Publications by authors named "Edward Akelman"

76 Publications

Do Patients Want to be Involved in Their Carpal Tunnel Surgery Decisions? A Multicenter Study.

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

Department of Orthopaedic Surgery, Value in Orthopaedics, Innovation and Choices Health Policy Research Center, Stanford University, Redwood City, CA; Hand Surgery Quality Consortium. Electronic address:

Purpose: Carpal tunnel syndrome requires multiple decisions during its management, including regarding preoperative studies, surgical technique, and postoperative wound management. Whether patients have varying preferences for the degree to which they share in decisions during different phases of care has not been explored. The goal of our study was to evaluate the degree to which patients want to be involved along the care pathway in the management of carpal tunnel syndrome.

Methods: We performed a prospective, multicenter study of patients undergoing carpal tunnel surgery at 5 academic medical centers. Patients received a 27-item questionnaire to rate their preferred level of involvement for decisions made during 3 phases of care for carpal tunnel surgery: preoperative, intraoperative, and postoperative. Preferences for participation were quantified using the Control Preferences Scale. These questions were scored on a scale of 0 to 4, with patient-only decisions scoring 0, semiactive decisions scoring 1, equally collaborative decisions scoring 2, semipassive decisions scoring 3, and physician-only decisions scoring 4. Descriptive statistics were calculated.

Results: Seventy-one patients completed the survey between November 2018 and April 2019. Overall, patients preferred semipassive decisions in all phases of care (median score, 3). Patients preferred equally collaborative decisions for preoperative decisions (median score, 2). Patients preferred a semipassive decision-making role for intraoperative and postoperative decisions (median score, 3), suggesting these did not need to be equally shared.

Conclusions: Patients with carpal tunnel syndrome prefer varying degrees of involvement in the decision-making process of their care and prefer a semipassive role in intraoperative and postoperative decisions.

Clinical Relevance: Strategies to engage patients to varying degrees for all decisions during the management of carpal tunnel syndrome, such as decision aids for preoperative surgical decisions and educational handouts for intraoperative decisions, may facilitate aligning decisions with patient preferences for shared decision-making.
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http://dx.doi.org/10.1016/j.jhsa.2022.03.025DOI Listing
June 2022

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

Charges for Distal Radius Fracture Fixation Are Affected by Fracture Pattern, Location of Service, and Anesthesia Type.

Hand (N Y) 2022 Mar 4:15589447221077379. Epub 2022 Mar 4.

Brown University and Rhode Island Hospital, Providence, RI, USA.

Background: This study sought to characterize charges associated with operative treatment of distal radius fractures and identify sources of variation contributing to overall cost.

Methods: A retrospective study was performed using the New York Statewide Planning and Research Cooperative System database from 2009-2017. Outpatient claims were identified using the International Classification of Diseases-9/10-Clinical Modification diagnosis codes for distal radius fixation surgery. A multivariable mixed model regression was performed to identify variables contributing to total charges of the claim, including patient demographics, anesthesia method, surgery location (ambulatory surgery center [ASC] versus a hospital outpatient department [HOPD], operation time, insurance type, Charlson Comorbidity Index, and billed procedure codes.

Results: A total of 9029 claims were included, finding older age, private primary insurance, surgery performed in a HOPD, and use of local anesthesia (vs general or regional) associated with increased total charges. There was no difference between gender, race, or ethnicity. Additionally, open reduction and internal fixation (ORIF), increased operative time/fracture complexity, and use of perioperative medications contributed significantly to overall costs.

Conclusions: Charges for distal radius fracture surgery performed in a HOPD were 28.3% higher than compared to an ASC, and cases with local anesthesia had higher billed claims compared to regional or general anesthesia. Furthermore, charges for percutaneous fixation were 54.6% lower than ORIF of extraarticular fracture, and claims had substantial geographic variation. These findings may be used by providers and payers to help improve value of distal radius fracture care.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1177/15589447221077379DOI Listing
March 2022

Current Concepts in the Management of Dupuytren Disease of the Hand.

J Am Acad Orthop Surg 2021 Jun;29(11):462-469

From the Department of Orthopaedic Surgery (Gil, Hresko, and E. Akelman), Alpert Medical School of Brown University, Providence, RI, and the Department of Orthopaedic Surgery (M. R. Akelman), Wake Forest School of Medicine, Winston-Salem, NC.

Dupuytren disease is a fibroproliferative disorder of the palmar fascia of the hand. Little agreement and remarkable variability exists in treatment algorithms between surgeons. Because the cellular and molecular etiology of Dupuytren has been elucidated, ongoing efforts have been made to identify potential chemotherapeutic targets that could modulate the phenotypic expression of the disease. Although these efforts may dramatically alter the approach to treating this disease in the future, these approaches are largely experimental at this point. Over the past decade, the mainstay nonsurgical options have continued to be percutaneous needle aponeurotomy and collagenase Clostridium hystoliticum, and the most common surgical option is limited fasciectomy.
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http://dx.doi.org/10.5435/JAAOS-D-20-00190DOI Listing
June 2021

COBRE for Skeletal Health and Repair: The Impact of Aging on the Capacity for Peripheral Nerve Regeneration.

R I Med J (2013) 2021 Mar 1;104(2):39-45. Epub 2021 Mar 1.

Department of Orthopaedics, Alpert Medical School of Brown University; Rhode Island Hospital; Center and Graduate Program in Biomedical Engineering, Brown University, Providence, RI.

Peripheral nerves are crucial to the motor and sensory function provided by our upper and lower extremities to our brain and spinal cord. Following trauma or illness, these nerves may be injured, leading to a loss of function that can be significantly debilitating. Fortunately, given the type of injury and under the right conditions, peripheral nerves can regenerate through well-coordinated biochemical processes. However, as individuals age, the ability for nerves to regenerate becomes less efficient, reducing nerve's potential for the nerve to return to its prior level of function. In this article, we review the research that has been conducted to illustrate the reasons for such a decline in regenerative capacity. In doing so, we explore the concept of inflammaging alongside aging-related impairments of the macrophage and Schwann cell during nerve regeneration.
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March 2021

Is Opioid-Limiting Legislation Effective for Hand Surgery Patients?

Hand (N Y) 2021 Feb 3:1558944720988132. Epub 2021 Feb 3.

Brown University, Providence, RI, USA.

Background: The Rhode Island State Legislature passed the in 2016 to limit opioid prescriptions. We aimed to objectively evaluate its effect on opioid prescribing for hand surgery patients and also identify risk factors for prolonged opioid use.

Methods: A 6-month period (January-June 2016) prior to passage of the law was compared with a period following its implementation (July-December 2017). Thumb carpometacarpal arthroplasty and distal radius fracture fixation were classified as "major surgery" and carpal tunnel and trigger finger release as "minor surgery." Prescription Drug Monitoring Database was used to review controlled substances filled during the study periods.

Results: A total of 1380 patients met our inclusion criteria, with 644 and 736 . Patients undergoing "major surgery" saw a significant decrease in the number of pills issued in the first postoperative prescription (41.1 vs 21.0) and a corresponding decrease in morphine milligram equivalents (MMEs) (318.6 vs 159.2 MMEs) after implementation. A 30% decrease in MMEs was also seen in those undergoing "major surgery" in the first 30 days postoperatively (544.7 vs 381.7 MMEs). Risk factors for prolonged opioid use included male sex and preoperative opioid use.

Conclusions: In Rhode Island, opioid-limiting legislation resulted in a significant decrease in the number of pills and MMEs of the initial prescription and a 30% decrease in total MMEs in the 30-day postoperative period after "major hand surgery." Additional research is needed to explore the association between legislation and clinical outcomes.
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http://dx.doi.org/10.1177/1558944720988132DOI Listing
February 2021

Global Volunteering in Orthopaedics: Availability and Implementation Considerations.

J Am Acad Orthop Surg 2021 Feb;29(4):139-147

From the Department of Orthopaedic Surgery, Alpert Medical School, Brown University, Providence, RI.

The World Health Organization describes traumatic injuries as a "neglected epidemic" in developing countries, accounting for more deaths annually than HIV/AIDS, malaria, and tuberculosis combined. Low- and middle-income countries rely on volunteer assistance to address the growing surgical disease burden of traumatic injuries. Efforts to increase the availability of international electives for orthopaedic trainees can help with the short-term need for surgical personnel abroad and facilitate sustainability through capacity building, maximizing long-term benefits for all parties. The volunteer invariably benefits from this cross-cultural experience with many citing improved skills in communication, clinical diagnostics, appreciation of equality and diversity, and cost-consciousness. A consolidated discussion regarding barriers and implementation strategies can assist interested individuals and institutions plan for future volunteering endeavors.
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http://dx.doi.org/10.5435/JAAOS-D-20-00740DOI Listing
February 2021

Larger Initial Opioid Prescriptions Following Total Joint Arthroplasty Are Associated with Greater Risk of Prolonged Use.

J Bone Joint Surg Am 2021 Jan;103(2):106-114

Department of Orthopaedic Surgery (D.B.C.R., K.N.S., E.A., E.M.C., and A.H.D.), Warren Alpert Medical School of Brown University (J.H.R. and B.H.S.), Providence, Rhode Island.

Background: The ongoing U.S. opioid epidemic threatens quality of life and poses substantial economic and safety burdens to opioid abusers and their communities, physicians, and health-care systems. Public health experts have argued that prescription opioids are implicated in this epidemic; however, opioid dosing following surgical procedures remains controversial. The purpose of this study was to evaluate the relationship between initial opioid prescribing following total hip arthroplasty (THA) and total knee arthroplasty (TKA) and the risk and quantity of long-term opioid use.

Methods: Patients undergoing THA or TKA from January 1, 2016, to June 30, 2016, were identified. Preoperative 30-day opioid and benzodiazepine exposures were evaluated using the Rhode Island Prescription Drug Monitoring Program. Cumulative morphine milligram equivalents (MMEs) in the postoperative inpatient stay, initial outpatient opioid prescription, and prescriptions filled from 31 to 90 days (prolonged use) and 91 to 150 days (chronic use) following the surgical procedure were calculated. Regression analyses evaluated the association between the initial postoperative opioid dosing and prolonged or chronic use, controlling for demographic characteristics, procedure, preoperative opioid and benzodiazepine exposures, anesthesia type, and use of a peripheral nerve block.

Results: A total of 507 patients (198 who underwent a THA and 309 who underwent a TKA) were identified. Increased inpatient opioid dosing (odds ratio [OR], 1.49 per 1 standard deviation increase in inpatient opioid MMEs; p = 0.001) and increased dosing in the first outpatient prescription (OR, 1.26 per 1 standard deviation increase in initial outpatient prescription MMEs; p = 0.049) were each independently associated with an increased risk of prolonged opioid use. Additionally, increased inpatient dosing postoperatively was strongly associated with a greater risk of chronic use (OR, 1.77 per 1 standard deviation increase in inpatient MMEs; p < 0.001). Among the 30% (151 of 507) of patients requiring prolonged postoperative opioids, each 1-MME increase in the initial outpatient prescription dose was associated with a 0.997-MME increase in quantity filled during the prolonged period (p < 0.001). Among the 14% (73 of 507) of patients requiring chronic opioids, every 1-MME increase in the initial outpatient dose was associated with a 1.678-MME increase in chronic opioid dosing (p = 0.008).

Conclusions: Increased opioid dosing in the early postoperative period following total joint arthroplasty (TJA) is associated with an increased risk of extended opioid use. A dose-dependent relationship between initial outpatient dosing and greater future quantities consumed by those with prolonged usage and those with chronic usage was noted. This study suggests that providers should attempt to minimize inpatient and early outpatient opioid utilization following TJA. Multimodal pain management strategies may be employed to assist in achieving adequate pain control while minimizing opioid utilization.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.20.00732DOI Listing
January 2021

Orthopaedic Surgery Faculty: An Evaluation of Gender and Racial Diversity Compared with Other Specialties.

JB JS Open Access 2020 Jul-Sep;5(3). Epub 2020 Jun 26.

Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island.

Background: The American Academy of Orthopaedic Surgeons has adopted the strategic goal of evolving its culture and governance to become more strategic, innovative, and diverse. Given the charge to increase diversity, a focus on assessing and increasing diversity at the faculty level may help this cause. However, an analysis of gender and racial diversity among orthopaedic faculty has not been performed. The purpose of this study was to evaluate faculty appointments for underrepresented minority (URM) and female orthopaedic surgeons. We also aim to draw comparisons between orthopaedic surgery and other specialties.

Methods: Data on gender, race, and faculty rank (clinical instructor, assistant professor, associate professor, and professor) of academic faculty for 18 specialties from 1997 to 2017 were obtained from the Association of American Medical Colleges (AAMC) Faculty Roster. Assistant professors were designated as junior faculty, whereas associate professor and professor were considered senior faculty. URMs were defined using the AAMC definition-groups having lower representation than in the general population. Regression analysis was used to evaluate and compare the change over time and to compare the change across different specialties.

Results: Over the 20-year study period, the number of female faculty increased (8.8% pts) but represents a lower proportion than other specialties (13.9% pts) (p = 0.029). Female orthopaedic senior faculty grew slower (7.3% pts) than other specialties (14.7% pts) (p < 0.001). There was no difference in the growth of URM faculty positions (2.0% pts) compared with all other specialties (2.4% pts) (p = 0.165). The proportion of orthopaedic URM senior faculty increased less (0.5% pts) than other specialties (2.5% pts) (p < 0.001), whereas more orthopaedic URM junior faculty were added than other specialties (2.2% pts) (p = 0.012).

Conclusions: Although orthopaedic surgery has increased the representation of female and URM faculty members, it continues to lag behind other specialties. In addition, fewer female and URM orthopaedic faculty members obtained senior faculty status than other specialties. To address the differences seen in faculty diversity, a concerted effort should be made to recruit and promote more diverse faculty, given similar qualifications and capabilities.

Level Of Evidence: Prognostic Level IV.
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http://dx.doi.org/10.2106/JBJS.OA.20.00009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7386543PMC
June 2020

Gorham Disease Limited to the Left Upper Extremity Without Hand Involvement.

J Hand Surg Am 2021 02 15;46(2):154.e1-154.e4. Epub 2020 May 15.

Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, RI.

In this case report, we present a young female patient with a history of Gorham disease, who sustained pathologic fractures of the left radius and ulna after a low-impact fall. Massive osteolysis of the left forearm and wrist was noted on plain radiographs. The patient had had 8 previous left upper-extremity fractures without evidence of disease in any other area of the body.
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http://dx.doi.org/10.1016/j.jhsa.2020.03.015DOI Listing
February 2021

Which Decisions For Management of Carpal Tunnel Syndrome and Distal Radius Fractures Should Be Shared?

J Hand Surg Am 2020 Aug 25;45(8):690-697.e7. Epub 2020 Apr 25.

Purpose: To evaluate, from the surgeon's perspective, the importance, feasibility, and appropriateness of sharing decisions during an episode of care of carpal tunnel syndrome (CTS) or distal radius fracture in patients aged greater than 65 years.

Methods: A consortium of 9 fellowship-trained hand/upper-limb surgeons used the RAND Corporation/University of California Los Angeles Delphi Appropriateness method to evaluate the importance, feasibility, and appropriateness of sharing 27 decisions for CTS and 28 decisions for distal radius fractures in patients aged greater than 65 years. Panelists rated each measure on a scale of 1 (definitely not important/feasible/appropriate) to 9 (definitely important/feasible/appropriate) in 2 voting rounds with an intervening face-to-face discussion. Panelist agreement and disagreement were assessed using predetermined criteria.

Results: Panelists achieved agreement on 16 decisions (29%) as important, 43 (78%) as feasible, and 17 (31%) as appropriate for sharing with patients. Twelve decisions met all 3 of these criteria and were therefore considered important, feasible, and appropriate to share with patients. Examples in CTS included decisions to perform extra confirmatory diagnostic testing, to have surgery, and to perform a steroid injection into the carpal tunnel. Examples in distal radius fracture management included the decision to have surgery, type of pain medication prescribed after surgery, and whether to remove the implant. The remaining 43 decisions did not reach consensus on the importance, feasibility, and appropriateness of sharing with patients.

Conclusions: Using a validated consensus-building approach, we identified 12 decisions made during an episode of care for CTS or distal radius fracture that were important, feasible, and appropriate to share with patients from the surgeon's perspective. These decisions merit inclusion in shared decision-making models (eg, preoperative patient preference elicitation tools or decision aids) to align patient preferences with care decisions.

Clinical Relevance: Understanding which aspects of care are important, feasible, and appropriate to share with patients may improve patient-centered care by aligning patient preferences with care decisions.
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http://dx.doi.org/10.1016/j.jhsa.2020.03.008DOI Listing
August 2020

Opioid-Limiting Regulation: Effect on Patients Undergoing Knee and Shoulder Arthroscopy.

Arthroscopy 2020 03 19;36(3):824-831. Epub 2019 Dec 19.

Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A.

Purpose: To determine the effect prescription-limiting legislation passed in Rhode Island has had on opioids prescribed following arthroscopic knee and shoulder surgery at various time points, up to 90 days postoperatively.

Methods: All patients undergoing the 3 most common arthroscopic procedures at our institution (anterior cruciate ligament reconstruction, partial meniscectomy, and rotator cuff repair) were included. Patients were selected from 2 6-month study periods (prepassage and postimplementation of the law). The state's Prescription Drug Monitoring Program database was queried for controlled substances filled in the perioperative period (from 30 days preoperatively to 90 days postoperatively). Multiple logistic regressions were used to identify predictors of chronic (>30 days) opioid use.

Results: The morphine milligram equivalents (MMEs) prescribed in the initial postoperative script decreased from 319.04 (∼43 5-mg oxycodone tablets) in the prepassage to 152.45 MMEs (∼20 5-mg oxycodone tablets) in the postimplementation group (P < .001). The total MMEs filled in the first 30 days decreased from 520.93 to 299.94 MMEs (∼70 to ∼40 5-mg oxycodone tablets) (P < .001). MMEs filled between 30 and 90 days fell by 22.5% for all patients in this study; however, this change was not statistically significant (P = .263). Preoperative opioid use (odds ratio, 10.85; P < .001) and preoperative benzodiazepine use (odds ratio, 2.13; P = .005) predicted chronic opioid use postoperatively.

Conclusions: State opioid-limiting legislation reduced cumulative MMEs following arthroscopic knee and shoulder surgery in the first 30 days. Further research assessing the impact of this legislation on postoperative pain control, patient satisfaction, and functional outcomes following surgery is warranted.

Level Of Evidence: Level III, case-control study.
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http://dx.doi.org/10.1016/j.arthro.2019.09.045DOI Listing
March 2020

Opioid-Limiting Legislation Associated With Reduced Postoperative Prescribing After Surgery for Traumatic Orthopaedic Injuries.

J Orthop Trauma 2020 Apr;34(4):e114-e120

Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, RI; and.

Objectives: To evaluate opioid-prescribing patterns after surgery for orthopaedic trauma before and after implementation of opioid-limiting mandates in one state.

Design: Retrospective review.

Setting: Level-1 trauma center.

Patients/participants: Seven hundred fifty-three patients (297 pre-law and 456 post-law) undergoing isolated fixation for 6 common fracture patterns during specified pre-law (January 1, 2016-June 28, 2016) and post-law (June 01, 2017-December 31, 2017) study periods. Polytrauma patients were excluded.

Intervention: Implementation of statewide legislation establishing strict limits on initial opioid prescriptions [150 total morphine milligram equivalents (MMEs), 30 MMEs per day, or 20 total doses].

Main Outcome Measurements: Initial opioid prescription dose, cumulative MMEs filled by 30 and 90 days postoperatively.

Results: Pre-law and post-law patient groups did not differ in terms of age, sex, opioid tolerance, recent benzodiazepine use, or open versus closed fracture pattern (P > 0.05). The post-law cohort received significantly less opioids (363.4 vs. 173.6 MMEs, P < 0.001) in the first postoperative prescription. Furthermore, the post-law group received significantly less cumulative MMEs in the first 30 postoperative days (677.4 vs. 481.7 MMEs, P < 0.001); This included both opioid-naïve (633.7 vs. 478.1 MMEs, P < 0.001) and opioid-tolerant patients (1659.2 vs. 880.0 MMEs, P = 0.048). No significant difference in opioid utilization between pre- and post-law groups was noted after postoperative day 30. Independent risk factors for prolonged (>30 days) postoperative opioid use included male gender (odds ratio 2.0, 95% confidence interval 1.4-2.9, P < 0.001) and preoperative opioid use (odds ratio 5.1, 95% confidence interval 2.4-10.5, P < 0.001).

Conclusions: Opioid-limiting legislation is associated with a statistically and clinically significant reduction in initial and 30-day opioid prescriptions after surgery for orthopaedic trauma. Preoperative opioid use and male gender are independently associated with prolonged postoperative opioid use in this population.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001673DOI Listing
April 2020

Opioid-limiting legislation associated with decreased 30-day opioid utilization following anterior cervical decompression and fusion.

Spine J 2020 01 2;20(1):69-77. Epub 2019 Sep 2.

Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, 2 Dudley St, Providence, RI, 02905, USA.

Background Context: Since 2016, 35 of 50 US states have passed opioid-limiting laws. The impact on postoperative opioid prescribing and secondary outcomes following anterior cervical discectomy and fusion (ACDF) remains unknown.

Purpose: To evaluate the effect of opioid-limiting regulations on postoperative opioid prescriptions, emergency department (ED) visits, unplanned readmissions, and reoperations following elective ACDF.

Study Design/setting: Retrospective review of prospectively-collected data.

Patient Sample: Two hundred and eleven patients (101 pre-law, 110 post-law) undergoing primary elective 1-3 level ACDF during specified pre-law (December 1st, 2015-June 30th, 2016) and post-law (June 1st, 2017-December 31st, 2017) study periods were evaluated.

Methods: Demographic, medical, surgical, clinical, and pharmacological data was collected from all patients. Total morphine milligram equivalents (MMEs) filled was compared at 30-day postoperative intervals, before and after stratification by preoperative opioid-tolerance. Thirty- and 90-day ED visit, readmission, and reoperation rates were calculated. Independent predictors of increased 30-day and chronic (>90 day) opioid utilization were evaluated.

Results: Demographic, medical, and surgical factors were similar pre-law versus post-law (all p>.05). Post-law, ACDF patients received fewer opioids in their first postoperative prescription (26.65 vs. 62.08 pills, p<.001; 202.23 vs. 549.18 MMEs, p<.001) and in their first 30 postoperative days (cumulative 30-day MMEs 444.14 vs. 877.87, p<.001). Furthermore, post-law reductions in cumulative 30-day MMEs were seen among both opioid-naïve (363.54 vs. 632.20 MMEs, p<.001) and opioid-tolerant (730.08 vs. 1,122.90 MMEs, p=.022) patient populations. Increased 30-day opioid utilization was associated with surgery in the pre-law period, preoperative opioid exposure, preoperative benzodiazepine exposure, and number of levels fused (all p<.05). Chronic (>90 day) opioid requirements were associated with preoperative opioid exposure (odds ratio 4.42, p<.001) but not with pre/post-law status (p>.05). Pre- and post-law patients were similar in terms of 30- or 90-day ED visits, unplanned readmissions, and reoperations (all p>.05).

Conclusions: Implementation of mandatory opioid prescribing limits effectively decreased 30-day postoperative opioid utilization following ACDF without a rebound increase in prescription refills, ED visits, unplanned hospital readmissions, or reoperations for pain.
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http://dx.doi.org/10.1016/j.spinee.2019.08.014DOI Listing
January 2020

Has a Prescription-limiting Law in Rhode Island Helped to Reduce Opioid Use After Total Joint Arthroplasty?

Clin Orthop Relat Res 2020 02;478(2):205-215

D.B.C. Reid, B. Shapiro, K.N. Shah, J.H. Ruddell, E.M. Cohen, E. Akelman, A.H. Daniels, Warren Alpert Medical School and the Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI.

Background: In the United States, since 2016, at least 28 of 50 state legislatures have passed laws regarding mandatory prescribing limits for opioid medications. One of the earliest state laws (which was passed in Rhode Island in 2016) restricted the maximum morphine milligram equivalents provided in the first postoperative prescription for patients defined as opioid-naïve to 30 morphine milligram equivalents per day, 150 total morphine milligram equivalents, or 20 total doses. While such regulations are increasingly common in the United States, their effects on opioid use after total joint arthroplasty are unclear.

Questions/purposes: (1) Are legislative limitations to opioid prescriptions in Rhode Island associated with decreased opioid use in the immediate (first outpatient prescription postoperatively), 30-day, and 90-day periods after THA and TKA? (2) Is this law associated with similar changes in postoperative opioid use among patients who are opioid-naïve and those who are opioid-tolerant preoperatively?

Methods: Patients undergoing primary THA or TKA between January 1, 2016 and June 28, 2016 (before the law was passed on June 28, 2016) were retrospectively compared with patients undergoing surgery between June 1, 2017 and December 31, 2017 (after the law's implementation on April 17, 2017). The lapse between the pre-law and post-law periods was designed to avoid confounding from potential voluntary practice changes by physicians after the law was passed but before its mandatory implementation. Demographic and surgical details were extracted from a large multi-specialty orthopaedic group's surgical billing database using Current Procedural Terminology codes 27130 and 27447. Any patients undergoing revision procedures, same-day bilateral arthroplasties, or a second primary THA or TKA in the 3-month followup period were excluded. Secondary data were confirmed by reviewing individual electronic medical records in the associated hospital system which included three major hospital sites. We evaluated 1125 patients. In accordance with the state's department of health guidelines, patients were defined as opioid-tolerant if they had filled any prescription for an opioid medication in the 30-day preoperative period. Data on age, gender, and the proportion of patients who were defined as opioid tolerant preoperatively were collected and found to be no different between the pre-law and post-law groups. The state's prescription drug monitoring program database was used to collect data on prescriptions for all controlled substances filled between 30 days preoperatively and 90 days postoperatively. The primary outcomes were the mean morphine milligram equivalents of the initial outpatient postoperative opioid prescription after discharge and the mean cumulative morphine milligram equivalents at the 30- and 90-day postoperative intervals. Secondary analyses included subgroup analyses by procedure and by preoperative opioid tolerance.

Results: After the law was implemented, the first opioid prescriptions were smaller for patients who were opioid-naïve (mean 156 ± 106 morphine milligram equivalents after the law's passage versus 451 ± 296 before, mean difference 294 morphine milligram equivalents; p < 0.001) and those who were opioid-tolerant (263 ± 265 morphine milligram equivalents after the law's passage versus 534 ± 427 before, mean difference 271 morphine milligram equivalents; p < 0.001); however, for cumulative prescriptions in the first 30 days postoperatively, this was only true among patients who were previously opioid-naïve (501 ± 416 morphine milligram equivalents after the law's passage versus 796 ± 597 before, mean difference 295 morphine milligram equivalents; p < 0.001). Those who were opioid-tolerant did not have a decrease in the cumulative number of 30-day morphine milligram equivalents (1288 ± 1632 morphine milligram equivalents after the law's passage versus 1398 ± 1274 before, mean difference 110 morphine milligram equivalents; p = 0.066).

Conclusions: The prescription-limiting law was associated with a decline in cumulative opioid prescriptions at 30 days postoperatively filled by patients who were opioid-naïve before total joint arthroplasty. This may substantially impact public health, and these policies should be considered an important tool for healthcare providers, communities, and policymakers who wish to combat the current opioid epidemic. However, given the lack of a discernible effect on cumulative opioids filled from 30 to 90 days postoperatively, further investigations are needed to evaluate more effective policies to prevent prolonged opioid use after total joint arthroplasty, particularly in patients who are opioid-tolerant preoperatively.

Level Of Evidence: Level III, therapeutic study.
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http://dx.doi.org/10.1097/CORR.0000000000000885DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7438153PMC
February 2020

Predicting Carpal Bone Kinematics Using an Expanded Digital Database of Wrist Carpal Bone Anatomy and Kinematics.

J Orthop Res 2019 12 22;37(12):2661-2670. Epub 2019 Aug 22.

Center for Biomedical Engineering and School of Engineering, Brown University, Providence, Rhode Island, 02912.

The wrist can be considered a 2 degrees-of-freedom joint with all movements reflecting the combination of flexion-extension and radial-ulnar deviation. Wrist motions are accomplished by the kinematic reduction of the 42 degrees-of-freedom of the individual carpal bones. While previous studies have demonstrated the minimal motion of the scaphoid and lunate as the wrist moves along the dart-thrower's path or small relative motion between hamate-capitate-trapezoid, an understanding of the kinematics of the complete carpus across all wrist motions remains lacking. To address this, we assembled an open-source database of in vivo carpal motions and developed mathematical models of the carpal kinematics as a function of wrist motion. Quadratic surfaces were trained for each of the 42-carpal bone degrees-of-freedom and the goodness of fits were evaluated. Using the models, paths of wrist motion that generated minimal carpal rotations or translations were determined. Model predictions were best for flexion-extension, radial-ulnar deviation, and volar-dorsal translations for all carpal bones with R  > 0.8, while the estimates were least effective for supination-pronation with R  < 0.6. The wrist path of motion's analysis indicated that the distal row of carpal bones moves rigidly together (<3° motion), along the anatomical axis of wrist motion, while the bones in the proximal row undergo minimal motion when the wrist moves in a path oblique to the main axes. The open-source dataset along with its graphical user interface and mathematical models should facilitate clinical visualization and enable new studies of carpal kinematics and function. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2661-2670, 2019.
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http://dx.doi.org/10.1002/jor.24435DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376386PMC
December 2019

Mandatory Prescription Limits and Opioid Utilization Following Orthopaedic Surgery.

J Bone Joint Surg Am 2019 May;101(10):e43

Department of Orthopaedics (D.B.C.R., K.N.S., E.A., and A.H.D.), Warren Alpert Medical School of Brown University (B.H.S. and J.H.R.), Providence, Rhode Island.

Background: Since 2016, over half of the states in the United States have passed mandatory limits on opioid prescriptions, with limited evidence of effectiveness. In this study, we evaluated postoperative opioid prescriptions following orthopaedic surgery before and after the implementation of one of the earliest such laws.

Methods: Following the implementation of state legislation limiting opioid prescriptions for opioid-naïve patients, 2 patient cohorts (pre-law and post-law) were compared. Both opioid-tolerant and opioid-naïve patients undergoing 6 common orthopaedic procedures (total knee arthroplasty, rotator cuff repair, anterior cruciate ligament reconstruction, open reduction and internal fixation for a distal radial fracture, open reduction and internal fixation for an ankle fracture, and lumbar discectomy) met inclusion criteria. Patients undergoing >1 primary procedure in the same operative session were excluded. All benzodiazepine and opioid prescriptions from 30 days before to 90 days after the surgical procedure were recorded. Logistic regression was performed to determine risk factors for prolonged postoperative opioid use.

Results: In this study, 836 pre-law patients were compared with 940 post-law patients. The 2 groups were similar with regard to demographic variables, baseline opioid tolerance, and recent benzodiazepine use (all p > 0.05). Post-law, for all patients, there were decreases in the initial prescription pill quantity (49.65 pills pre-law and 22.08 pills post-law; p < 0.001) and the total morphine milligram equivalents (MMEs) (417.67 MMEs pre-law and 173.86 MMEs post-law; p < 0.001), regardless of patient preoperative opioid exposure (all p < 0.001). Additionally, there were decreases in the mean cumulative 30-day MMEs (790.01 MMEs pre-law and 524.61 MMEs post-law; p < 0.001) and the 30 to 90-day MMEs (243.51 MMEs pre-law and 208.54 MMEs post-law; p = 0.008). Despite being specifically exempted from the legislation, opioid-tolerant patients likewise experienced a significant decrease in cumulative 30-day MMEs (1,304.08 MMEs pre-law and 1,015.19 MMEs post-law; p = 0.0016). Opioid-tolerant patients required more postoperative opioids at all time points and had an increased likelihood of prolonged opioid use compared with those who were opioid-naïve preoperatively (odds ratio, 8.73 [95% confidence interval, 6.21 to 12.29]).

Conclusions: A clinically important and significant reduction in opioid utilization after orthopaedic surgery was observed following the implementation of statewide mandatory opioid prescription limits.

Clinical Relevance: After implementation of mandatory opioid prescription regulations, a clinically important and significant decline in the volume of opioids dispensed in the short term and intermediate term following orthopaedic surgery was observed. Furthermore, important clinical predictors of prolonged postoperative opioid use, including preoperative opioid use and preoperative benzodiazepine use, were identified. These findings have important implications for public health, as well as the potential to influence policymakers and to change practice among orthopaedic surgeons.
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http://dx.doi.org/10.2106/JBJS.18.00943DOI Listing
May 2019

Common Topics of Publication and Levels of Evidence in the Current Hand Surgery Literature.

J Hand Microsurg 2019 Apr 9;11(1):14-17. Epub 2018 Aug 9.

Department of Plastic Surgery, Department of Biomedical Informatics, Center for Biomedical Ethics and Society; Vanderbilt University Medical Center, Nashville, Tennessee, United States.

Scientific publications are the primary vehicle for the distribution of scientific findings, but there has been limited research on literature topic surveillance. We sought to identify and characterize the most commonly published topic domains in the hand surgery literature. We performed a 6-month hypothesis testing phase to identify the most frequently published topics in three hand surgery journals: (American), and (European). We reviewed all of the published articles in these journals from June 2010 to May 2015 to identify and characterize publications related to the three most common topic domains. A total of 2,146 articles were published during the 5-year study period. The three most frequent topics domains included distal radius (DR) (11% of all articles), flexor tendon (FT) (9%), and carpal tunnel (CT) (7.5%). These subjects accounted for a total of 584 articles (27% of all publications) and 3,014 published pages during the study period. FT, CT, and DR publications were cited on average 2.3 times per year (2.5, 2.4, and 2.0, respectively). A small subset of topic domains makes up a significant proportion of scientific publications in hand surgery.
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http://dx.doi.org/10.1055/s-0038-1661423DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6431293PMC
April 2019

A Prospective Evaluation of the Effect of Supervised Hand Therapy After Carpal Tunnel Surgery.

Hand (N Y) 2020 05 12;15(3):315-321. Epub 2018 Nov 12.

The Warren Alpert Medical School of Brown University, Providence, RI, USA.

The objective of this investigation is to examine the effect of postoperative therapy after routine carpal tunnel release. Our hypothesis was that supervised hand therapy does not improve outcomes after routine carpal tunnel release. : Patients with carpal tunnel syndrome were randomly assigned to one of 3 groups based on the last digit of their medical record numbers to one of 3 groups: standard 6-week postoperative rehabilitation (standard therapy), expedited one-session postoperative rehabilitation group (expedited therapy), and no postoperative rehabilitation group (no therapy). The primary outcome measures were Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and return to work. The outcome questionnaire was completed preoperatively, at the 2-week follow-up visit, and monthly to 6 months after surgery. All 3 treatment groups had similar mean QuickDASH scores preoperatively. At 1- to 6-month follow-up, all 3 groups had similar QuickDASH scores at each visit, and all showed a significant decline from baseline (preoperative) QuickDASH score. Overall, QuickDASH score decreased significantly from a preoperative visit mean of 42.7 to a final postoperative (visit 8) mean of 6.69. There was no significant difference in the mean QuickDASH score among all 3 groups at 6-month follow-up. There was no significance in the time of return to work among the 3 groups (standard therapy, 21.8 days; expedited therapy, 20.9 days; no therapy, 16.6 days). : This investigation adds evidence that supervised hand therapy does not improve the outcomes of routine carpal tunnel surgery as measured by QuickDASH and return to work.
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http://dx.doi.org/10.1177/1558944718812155DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7225875PMC
May 2020

Effect of narcotic prescription limiting legislation on opioid utilization following lumbar spine surgery.

Spine J 2019 04 14;19(4):717-725. Epub 2018 Sep 14.

Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA.

Background Context: Prescription opioid abuse is a public health emergency. Opioid prescriptions for spine patients account for a large proportion of use. Some states have implemented statutory limits on prescribers, however it remains unclear whether such laws are effective.

Purpose: This investigation compares opioid prescription patterns for patients undergoing lumbar spine surgery before and after the passage of statewide narcotic-limiting legislation in Rhode Island.

Study Design/setting: Retrospective review of prospectively-collected medical and pharmacologic data.

Patient Sample: Two patient cohorts (pre-law January 1, 2016-June 31, 2016 and post-law June 1, 2017-December 31, 2017) that included all patients undergoing selected lumbar spine surgeries (lumbar discectomy, lumbar decompression without fusion, and posterior lumbar fusion).

Methods: Demographic and surgical variables were collected from the patient's medical charts, and information on controlled substances was collected from the state prescription drug monitoring program database. Variables collected included the number of pills and total morphine milligram equivalents (MMEs) of the first prescription, number of prescriptions filled within 30 days of surgery, total MMEs filled in the 30-day postoperative period, and total MMEs filled from 30 to 90 days after surgery. For comparison of continuous variables, t test or Mann-Whitney U test were used as appropriate. Chi-squared analysis was utilized for comparison of categorical variables. Independent risk factors for prolonged postoperative opioid use were evaluated using logistic regression.

Results: There were no significant differences between pre-law (n = 241) and post-law (n = 311) cohorts in terms of age, sex, preoperative opioid use, or preoperative anxiolytic use (p > .05). A greater than 50% decline was observed among all patients from the pre-law to the post-law period in terms of the number of pills (51.61 vs 23.60 pills, p < .001) and MMEs (525.56 vs 218.77 MMEs, p < .001) provided in the first postoperative opioid prescription. The mean total MMEs provided in the first 30 days decreased significantly (891.26 vs 628.63 MMEs, p < .001) despite an increase in the average number of opioid prescriptions filled (1.75 vs 2.04 prescriptions, p = .002) during this time. There was no significant difference in mean MMEs filled from 30 to 90 days. Upon subgroup analysis, there was a statistically significant decline in both the mean first prescription and total 30-day MMEs regardless of preoperative opioid status (all p < .05) or specific procedure performed (all p < .05). Preoperative opioid use was strongly associated with prolonged postoperative opioid requirements throughout the study period (OR 4.71, 95% CI 3.11-7.13, p < .001). There were no significant differences between cohorts in terms of emergency department (ED) visits or unplanned hospital readmissions at 30 and 90 days following surgery (all p > .05).

Conclusions: The institution of mandatory statewide opioid prescription limits has resulted in a significant reduction in initial and 30-day opioid prescriptions following lumbar spine surgery. Decreased opioid utilization was observed in all patients, regardless of preoperative opioid tolerance or procedure performed. No significant change in postoperative ED visits or unplanned hospital readmissions was seen following implementation of the legislation. This investigation provides preliminary evidence that narcotic limiting legislation may be effective in decreasing opioid prescriptions after lumbar spine surgery for both opioid-naïve and opioid-tolerant patients.
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http://dx.doi.org/10.1016/j.spinee.2018.09.007DOI Listing
April 2019

Utility of Prolotherapy for Upper Extremity Pathology.

J Hand Surg Am 2019 Mar 23;44(3):236-239. Epub 2018 Jun 23.

Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI.

Prolotherapy is a method of treatment of painful musculoskeletal conditions whereby a sclerosing agent is injected into an area of tendinosis or osteoarthritis to strengthen and repair painful connective tissue. It is a safe, effective, and relatively inexpensive nonsurgical treatment modality. This article provides a history of prolotherapy, discusses its proposed mechanisms of action, and provides a review of the existing literature on prolotherapy as a treatment for upper extremity pathologies, specifically, hand osteoarthritis, lateral epicondylitis, and rotator cuff disease.
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http://dx.doi.org/10.1016/j.jhsa.2018.05.021DOI Listing
March 2019

The Affordable Care Act Decreased the Proportion of Uninsured Patients in a Safety Net Orthopaedic Clinic.

Clin Orthop Relat Res 2018 05;476(5):925-931

J. A. Gil, A. D. Goodman, E. Akelman, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA J. Kleiner, Warren Alpert Medical School, Brown University, Providence, RI, USA R. N. Kamal, Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA, USA L. C. Baker, Department of Health Research & Policy, Stanford University, Stanford, CA, USA.

Background: The Patient Protection and Affordable Care Act (ACA) was approved in 2010, substantially altering the economics of providing and receiving healthcare services in the United States. One of the primary goals of this legislation was to expand insurance coverage for under- and uninsured residents. Our objective was to examine the effect of the ACA on the insurance status of patients at a safety net clinic. Our institution houses a safety net clinic that provides the dominant majority of orthopaedic care for uninsured patients in our state. Therefore, our study allows us to accurately examine the magnitude of the effect on insurance status in safety net orthopaedic clinics.

Questions/purposes: (1) Did the ACA result in a decrease in the number of uninsured patients at a safety net orthopaedic clinic that provides the dominant majority of orthopaedic care for the uninsured in the state? (2) Did the proportion of patients insured after passage of the ACA differ across age or demographic groups in one state?

Methods: We retrospectively examined our longitudinally maintained adult orthopaedic surgery clinic database from January 2009 to March 2015 and collected visit and demographic data, including zip code income quartile. Based on the data published by the Rhode Island Department of Health, our clinic provides the dominant majority of orthopaedic care for uninsured patients in our state. Therefore, examination of the changes in the proportion of insurance status in our clinic allows us to assess the effect of the ACA on the state level. Univariate and multivariable logistic regression analyses were used to determine the relationship between demographic variables and insurance status. Adjusted odds ratios and 95% CIs were calculated for the proportion of uninsured visits. The proportion of uninsured visits before and after implementation of the ACA was evaluated with an interrupted time-series analysis. The reduction in the proportion of patients without insurance between demographic groups (ie, race, gender, language spoken, and income level) also was compared using an interrupted time-series design.

Results: There was a 36% absolute reduction (95% CI, 35%-38%; p < 0.001) in uninsured visits (73% relative reduction; 95% CI, 71%-75%; p < 0.001). There was an immediate 28% absolute reduction (95% CI, 21%-34%; p < 0.001) at the time of ACA implementation, which continued to decline thereafter. After controlling for potential confounding variables such as gender, race, age, and income level, we found that patients who were white, men, younger than 65 years, and seen after January 2014 were more likely to have insurance than patients of other races, women, older patients, and patients treated before January 2014.

Conclusions: After the ACA was implemented, the proportion of patients with health insurance at our safety net adult orthopaedic surgery clinic increased substantially. The reduction in uninsured patients was not equal across genders, races, ages, and incomes. Future studies may benefit from identifying barriers to insurance acquisition in these subpopulations. The results of this study could affect orthopaedic practices in the United States by guiding policy decisions regarding health care.

Level Of Evidence: Level III, therapeutic study.
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http://dx.doi.org/10.1007/s11999.0000000000000078DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5916608PMC
May 2018

Thirty-Day Reoperation and/or Admission After Elective Hand Surgery in Adults: A 10-Year Review.

J Hand Surg Am 2018 04 15;43(4):383.e1-383.e7. Epub 2017 Nov 15.

Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI.

Purpose: Whereas acute complications following elective hand surgery have been assumed to be rare, the incidence of 30-day unplanned reoperation and/or admission for the most common elective procedures has not been well described. Our goal was to calculate the incidence and identify the risk factors associated with these complications in a busy academic practice.

Methods: Our institution's quality assurance database was examined retrospectively for unplanned reoperations and/or admissions within 30 days in adults undergoing elective procedures with 2 senior attending surgeons from February 2006 to January 2016. Each event was categorized by causative factor and charts were reviewed to establish risk factors and cultured organisms. Our billing database was examined for the concomitant procedural volume.

Results: In our cohort of 18,081 surgeries (57.6% carpal tunnel or trigger digit releases), 27 patients had an unplanned reoperation and/or admission within 30 days (0.15% total incidence; including carpal tunnel release, 0.10%; trigger digit release, 0.09%; major wrist surgery, 0.74%) including 17 infections (0.09%). These were unevenly distributed over time after surgery with 29.6% occurring within 7 days, 59.2% in 8 to 14 days, 11.1% in 15 to 21 days, and none between 22 and 30 days.

Conclusions: Reoperations and/or unplanned admission within 30 days after elective hand surgery are infrequent (15 per 10,000 cases) and are most commonly related to infections (63.0%). More invasive surgeries are associated with a higher incidence than simpler procedures, and these complications are most likely to occur within 3 weeks after surgery. These data in elective patients do not cover certain clinically relevant outcomes, such as chronic pain or limited function, and may not be generalizable to all practices.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2017.10.015DOI Listing
April 2018

A Biomechanical Evaluation of a 2-Suture Anchor Repair Technique for Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament Injuries.

Hand (N Y) 2018 09 24;13(5):581-585. Epub 2017 Aug 24.

1 Brown University, Providence, RI, USA.

Background: A complete thumb ulnar collateral ligament (UCL) repaired with 1-suture anchor has been demonstrated to be significantly weaker compared with the intact UCL. The objective of this study is to test the biomechanical strength of a 2-anchor thumb UCL repair.

Methods: Nine paired fresh-frozen hands were used for this biomechanical analysis. One thumb from each pair was randomized to the control group and one to the repair group. In the control group, the UCL was loaded to failure in tension. In the repair group, the UCL was dissected off of the proximal phalanx, subsequently repaired with a 2-anchor technique, and then tested to failure.

Results: The mean yield load was 342 N (95% confidence interval [CI], 215-470 N) in the control group and 68 N (95% CI, 45-91 N) in the repair group. The mean maximum load at failure was 379 N (95% CI, 246-513 N) in the control group and 84 N (95% CI, 62-105 N) in the repair group. The mean stiffness was 72 N/m (95% CI, 48-96 N/m) in the control group and 17 N/m (95% CI, 13-21 N) in the repair group. The mean displacement at failure was 7.8 mm (95% CI, 7-9 mm) in the control group and 7.8 mm (95% CI, 7-9 mm) in the repair group.

Conclusions: The 2-anchor repair technique we tested does not acutely reestablish the strength of the insertion of the native insertion of the UCL with this technique.
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http://dx.doi.org/10.1177/1558944717725380DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109898PMC
September 2018

Evaluation of Ulnar-sided Wrist Pain.

J Am Acad Orthop Surg 2017 Aug;25(8):e150-e156

From the Department of Orthopaedic Surgery, Brown University, Rhode Island Hospital, Providence, RI.

Determining the etiology of ulnar-sided wrist pain is often challenging. The condition may be acute or chronic, and differential diagnoses include injuries to the ulnar carpal bones, ligament tears, tendinitis, vascular conditions, osteoarthritis and systemic arthritis, and ulnar nerve compression. An anatomically based, methodical physical examination coupled with provocative maneuvers, including piano key, ulnar impaction, shuck, foveal stress, and extensor carpi ulnaris synergy tests, further defines the differential diagnosis. Diagnostic imaging used in the evaluation of ulnar-sided wrist pain includes plain radiographs and MRI with or without arthrography. Wrist arthroscopy is becoming increasingly important in the diagnosis and management of ulnar-sided intra-articular wrist pathology.
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http://dx.doi.org/10.5435/JAAOS-D-16-00407DOI Listing
August 2017

Polymicrobial pyogenic flexor tenosynovitis of the index finger and first ray resulting from autophagia.

J Orthop 2017 Sep 30;14(3):403-405. Epub 2017 Jun 30.

Department of Orthopaedics,Alpert Medical School of Brown University, Providence, RI, United States.

Pyogenic flexor tenosynovitis (PFT) is a well known infectious condition of the hand, involving the inoculation of the flexor tendon sheath with microorganisms. Many cases have been reported, common causes including direct inoculation by a puncture wound and deep lacerations extending into the flexor tendon sheath. In this report, we present a case of a 50 year old female with PFT resulting from autophagia (consuming one's own body parts, in our case, fingers) successfully treated with irrigation and debridement, amputation of the index finger at the metacarpophalangeal joint and antibiotic therapy.
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http://dx.doi.org/10.1016/j.jor.2017.06.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5502698PMC
September 2017

Fixation Strength in Full and Limited Fixation of Osteoporotic Distal Radius Fractures.

Hand (N Y) 2018 07 16;13(4):461-465. Epub 2017 May 16.

2 Brown University, Providence, RI, USA.

Background: The purpose of this investigation is to determine whether osteoporotic intra-articular distal radius fractures surgically treated by filling all 7 distal screws of a volar plate will have a higher load to failure than those treated by filling only 4 distal screws.

Methods: Ten matched pairs of fresh frozen cadaveric forearms were randomized within each pair to be treated by using either all 7 of the distal holes of a volar plate or only 4 distal screws. The distal radius fixation was performed with unicortical screws going to but not through the dorsal cortex, and the most distal screws were placed within 4 mm of the joint surface. An AO C2 type fracture was then created. All specimens were tested cyclically, with an axial load of 60 N, at 3 Hz for 1000 cycles to simulate early postoperative motion. All specimens were subsequently tested to mechanical failure.

Results: There were no failures in either group during cyclic testing. There was no difference detected between groups for mean stiffness, yield load, peak load, or load to clinical failure. In both groups, the yield load, peak load, and load to clinical failure were higher than the 60- to 100-N forces encountered during postoperative rehabilitation.

Conclusions: There was no difference detected between osteoporotic intra-articular distal radius fractures treated by utilizing all 7 of the distal screws of a volar plate compared with those treated with only 4 distal screws.
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http://dx.doi.org/10.1177/1558944717708032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6081775PMC
July 2018

Multifocal Neuropathy: Expanding the Scope of Double Crush Syndrome.

J Hand Surg Am 2016 Dec 15;41(12):1171-1175. Epub 2016 Oct 15.

The Philadelphia Hand Center, PC, Thomas Jefferson University, Philadelphia, PA.

Double crush syndrome (DCS), as it is classically defined, is a clinical condition composed of neurological dysfunction due to compressive pathology at multiple sites along a single peripheral nerve. The traditional definition of DCS is narrow in scope because many systemic pathologic processes, such as diabetes mellitus, drug-induced neuropathy, vascular disease and autoimmune neuronal damage, can have deleterious effects on nerve function. Multifocal neuropathy is a more appropriate term describing the multiple etiologies (including compressive lesions) that may synergistically contribute to nerve dysfunction and clinical symptoms. This paper examines the history of DCS and multifocal neuropathy, including the epidemiology and pathophysiology in addition to principles of evaluation and management.
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http://dx.doi.org/10.1016/j.jhsa.2016.09.009DOI Listing
December 2016

Carpal Kinematics and Kinetics.

J Hand Surg Am 2016 Oct 25;41(10):1011-1018. Epub 2016 Aug 25.

Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI.

The complex interaction of the carpal bones, their intrinsic and extrinsic ligaments, and the forces in the normal wrist continue to be studied. Factors that influence kinematics, such as carpal bone morphology and clinical laxity, continue to be identified. As imaging technology improves, so does our ability to better understand and identify these factors. In this review, we describe advances in our understanding of carpal kinematics and kinetics. We use scapholunate ligament tears as an example of the disconnect that exists between our knowledge of carpal instability and limitations in current reconstruction techniques.
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http://dx.doi.org/10.1016/j.jhsa.2016.07.105DOI Listing
October 2016

Distal radius fracture reduction using the looped-stockinette technique.

Am J Emerg Med 2016 Oct 27;34(10):2038-2040. Epub 2016 Jul 27.

Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University.

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http://dx.doi.org/10.1016/j.ajem.2016.07.038DOI Listing
October 2016
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