributed to posts. Parents of a child with a congenital UE difference accounted for the majority of users (65%), most of which were postnatal (91%). Of posts written by patients, 48% expressed negative emotions pertaining to their difference, whereas 17% conveyed a positive experience. Five selective codes were identified from posts written by non-administrators: (1) Connecting With Others, (2) Emotional Aspects, (3) Treatment, (4) Diagnosis, and (5) Function. Connecting With Others was the most frequently assigned selective code; users were looking to establish a connection in 73% of posts. Posts seeking information (n = 106) were more often technical in nature than were posts providing information (54% vs 44%). Posts providing information (n = 206) were more often emotional (18% vs 13%).

Conclusions: Individuals accessing on-line DBs are commonly searching for technical and emotional support from others. Through analysis and identification of the themes from these posts, we believe physicians should be proactive in addressing technical concerns through education and counseling, but should also validate emotional concerns and assist families and patients via support groups or connections to others.

Clinical Relevance: Treating surgeons can improve their care of patients with congenital UE differences by better understanding the needs of patients and their families that may not be elucidated in a traditional patient encounter.
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http://dx.doi.org/10.1016/j.jhsa.2020.08.006DOI Listing
April 2021

Treatment of Radial Longitudinal Deficiency: An International Survey.

J Hand Surg Am 2021 03 17;46(3):241.e1-241.e11. Epub 2020 Sep 17.

Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO.

Purpose: The treatment of radial longitudinal deficiency (RLD) is highly variable without clear guidelines in the literature. The current study investigated variability among hand surgeons in treatment approaches for RLD patients with anomalies of the thumb and forearm.

Methods: An online survey was distributed to 105 self-identified North American pediatric hand surgeons and 23 international pediatric hand surgeons. The survey was developed after consideration of the controversies in RLD treatment. Variations in diagnostic approach, timing of treatment, surgical indications, and surgical techniques were presented in a 21-question survey.

Results: Seventy-four (57.8%) surgeons completed the survey. For type 2 hypoplastic thumb reconstruction, 81% of surgeons prefer the flexor digitorum superficialis transfer with others using the abductor digiti minimi transfer. Ninety-four percent and 100% of surgeons favored pollicization for type 3B and type 4 hypoplastic thumb, respectively. When performing pollicization, 88% of surgeons strive for tip-to-tip pinch, with 50% preferring 100° rotation and 38% greater than 120°, compared with 12% who preferred tip-to-side pinch. Nearly half of surgeons stated they would not recommend pollicization for a patient with a stiff index finger who utilizes ulnar prehension. Ninety percent of surgeons preferred observation for a type 1 radius. Type 2 treatment preferences were highly variable, the most common response being radius lengthening. For type 3/4 radius deficiency, surgeons were divided between soft tissue release with bilobed flap and centralization (42% and 36%, respectively). If radial deviation could not be passively corrected, 63% preferred an external fixator for soft tissue distraction before centralizing. Ulnar prehension functional pattern changed treatment for 45% of surgeons in type 3/4 radius.

Conclusions: This study provides information on areas of agreement and disagreement in the treatment of RLD. Specifically, there was consensus for treatment of types 3B and 4 thumbs and type 1 radius. Consensus was lacking for the amount of rotation in positioning of the pollicized digit, the role of pollicization with the stiff index finger, and also in the treatment of types 2, 3, or 4 radius.

Clinical Relevance: This study provides a framework to establish treatment guidelines for thumb hypoplasia and RLD and has identified areas lacking consensus and that require additional study.
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March 2021

Treatment of Blauth Type IIIB Thumb Hypoplasia Using a Nonvascularized Toe Phalanx.

J Hand Surg Am 2021 Jan 27;46(1):68.e1-68.e7. Epub 2020 Aug 27.

Department of Orthopaedic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO.

Purpose: The purpose of this study was to evaluate surgical outcomes of thumb preservation surgery for Blauth type IIIB hypoplastic thumbs using a nonvascularized toe phalanx to reconstruct the carpometacarpal joint.

Methods: We reviewed the records of 12 patients with Blauth type IIIB thumb hypoplasia who underwent nonvascularized toe proximal phalanx transfer from the fourth toe. Stability and mobility of the thumb, lateral pinch power, and the percentage of the thumb length relative to the index finger proximal phalanx were evaluated. Outcomes were also assessed with the Functional Dexterity Test, a visual analog scale for daily use of the operated thumb, and for overall functional and appearance satisfaction of the parents.

Results: Age at operation ranged from 0.9 to 11 years (mean, 3.0 years; median, 1.5 years). The mean follow-up period was 7.6 years (minimum, 3 years). Secondary reconstruction was planned in all 12 patients, but 2 families did not desire a second surgery. Secondary reconstruction consisted of tendon transfer for opposition, adduction, and/or extension of the reconstructed thumb and/or realignment surgery of the thumb axis by arthrodesis or corrective osteotomy. Eleven patients had good carpometacarpal joint stability. Thumb opposition was possible to the little finger in 7, to the middle finger in 3, and not possible in 2 patients. The mean lateral pinch strength was 18% of the contralateral normal side. The relative length of the thumb was 57% of the index finger. Time in seconds to complete Functional Dexterity Test was 83 seconds in the affected side and 38 seconds for the contralateral side. The visual analog scale suggested parental satisfaction for both the appearance and the function. The parents felt that their child used the reconstructed thumb more frequently when manipulating large objects than when manipulating small objects.

Conclusions: Nonvascularized toe phalanx transfer is a useful procedure to preserve the thumb in Blauth type IIIB thumb hypoplasia. It provides a mobile, stable thumb that is functionally useful for the child and satisfying for the family.

Type Of Study/level Of Evidence: Therapeutic IV.
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January 2021
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