Publications by authors named "Louis C Grandizio"

42 Publications

The Impact of Smoking on Delayed Osseous Union After Arthrodesis Procedures in the Hand and Wrist.

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

Department of Orthopedic Surgery, Geisinger Medical Center, Geisinger Musculoskeletal Institute, Danville, PA. Electronic address:

Purpose: The purpose of this study was to evaluate the relationship between smoking and delayed radiographic union after hand and wrist arthrodesis procedures. We hypothesized that smoking would be associated with a higher rate of delayed union.

Methods: All cases of hand or wrist arthrodesis procedures in patients aged ≥18 years from 2006 to 2020 were identified. Cases were included if they had >90 days of radiographic follow-up or evidence of union before 90 days. Baseline demographics were recorded for each case including smoking status at the time of surgery. Complications were recorded and all postoperative radiographs were reviewed to assess for evidence of delayed union (defined as lack of osseous union by 90 days after surgery). We compared active smokers and nonsmokers and performed a logistic regression analysis to estimate the odds of experiencing a delayed radiographic union.

Results: A total of 309 arthrodesis cases were included and 24% were active smokers. Overall, radiographic evidence of a delayed union was found in 17% of cases. Smokers were significantly more likely to have a delayed union compared with nonsmokers (27% vs 14%). Results of the adjusted logistic regression analysis demonstrated that there was a significantly increased odds of experiencing a delayed union for patients who were active smokers compared with nonsmokers (odds ratio, 2.20; 95% confidence interval, 1.09-4.43). In addition, the rate of symptomatic nonunion requiring reoperation was higher in smokers (15%) compared with nonsmokers (6%).

Conclusions: Smoking was associated with increased odds of delayed radiographic union in patients undergoing hand and wrist arthrodesis procedures. Patients should be counseled appropriately on the risks of smoking on bone healing and encouraged to abstain from nicotine use in the perioperative period.

Type Of Study/level Of Evidence: Prognostic II.
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http://dx.doi.org/10.1016/j.jhsa.2022.05.016DOI Listing
August 2022

A Comparison of Acute Versus Chronic Thumb Ulnar Collateral Ligament Surgery Using Primary Suture Anchor Repair and Local Soft Tissue Advancement.

J Hand Surg Glob Online 2022 May 27;4(3):141-146. Epub 2022 Mar 27.

Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA.

Purpose: To assess patient satisfaction and functional outcomes of primary suture anchor repair with local soft tissue advancement for both acute and chronic thumb ulnar collateral ligament (UCL) injuries.

Methods: We retrospectively reviewed patient charts who had undergone operative UCL repair between 2006 and 2013. Patients who had more than 8 weeks between the time of injury and surgery were classified as having chronic injuries. In both acute and chronic cases, a primary suture anchor repair of the ligament was performed with local soft tissue advancement. For each patient, baseline demographics, operative complications, and associated injuries were recorded along with visual analog scale pain scores; Quick Disabilities of the Arm, Shoulder, and Hand scores; and their return to work or sport status. Comparisons of outcomes and complications were made between the groups (acute vs chronic injuries).

Results: Among the 36 patients who met our inclusion criteria, both the acute (n = 19) and chronic (n = 17) groups were similar with regards to major or minor comorbidities, visual analog scale scores; Quick Disabilities of the Arm, Shoulder, and Hand scores; return to work or sport status; or patient satisfaction.

Conclusions: Patients with both acute and chronic thumb UCL injuries have similarly acceptable functional outcomes, postoperative pain, and satisfaction. Primary suture anchor repair without ligament reconstruction appears to be a safe and effective treatment option for patients' thumb UCL injuries, even in the chronic setting.

Type Of Study/level Of Evidence: Therapeutic III.
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http://dx.doi.org/10.1016/j.jhsg.2022.02.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9120786PMC
May 2022

Distal Biceps Tendon Rupture Videos on YouTube: An Analysis of Video Content and Quality.

J Hand Surg Glob Online 2022 Jan 1;4(1):3-7. Epub 2021 Dec 1.

Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA.

Purpose: Our purpose was to analyze the content and quality of YouTube videos related to distal biceps tendon (DBT) ruptures and repair. We aimed to compare differences between academic and nonacademic video sources.

Methods: The most popular YouTube videos related to DBT injuries were compiled and analyzed according to source. Viewing characteristics were determined for each video. Video content and quality were assessed by 2 reviewers and analyzed according to the benchmark criteria, DISCERN criteria, and a Distal Biceps Content Score. Cohen's kappa was used to measure interrater reliability.

Results: A total of 59 DBT YouTube videos were included. The intraclass correlation coefficients ranged from moderate to excellent for the content scores. The mean DISCERN score was 29, and no videos were rated as either "good" or "excellent" for content quality. With the exception of the mean criteria score (1.5 vs 0.5), videos from academic sources did not demonstrate significantly higher levels of content quality. Only 4/59 videos (7%) discussed the natural history of nonsurgically treated DBT ruptures. Of the 32 videos that discussed surgical techniques, only 3/32 (9%) had a preference for 2-incision techniques. No videos discussed the association between spontaneous DBT ruptures and cardiac amyloidosis.

Conclusions: The overall content, quality, and reliability of DBT videos on YouTube are poor. Videos from academic sources do not provide higher-quality information than videos from nonacademic sources. Videos related to operative treatment of DBT ruptures more frequently discuss single-incision techniques.

Clinical Relevance: Social media videos can function as direct-to-consumer marketing materials, and surgeons should be prepared to address misconceptions regarding the management of DBT tears. Patients are increasingly seeking health information online, and surgeons should direct patients toward more reliable and vetted sources of information.
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http://dx.doi.org/10.1016/j.jhsg.2021.10.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8991868PMC
January 2022

The Reliability of the CTS-6 for Examiners With Varying Levels of Clinical Experience.

J Hand Surg Am 2022 06 5;47(6):501-506. Epub 2022 Mar 5.

Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Department of Orthopaedic Surgery, 16 Woodbine Lane, Danville, PA.

Purpose: To assess the interrater reliability of the CTS-6 for examiners with varying levels of clinical expertise. We also aimed to analyze this instrument's sensitivity (Sn) and specificity (Sp), using the CTS-6 score obtained by a hand surgeon as a reference standard.

Methods: Three examining groups consisting of medical students, occupational hand therapists, and hand surgeons examined a consecutive series of patients in an academic upper-extremity clinic. A total of 3 examiners (1 from each group) recorded a CTS-6 score for each patient. The examiners were blinded to the scores from the other groups. The interrater reliability was determined between the groups with respect to the diagnosis of CTS and the individual CTS-6 components. Sn and Sp were calculated for each of the groups using the CTS-6 obtained by the hand surgeons as the reference standard.

Results: Two hundred seven patients were included. For the diagnosis of CTS (CTS-6 score of 12 or greater as determined by a hand surgeon), there was substantial agreement between the 3 groups (Fleiss kappa 0.73; 95% CI [0.65 -0.82]; P < .05). For individual CTS-6 components, the agreement between the groups was highest for assessing subjective numbness and lowest for assessing a Tinel sign (Fleiss kappa of 0.77 and 0.49, respectively). The Sn/Sp for diagnosing CTS was 87%/91% for the medical student group and 81%/95% for the occupational hand therapist group.

Conclusions: The CTS-6 can be reliably used as a screening and diagnostic tool for CTS by clinicians with a variety of experience levels and without specific fellowship training in upper-extremity surgery.

Type Of Study/level Of Evidence: Diagnostic I.
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http://dx.doi.org/10.1016/j.jhsa.2022.01.024DOI Listing
June 2022

Elbow Ulnar Collateral Ligament Injuries in Throwing Athletes: Diagnosis and Management.

J Hand Surg Am 2022 03;47(3):266-273

Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger MSKI, Danville, PA. Electronic address:

Ulnar collateral ligament (UCL) injuries of the elbow are common in overhead throwing athletes. With throwing, the elbow experiences substantial valgus stress and repetitive microtrauma can lead to injury. Increasing rates of injury among both youth and professional throwers has resulted in a "UCL epidemic." Ulnar collateral ligament reconstruction ("Tommy John Surgery") became a part of the public consciousness after Tommy John returned to professional baseball after a UCL reconstruction with Dr Frank Jobe for what was once considered a career-ending injury. Partial tears and some athletes with complete UCL injuries can be managed without surgery. Since the introduction of UCL reconstruction, technical modifications have aimed to decrease complications and increase return-to-play rates. Ulnar collateral ligament repair has reemerged as a potential surgical option for some throwers. Future prospective and comparative studies are necessary to better define the optimal operative treatment for these injuries.
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http://dx.doi.org/10.1016/j.jhsa.2021.11.026DOI Listing
March 2022

The impact of self-efficacy on nonoperative treatment of atraumatic shoulder pain.

J Osteopath Med 2022 Feb 25;122(6):297-302. Epub 2022 Feb 25.

Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, 100 N. Academy Avenue, Danville, PA, USA.

Context: Atraumatic shoulder pain is frequently encountered in primary care and surgical clinics. With increased recognition of the biopsychosocial model, there has been an increased emphasis on identifying patient factors associated with less effective coping strategies such as pain catastrophizing. It remains uncertain what impact self-efficacy has on the response to nonoperative treatment of shoulder pain.

Objectives: Our purpose is to determine the influence of patient coping strategies (self-efficacy) on the outcome of nonoperative treatment of atraumatic shoulder pain. We hypothesize that higher levels of self-efficacy are associated with increased self-reported function after nonoperative treatment.

Methods: We conducted a retrospective case-control study for a consecutive series of patients seen in our clinic with nonoperatively managed atraumatic shoulder pain. Baseline demographics and range of motion were recorded. Patients completed the Simple Shoulder Test (SST), PROMIS Pain Interference (PI), and PROMIS Self-Efficacy for Managing Symptoms (SE). After 3 months of nonoperative treatment, patients were placed into two groups: patients who clinically improved (Group 1) and those that did not (Group 2), with clinical improvement defined as an increase of 2 or greater on the SST.

Results: Seventy-eight patients returned for follow-up and completed all questionnaires. There were no statistically significant differences for age, sex, or tobacco use between the two groups. Half of the patients in our series had symptoms for >12 months, with rotator cuff syndrome being the most frequent diagnosis (40.0%). Patients in Group 1 had significantly higher PROMIS SE scores (42 vs. 39, p=0.0094) at initial evaluation. At 3-month follow-up, patients in Group 1 also had significantly lower Numeric Pain Rating Scale (NPRS) scores (4.5 vs. 6.5, p=0.0067), compared to Group 2.

Conclusions: Patients who experience clinical improvement with nonoperative treatment of atraumatic shoulder conditions demonstrate higher self-efficacy than patients who fail to improve. Guiding patients with atraumatic shoulder pain and low self-efficacy toward interventions aimed at improving coping strategies, rather than addressing musculoskeletal factors alone, may contribute to the goal of improving outcomes.
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http://dx.doi.org/10.1515/jom-2021-0132DOI Listing
February 2022

The Effect of Salary Compensation for Time Spent Teaching in an Orthopaedic Residency Program: An Analysis of Teaching Performance Reviews.

J Am Acad Orthop Surg Glob Res Rev 2022 01 7;6(1). Epub 2022 Jan 7.

From the Geisinger Medical Center, Department of Orthopaedic Surgery, Danville, PA (Dr. Grandizio), and the Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA (Dr. Warnick, Dr. Gehrman, and Dr. Klena).

Introduction: Although there has been a recent emphasis on standardized resident assessments within Accrediation Council for Graduate Medical Education programs, assessments of faculty teaching performance and effectiveness are less frequent. Our purpose was to compare the teaching performance of orthopaedic surgery faculty receiving compensation for time spent teaching with faculty without compensation.

Methods: For this prospective investigation, we collected anonymous resident reviews of 23 orthopaedic faculty within a rural, academic orthopaedic residency program over 2 academic years. Performance reviews of the faculty used a validated assessment of clinical teaching effectiveness with nine domains (faculty knowledge, organization, enthusiasm, rapport, involvement in learning experiences, feedback, clinical skill, accessibility, and overall effectiveness). A composite teaching effectiveness score was determined by adding each of the scores from the individual domains. We compared reviews for faculty members with and without compensation for time spent teaching.

Results: A total of 202 performance reviews for 23 orthopaedic faculty were analyzed. Most of the faculty were male (91%), and 61% received compensation for teaching. No demographic differences were observed between the two faculty groups. Notable differences between the groups were noted in three domains: enthusiasm, ability to establish rapport as well as direction, and feedback. Faculty compensated for teaching demonstrated a markedly higher composite teaching effectiveness score than those without compensation.

Discussion: These data suggest that orthopaedic faculty compensated for teaching responsibilities provide a better educational experience for resident trainees compared with faculty without compensation for teaching. Future studies should aim to assess varying compensation models for teaching responsibilities across different departments.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-21-00307DOI Listing
January 2022

Median Nerve and Carpal Tunnel Morphology Before and After Endoscopic Carpal Tunnel Release: A 6-Year Follow-up Study.

Hand (N Y) 2021 Dec 21:15589447211058819. Epub 2021 Dec 21.

Geisinger Medical Center, Danville, PA, USA.

Background: Our purpose was to describe structural and morphological features of the median nerve and carpal tunnel on magnetic resonance imaging (MRI) studies obtained before, immediately after, 6 weeks after, and 6 years after endoscopic carpal tunnel release (ECTR).

Methods: In this prospective cohort study, 9 patients with a diagnosis of carpal tunnel syndrome (CTS) underwent ECTR. Standardized MRI studies were obtained before ECTR, immediately after ECTR, and 6 weeks and 6 years after surgery. Structural and morphological features of the median nerve and carpal tunnel were measured and assessed for each study with comparisons made between each time point.

Results: All 9 patients had complete symptom resolution postoperatively. On the immediate postoperative MRI, there was a discrete gap in the transverse carpal ligament in all patients. There was retinacular regrowth noted at 6 weeks in all cases. The median nerve cross-sectional area and the anterior-posterior dimension of the carpal tunnel at the level of the hamate increased immediately after surgery and these changes were maintained at 6 years.

Conclusions: We defined structural and morphological changes on MRI for the median nerve and carpal tunnel in patients with continued symptom resolution 6 years after ECTR. Changes in median nerve and carpal tunnel morphology that occur immediately after surgery remain unchanged at mid-term follow-up in asymptomatic patients. Established imaging criteria for CTS may not apply to postoperative patients. Magnetic resonance imaging appears to be of limited clinical utility in the workup of persistent or recurrent CTS.
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http://dx.doi.org/10.1177/15589447211058819DOI Listing
December 2021

Evaluation of a Comprehensive Telemedicine Pathway for Carpal Tunnel Syndrome: A Comparison of Virtual and In-Person Assessments.

J Hand Surg Am 2022 02 28;47(2):111-119. Epub 2021 Oct 28.

Geisinger Medical Center, Geisinger Musculoskeletal Institute, Danville, PA.

Purpose: We evaluated a comprehensive telemedicine pathway for carpal tunnel syndrome (CTS). Our primary aim was to compare telemedicine and in-person administration of the six item CTS-6 instrument (CTS-6) in patients undergoing carpal tunnel release (CTR) and to determine whether surgical plans determined via telemedicine were altered by in-person assessments. We additionally aimed to assess agreement between telemedicine and in-person examinations.

Methods: In this prospective investigation, patients referred to a hand surgeon for evaluation of CTS were offered a telemedicine pathway. A modified, virtual CTS-6 was administered during the telemedicine consultation and a virtual exam was performed. Patients indicated for CTR were evaluated in person on the day of surgery. Agreement between the telemedicine and in-person CTS-6 and exam findings was determined. Patients were evaluated via telemedicine postoperatively to determine satisfaction with the program and assess surgical complications.

Results: A total of 32 cases were included. The mean CTS-6 score administered via telemedicine was 17.7, compared with 16.8 in person; this difference was not statistically significant. There were no cases indicated for CTR during the telemedicine visit that had a subsequent change in management based on the in-person evaluation. Agreement was lowest for the sensory assessment (63%). The Phalen and Durkan compression tests demonstrated high levels of agreement (97% and 94%, respectively). Satisfaction was high for patients in the telemedicine CTS pathway.

Conclusions: Overall agreement between telemedicine and in-person administration of the CTS-6 is high for patients with CTS. In patients indicated for CTR via telemedicine, an in-person examination does not appear to alter management. The telemedicine examination of hand sensation demonstrates lower levels of agreement with the in-person assessment. Telemedicine can serve as an alternative to conventional, in-person clinic visits for the diagnosis and postoperative management of uncomplicated, primary CTS.

Type Of Study/level Of Evidence: Diagnostic II.
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http://dx.doi.org/10.1016/j.jhsa.2021.08.024DOI Listing
February 2022

Formal Patient Complaints and Malpractice Events Involving Orthopedic Spine Surgeons: A Ten-Year Analysis.

Spine (Phila Pa 1976) 2022 Jul 2;47(14):E521-E526. Epub 2021 Nov 2.

Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA.

Study Design: Case-control study.

Objective: To analyze patient complaints, potential risk, and malpractice events involving orthopedic spine surgeons over a 10-year period.

Summary Of Background Data: Unsolicited patient complaints may be associated with risk management and malpractice events.

Methods: We analyzed patient complaint, potential risk event, and malpractice event data for six orthopedic spine surgeons over a 10-year period. Patient complaints were analyzed and classified according to the Patient Complaint Analysis System. Baseline demographics were recorded for patients with complaints as well as the surgeons. A control group consisting of all patients seen by the six surgeons during the study period was created to identify patient and physician risk factors for formal patient complaints. Event rates (for complaints, risk, and malpractice events) were calculated by dividing the number of events by the total number of unique patients seen.

Results: There were 214 complaint designations among 202 patients with formal complaints, resulting in a complaint rate of 0.79%. Patients were most likely to complain about access and availability (35%) followed by care and treatment (32%). Of the 68 complaints regarding care and treatment, 34 were related to dissatisfaction with surgical outcome. Complications were identified in 26/34 cases. The malpractice event rate ranged from 0.06% to 0.65%. Patients who had surgery ( P < 0.0001) or a mental, behavioral, or neurodevelopmental disorder ( P = 0.0004) were more likely to file complaints compared with the control group.

Conclusion: While infrequent, patient complaints against orthopedic spine surgeons are most related to access and availability. The rate of malpractice events varies widely between surgeons.
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http://dx.doi.org/10.1097/BRS.0000000000004272DOI Listing
July 2022

A Comparison of Histologic and Intraoperative Visual Assessments of Transverse Carpal Ligament During Revision Carpal Tunnel Release.

J Hand Surg Am 2021 Sep 18. Epub 2021 Sep 18.

Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA.

Purpose: We sought to determine surgeon-pathologist agreement with respect to distinguishing between a previously undivided transverse carpal ligament (TCL) and scar during revision carpal tunnel release (CTR). Additionally, we aimed to describe the histologic findings of the TCL and flexor tenosynovium during revision CTR.

Methods: All patients undergoing revision CTR for persistent or recurrent CTS by a single surgeon between 2013 and 2019 were included. An intraoperative assessment was made as to the presence of scar versus a previously undivided TCL by the surgeon. Two pathology specimens (1 consisting of flexor retinaculum and 1 consisting of tenosynovium) were sent for histopathological analysis with hematoxylin-eosin staining. The pathologist's assessment of the flexor retinaculum specimen was categorized as either "ligamentous" if a previously undivided TCL was identified or "nonligamentous" if scar or any other tissue was identified. The surgeon's intraoperative assessment served as the reference standard when comparing the histologic assessment.

Results: A total of 40 patients underwent 46 revision CTRs. The histologic assessment agreed with the surgeon's intraoperative assessment of a previously undivided TCL versus a scar in 30 of 46 (65%) cases. In 12 of 46 (26%) revision cases, the surgeon determined that there was a previously undivided TCL. In these 12 cases, the pathologist identified a ligament 17% of the time.

Conclusions: Surgeon-pathologist agreement is low with respect to determining previously undivided TCLs versus nonligamentous tissue in the setting of revision CTR. The results of this investigation suggest that pathologists (with limited clinical information) have difficulty confirming the clinical diagnosis of persistent CTS with previously unreleased TCL when using routine hematoxylin-eosin staining. Routine biopsy of the TCL during revision CTR may be of limited clinical utility, as it does not alter the diagnosis or management in these cases.

Type Of Study/level Of Evidence: Diagnostic III.
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http://dx.doi.org/10.1016/j.jhsa.2021.07.030DOI Listing
September 2021

An analysis of body weight changes after shoulder arthroplasty.

JSES Int 2021 May 25;5(3):377-381. Epub 2021 Mar 25.

Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA, USA.

Background: To determine if there are postoperative weight changes for patients undergoing primary shoulder arthroplasty (SA). In addition, we aimed to determine if glycemic control (hemoglobin A1C levels) change postoperatively for patients undergoing SA.

Methods: All patients 18 years of age or older who had undergone primary SA over a 12-year period were analyzed. Patients were excluded if they did not have a preoperative body mass index or if they had less than 1-year follow-up. Baseline demographics were recorded for all patients and comparisons were made between the obese and nonobese groups. Clinically meaningful weight loss was defined as a ≥ 5% reduction in body weight postoperatively.

Results: A total of 469 patients met inclusion criteria. Of them, 65% of patients were obese, and the mean preoperative body mass index for all patients was 33. With a mean follow-up of 40 months, 70% of patients demonstrated clinically significant weight loss. Compared with patients without obesity, patients with obesity lost significantly more weight (10 vs. 6 kg) and demonstrated significantly greater postoperative body mass index reductions (4 vs. 2). Overall, 72% of patients with obesity demonstrated clinically meaningful postoperative weight loss of ≥5% body weight. Patients with obesity who lost weight also saw a decrease in their postoperative hemoglobin A1C: for every 10 pounds of weight loss, A1C decreased by 0.08 units.

Conclusions: In our series, 72% of patients with obesity undergoing primary SA achieved clinically meaningful weight loss, with a mean follow-up of more than 3 years. Patients who lose weight after SA additionally demonstrate improved glycemic control. Surgeons and patients should balance the association between postoperative weight loss after SA with the potential increased risks of operative complications, particularly for severely obese patients.
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http://dx.doi.org/10.1016/j.jseint.2021.01.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8178630PMC
May 2021

Analysis of Gender Diversity Within Hand Surgery Fellowship Programs.

J Hand Surg Am 2021 09 7;46(9):772-777. Epub 2021 Jun 7.

Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA.

Purpose: To define and compare gender diversity among faculty and trainees within hand surgery fellowship programs.

Methods: We determined the gender of each program director for all orthopedic residency and fellowship programs. Specific to hand fellowship programs, we determined the gender of the fellowship director and all faculty members for all plastic surgery and orthopedic hand fellowship programs. Lists of prior hand surgery fellows from 2014 to 2019 were obtained from official program websites or program coordinators. The gender distribution of the hand fellowship program directors and faculty was compared to the prior fellows.

Results: Hand surgery fellowship programs had the second highest percentage of female fellowship directors (13%) behind orthopedic oncology (27%). Within hand surgery, 614 total faculty positions were identified, and 15% were female. Of the 89 hand surgery programs evaluated, 36 (60%) had at least 1 female faculty member. For the 849 prior fellows identified, 213 (25%) were female, and 79% of programs had at least 1 female fellow. Hand programs led by a female director did not have a higher percentage of prior female fellows compared to programs led by a male director (26% vs 25%). Programs with a female fellowship director were as likely to have had at least 1 prior female fellow compared to programs with a male fellowship director.

Conclusions: For orthopedic subspecialties, hand surgery fellowship programs had the second highest percentage of female fellowship directors (13%). While mentorship plays an important role in surgical education, hand fellowship programs with female faculty did not appear to attract more female fellows or faculty.

Clinical Relevance: Hand fellowship programs should recognize that the presence of female faculty may not be a primary factor in fellowship selection for female applicants, and further study into recruiting qualified female candidates should be encouraged.
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http://dx.doi.org/10.1016/j.jhsa.2021.04.023DOI Listing
September 2021

An Analysis of Formal Patient Complaints and Malpractice Events Involving Hand and Upper Extremity Surgeons.

J Am Acad Orthop Surg 2021 Aug;29(15):659-665

From the Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA.

Introduction: Our purpose was to define and categorize patient complaints within a hand surgery practice over a 10-year period. In addition, we aimed to define surgeon and patient factors associated with formal complaints.

Methods: All patients who filed a complaint with our institution's patient advocacy service against six hand surgeons in an academic practice over a 10-year period were recorded and categorized using the Patient Complaint Analysis System. A control group consisting of all patients seen by the surgeons during the study period was created. Demographic differences between the complaint and control groups were analyzed, as were complaint rates between surgeons. We obtained the number of malpractice events involving each of the surgeons.

Results: During the 10-year study period, 73 of 36,010 unique patients seen (0.20%) filed a complaint. Care and treatment category comprised the highest percentage of complaint designations (30%), followed by access and availability (23%). Forty-three patients (59%) who filed complaints were treated surgically. Patients with a complaint had a significantly higher percentage of mental, behavioral, or neurodevelopmental disorders compared with controls (55% versus 42%, P = 0.03). The complaint rate (total complaints/total new patients seen) ranged between 0.09% and 0.29% for the six surgeons, and these results were not statistically significant.

Discussion: Within an academic hand and upper extremity surgery practice, the rate of patient complaints is 0.20% or approximately one complaint for every 500 new patients seen. Most patient complaints are categorized within the care and treatment domain. Underlying mental health conditions are associated with more frequent complaints. Communication issues appear to represent a modifiable area that hand surgeons can improve to help mitigate potential complaints. Understanding both the frequency and types of patient complaints may allow hand surgeons to recognize areas for improvement and avoid potential exposure to malpractice litigation.

Level Of Evidence: Prognostic level III (case-control).
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http://dx.doi.org/10.5435/JAAOS-D-21-00073DOI Listing
August 2021

Formal Patient Complaints and Malpractice Events Against Pediatric Orthopaedic Surgeons.

J Pediatr Orthop 2021 Apr 29. Epub 2021 Apr 29.

Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA.

Background: Formal patient complaints are associated with increased malpractice litigation and can have adverse occupational consequences for surgeons. Our purpose was to define and categorize patient complaints within an academic pediatric orthopaedic surgery practice over a 10-year period. We further aimed to define risk factors associated with patient complaints.

Methods: We reviewed all complaints within our institution's patient advocacy service filed on behalf of a patient against 4 pediatric orthopaedic surgeons over a 10-year period. Complaints were categorized using the Patient Complaint Analysis System. A control group of all patients seen by the surgeons during the study period was created. We compared baseline demographics between the patients with a complaint and the control group and compared complaint rates between the surgeons. Any malpractice events (lawsuits and claims) associated with the surgeons were obtained. We queried our institutional MIDAS reporting system (which allows for anonymous reporting of potential patient-safety or "near-miss" events), to assess whether patients with a complaint had a reported event.

Results: The 4 pediatric orthopaedic surgeons saw a total of 25,747 unique patients during the study period. Forty-one patients had a formal complaint, resulting in a complaint rate of 0.15%. Complaint rates varied from 0.08% to 0.30% between surgeons. Humanness was the most frequent complaint designation category (32%) followed by Care and Treatment (19%). Of the 41 patients with a complaint, 18 (44%) underwent surgical treatment. Only 1 patient with a complaint also had an entry within our institutional patient-safety reporting system.

Conclusions: The rate of patient complaints within an academic pediatric orthopaedic surgery practice over a decade was 0.15%, or ~1 complaint for every 670 new patients seen. The majority of patient complaints involved communication; a potentially modifiable area that can be targeted for improvement. While complaint rates among surgeons can vary, patient demographic factors are not associated with increased complaints. Understanding patient complaints rates and types may allow surgeons to target areas for improvement and decrease exposure to malpractice litigation.

Level Of Evidence: Level II-prognostic.
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http://dx.doi.org/10.1097/BPO.0000000000001840DOI Listing
April 2021

The Ability of Upper Extremity Surgeons to Assess Patient's Functional Status.

J Hand Surg Am 2021 09 9;46(9):819.e1-819.e8. Epub 2021 Apr 9.

Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA.

Purpose: To compare surgeon and patient assessment of upper extremity functional status at the time of initial consultation. We hypothesized that surgeons and patients demonstrate low levels of agreement with respect to assessing pain scores, functional status, and self-efficacy.

Methods: One hundred forty-three consecutive new patients were evaluated by 1 of 5 fellowship-trained upper extremity surgeons. Patients completed a Numeric Pain Rating Scale as well as the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE), Pain Interference (PI), and Self-Efficacy (SE) instruments. Surgeons provided their own estimates of patient function on each questionnaire at the conclusion of the visit and were blinded to the results of the patient-reported outcome measures (PROMs) for the duration of the study. Estimation errors, which represent the absolute value of the difference between the patient's actual score and the surgeon's estimated score on each questionnaire, were calculated for each questionnaire.

Results: As a group, surgeons assumed that the PROMIS UE and SE scores were higher than the patients' actual scores and assumed that patients had lower PROMIS PI scores than were actually reported. Mean estimation errors for all PROMIS instruments were greater than 10 points and larger than the SD for these instruments in the general population.

Conclusions: Upper extremity surgeons demonstrate difficulty assessing their patient's self-reported functional status, pain interference, and level of self-efficacy during initial consultations.

Clinical Relevance: Although formalized PROMs are infrequently administered in orthopedic clinics, increased utilization of these questionnaires would allow for a more accurate baseline functional assessment. When evaluating new patients in the outpatient clinic, surgeons should recognize the potential limitations of their assessments of patient-reported function.
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http://dx.doi.org/10.1016/j.jhsa.2021.02.007DOI Listing
September 2021

Analysis of driving simulator performance for post-call orthopaedic surgery residents.

Postgrad Med J 2022 Jul 29;98(1161):e13. Epub 2021 Mar 29.

Department of Orthopaedic Surgery, Geisinger Health System, Danville, Pennsylvania, USA.

Purpose: Despite the associations between workhours, fatigue and motor vehicle accidents, driving abilities for residents post-call have been infrequently analysed. Our purpose was to compare orthopaedic surgery resident performance on a driving simulator after a night of call compared with their baseline.

Study Design: All residents from a single orthopaedic programme were asked to complete baseline and post-call driving simulator assessments and surveys. The primary outcome measure was brake reaction time (BRT) and secondary outcome measures included lane variance, speed variance and accidents on the driving simulator.

Results: All 19 orthopaedic residents agreed to participate. Compared with the baseline assessment, residents demonstrated significantly higher levels of sleepiness on the Stanford Sleepiness Scale post-call (1.6 vs 3.4; p<0.0001). Despite higher levels of fatigue post-call, there was no statistically significant differences between baseline and post-call assessments for mean BRT, accidents, lane variation and speed variation.

Conclusions: These data suggest that for orthopaedic residents, driving simulator performance does not appear to be worse after a single night of call compared with baseline. Future collaborative, multicentre investigations on post-call driving safety that incorporate different call types and frequencies are necessary to better define the impact of post-call fatigue on driving performance. Recognising that motor vehicle accidents remain the leading cause of death for people under the age of 30 years, these continued areas of study are necessary to truly establish a culture of resident safety.
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http://dx.doi.org/10.1136/postgradmedj-2021-139908DOI Listing
July 2022

Technology, Social Media, and Telemedicine Utilization for Rural Hand and Upper-Extremity Patients.

J Hand Surg Am 2021 04 22;46(4):301-308.e1. Epub 2021 Jan 22.

Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA.

Purpose: To define technology and social media use among rural upper-extremity patients. In addition, we aimed to assess how patients use social media in relation to health care and their willingness to participate in telemedicine programs.

Methods: An anonymous multiple-choice written survey was administered to 550 upper-extremity patients at 4 rural outreach clinics. Demographic information was obtained, as was social media use, habits and interests. We compared both users and nonusers of social media to define demographic differences between these groups.

Results: A total of 412 patients completed surveys and were included in our analysis (75%); 225 reported using social media (55%). Of the respondents, 67% had a high school education or less and 60% reported an income of less than $50,000/y with an unemployment rate of 58%. In addition, 28% reported not owning a smartphone and 20% lacked home Internet access. Multivariable regression demonstrated that age, female sex, and home Internet access were all independently associated with increased social media use. Facebook was the most frequently used social media platform. Moreover, 42% were interested in telemedicine and social media users were significantly more likely to be interested in telemedicine programs compared with non-social media users.

Conclusions: Within a population of rural and economically disadvantaged upper-extremity patients, 55% currently use social media; 32% used these platforms to research health conditions. Whereas younger female patients with home Internet access were more likely to use social media, older patients were more likely to use these platforms to research health conditions.

Clinical Relevance: As more health information moves on-line and as telemedicine programs continue to evolve, some rural upper-extremity patients may still have technological barriers in the form of smartphone and computer ownership as well as a lack of home Internet access.
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http://dx.doi.org/10.1016/j.jhsa.2020.11.019DOI Listing
April 2021

The Handshake Test: A Nonverbal Assessment of Coping Strategies and Functional Status in Patients with Atraumatic Upper-Extremity Conditions.

Iowa Orthop J 2020 ;40(1):49-52

Geisinger Medical Center, Department of Orthopaedic Surgery, Danville, PA.

Background: Maladaptive coping strategies can lead to less functional improvement after upper-extremity surgery. It remains uncertain how well surgeons can recognize signs of less effective coping strategies in patients in the absence of formalized questionnaires. Our purpose is to determine if the "Handshake Test" can be used to identify patients with less effective coping strategies. We hypothesize that a simple physical examination finding (a refusal or inability to shake hands) is associated with higher pain level, maladaptive coping strategies and decreased functional status.

Methods: We prospectively analyzed 246 consecutive new patients presenting to one of three surgeons with atraumatic upper-extremity conditions. Patients completed a pain scale (NPRS) and PROMIS instruments including Self-Efficacy (SE) for Managing Symptoms, Pain Interference (PI) and Upper Extremity (UE). Each surgeon recorded a refusal to shake hands as part of a normal greeting, referred to as a "positive Handshake Test".

Results: 200 patients (81%) patients completed all outcome measures and were included in our analysis. 8% demonstrated a positive Handshake Test. Patients with a positive Handshake Test were more likely to use tobacco; otherwise baseline demographics were similar between the two groups. Patients with a positive Handshake Test demonstrated higher pain scores (NPRS and PROMIS PI), lower levels of self-efficacy and worse self-reported functional status on the PROMIS UE.

Conclusions: For patients with atraumatic upper-extremity conditions, those with a positive Handshake Test report higher pain levels, lower self-efficacy, and decreased self-reported functional status than patients who can perform a handshake. This simple test can aid in identifying patients with less effective coping strategies, allowing surgeons to guide patients towards interventions to improve both illness behavior and functional outcomes..
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368538PMC
February 2021

Telemedicine After Upper Extremity Surgery: A Prospective Study of Program Implementation.

J Hand Surg Am 2020 Sep 18;45(9):795-801. Epub 2020 Jul 18.

From the Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Medical Center, Danville, PA.

Purpose: Our purpose was to evaluate the implementation of a postoperative hand and upper extremity telemedicine program. We aimed to compare travel burden, visit time, and patient satisfaction between an initial postoperative telemedicine visit and a second conventional in-clinic visit.

Methods: Telemedicine guidelines established by our hospital system were used as inclusion criteria for this prospective study, which included patients indicated for surgery in the outpatient clinic during a 3-month period. Patients were excluded if they had wounds closed with nonabsorbable suture, remained admitted to the hospital, or required a custom orthosis at their first postoperative visit. Baseline demographics and patient-reported outcome measures were collected prior to surgery. Information pertaining to technology usage was collected for the telemedicine visit and travel information was obtained for the in-clinic visit. Patient satisfaction was recorded for both visits.

Results: Fifty-seven of 87 patients (66%) who met the inclusion criteria elected to participate in the study. A cell phone was utilized by 89% of patients and 88% of visits were performed from the patient's home. There were 4 technological complications during the study period (7%). Mean round-trip travel distance for the in-clinic visit was 60 miles with an average drive time of 85 minutes. Visit times were significantly shorter with telemedicine (7 minutes vs 38 minutes). Telemedicine was preferred by 90% of patients for subsequent encounters. All 4 clinical complications were recognized during the telemedicine visit.

Conclusions: A telemedicine program for postoperative care after hand and upper extremity surgery decreases travel burdens associated with conventional in-clinic appointments. Telemedicine significantly decreases visit times without decreasing patient satisfaction for patients who elect to participate in remote video visits. The ability to recognize early postsurgical complications was not compromised by utilizing this technology, even during our early experience.

Clinical Relevance: Telemedicine after hand and upper extremity surgery results in high levels of patient satisfaction and decreases visit times and the travel burdens associated with conventional in-clinic appointments.
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http://dx.doi.org/10.1016/j.jhsa.2020.06.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368157PMC
September 2020

Current Trends in WALANT Surgery: A Survey of American Society for Surgery of the Hand Members.

J Hand Surg Glob Online 2020 Jul 17;2(4):186-190. Epub 2020 Jun 17.

Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA.

Purpose: To define self-reported WALANT use among American Society for Surgery of the Hand (ASSH) members. We aimed to define surgeon and practice demographics relative to WALANT use and identify potential barriers for WALANT implementation.

Methods: An anonymous multiple-choice survey was electronically distributed to all active ASSH members. Incomplete surveys were included in the final analysis. Surgeons were asked to provide reasons for not performing WALANT, which were categorized based on general themes. We compared practice and surgeon demographic information relative to WALANT use.

Results: Of 3,826 ASSH members, 869 responded (23%). A total of 79% of respondents had performed at least one WALANT procedure; 62% currently incorporated WALANT into their practice. Hospital-owned outpatient surgery centers were the most common location for WALANT procedures (31%). Canadian surgeons were more likely to use WALANT, compared with US and international surgeons. Surgeons with fewer years in practice and higher-volume surgeons were more likely to use WALANT. There was no statistically significant association between either practice or income structure and WALANT use. For carpal tunnel release (CTR), 13% did not offer patients WALANT, whereas 43% offered WALANT to all patients. Moreover, 51% of surgeons reported that anesthesia staff was required to be present for WALANT cases at their institution. In determining reasons for not using WALANT, 16% reported that they preferred a tourniquet for visualization. Only 2% had concerns regarding epinephrine use in the hand.

Conclusions: The results of this survey illustrate current WALANT use among ASSH members and defines the demographics of those employing WALANT. Lack of familiarity with WALANT and an acceptance of the use of epinephrine in the hand has increased from prior ASSH surveys. Lack of familiarity with the technique, concerns regarding operating room efficiency, and patient preferences remain considerable barriers to more widespread adoption of WALANT procedures.

Type Of Study/level Of Evidence: Economic and Decision Analysis V.
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http://dx.doi.org/10.1016/j.jhsg.2020.04.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8991637PMC
July 2020

Comparison of Editor, Reviewer, and Author Demographics in .

J Hand Surg Glob Online 2020 Jul 17;2(4):182-185. Epub 2020 Jun 17.

Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA.

Purpose: To determine whether demographic differences exist among editors, reviewers, and authors in (JHS). We aimed to test the null hypothesis that there would be no difference among these 3 groups with respect to gender, geographic location, academic productivity, and financial relationships with industry.

Methods: Editors, reviewers, and physician authors were identified for 2018 JHS. Gender and geographic location were recorded for each person. We used the Scopus database to determine the Hirsch index (h-index) as well as the number of publications and citations for members of each group. Industry payment information was obtained using the Open Payments Web site.

Results: The editor group contained 20% women compared with the author group (17% women). Authors (59%) were less likely to be from the United States compared with editors (91%) and reviewers (88%). Editors were found to have a higher h-index (16) compared with reviewers (14) and authors (12). Authors demonstrated significantly higher mean total payments from industry ($41,738) compared with editors ($13,712) and reviewers ($20,457).

Conclusions: In 2018, there appeared to be an even distribution with respect to gender among editors, authors and reviewers in the JHS. International editors and reviewers are relatively under-represented compared to authors. Whereas editors and reviewers demonstrated higher h-indices compared with authors, JHS authors had significantly higher mean total payments in the Open Payments database.

Clinical Relevance: Defining demographics, academic productivity, and conflicts of interest for journal editors, reviewers, and authors may aid in identifying potential sources of both author and peer review bias.
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http://dx.doi.org/10.1016/j.jhsg.2020.05.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8991536PMC
July 2020

Telemedicine in Hand and Upper-Extremity Surgery.

J Hand Surg Am 2020 Mar 9;45(3):239-242. Epub 2019 Nov 9.

Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA.

Smartphones, computers, and Internet access continue to become more available to both patients and physicians. As these technologies develop with respect to health care, opportunities for telemedicine visits continue to emerge. The purpose of this review article was to analyze the current use and potential applications of telemedicine in hand and upper-extremity surgery. Although the literature pertaining to the use of telemedicine in hand surgery is limited, videoconferencing visits may provide benefits to patients. Particularly in rural and underserved regions, patients can decrease considerable travel burdens. Potential applications for this technology include remote inpatient and emergency room consultations, outpatient clinic visits, and postoperative care. There are unique considerations with respect to confidentiality and security. As with any new technology, it is important to analyze safety concerns. Future randomized, prospective investigations are necessary to define the economic implications of telemedicine programs more clearly within hand and upper-extremity surgery.
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http://dx.doi.org/10.1016/j.jhsa.2019.09.007DOI Listing
March 2020

Opioid Versus Nonopioid Analgesia After Carpal Tunnel Release: A Randomized, Prospective Study.

Hand (N Y) 2021 01 29;16(1):38-44. Epub 2019 Mar 29.

Geisinger Medical Center, Danville, PA, USA.

The purpose of this investigation was to compare pain control and patient satisfaction for conventional postoperative opioid analgesia and nonopioid multimodal analgesia after elective open or endoscopic carpal tunnel release (CTR). As part of a randomized, prospective study, patients undergoing primary, elective CTR were randomized to receive either postoperative opioids or nonopioid medications as part of a multimodal pain control strategy. Patients currently taking opioids were excluded. Patients completed a postoperative pain journal and completed the shortened version of the Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH), Boston Carpal Tunnel Questionnaire, Numeric Pain Rating Scale (NPRS), and satisfaction ratings at their 2-week visit. A total of 68 patients were included. Preoperatively, there were no statistically significant differences between the 2 groups with respect to pain scores, coping skills, or carpal tunnel symptoms. At 2 weeks postoperatively, patients in the nonopioid group had lower average NPRS and QuickDASH scores. Patients who took opioids consumed an average of 5 pills. No patient randomized to the nonopioid group required any opioids. Patients in the nonopioid group demonstrated lower early postoperative NPRS scores. Patient satisfaction with their pain control regimen and outcome was not significantly different between the 2 groups at any time point. Nonopioid medications as part of a perioperative pain control strategy demonstrate improved pain scores compared with opioid medications with similar patient satisfaction and functional outcomes. Considering the risks associated with the use of opioid analgesics, we recommend against prescribing opioids after CTR, particularly in patients not currently taking narcotic medications.
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http://dx.doi.org/10.1177/1558944719836211DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7818044PMC
January 2021

The 70° Supinated Oblique View: A Cadaveric Analysis to Determine Ideal Radial Styloid Screw Position in Locked Volar Plating of Distal Radius Fractures.

Hand (N Y) 2021 01 29;16(1):99-103. Epub 2019 Mar 29.

Geisinger Medical Center, Danville, PA, USA.

Defining an intraoperative radiographic view to best determine the radial styloid screw position in locked volar plating of distal radius fractures may improve fixation and aid in decreasing cortical penetration and implant complication. We used a cadaveric model to demonstrate a reproducible, oblique radiographic view to identify the radial styloid screw position. Nine fresh-frozen elbow-to-fingertip cadavers were used for this study. A 2.4-mm variable angle volar distal radius locking plate was applied to the distal radius. A Kirschner wire (K-wire) was inserted into the radial styloid through the plate. Placement of the K-wire through the tip of the styloid at the cortical edge was confirmed through a separate radial incision. A second K-wire was placed through the radius shaft into the ulna to aid in angular measurements. Live fluoroscopic imaging was used as the forearm was brought from full 90° of supination toward neutral. Once the K-wire was abutting the cortical edge, rotation ceased, and a goniometer was used to measure the angle of forearm rotation. This was repeated for a total of 3 repetitions on each specimen. The average angle of supination best depicting the position of the radial styloid screw was 68.5° (range = 64.3°-70.5°). Radial styloid screw fixation in locked volar plating of distal radius fractures increases the ultimate strength to failure, but screw penetration and tendon irritation can occur. The 70° supinated oblique intraoperative view provides the most accurate evaluation of the position of the radial styloid screw.
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http://dx.doi.org/10.1177/1558944719836210DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7818033PMC
January 2021

The Use of Preoperative Dynamic Ultrasound to Predict Ulnar Nerve Stability Following In Situ Decompression for Cubital Tunnel Syndrome.

J Hand Surg Am 2019 Jan 27;44(1):35-38. Epub 2018 Nov 27.

Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA.

Purpose: To assess the use of preoperative, dynamic ultrasound to predict ulnar nerve instability following in situ decompression for cubital tunnel syndrome.

Methods: Prior to undergoing in situ decompression, 43 consecutive patients underwent dynamic ultrasound to assess the stability of the ulnar nerve during elbow flexion. The dynamic ultrasound findings were compared with the intraoperative assessment of nerve stability following in situ decompression.

Results: The preoperative dynamic ultrasound agreed with intraoperative findings in 38 of 43 patients (88%). Physical examination of ulnar nerve stability agreed with the intraoperative findings in 5 of 43 patients (12%). For the 5 of 43 cases in which the dynamic ultrasound did not correlate with the degree of ulnar nerve stability after in situ decompression, dynamic ultrasound overestimated the degree of ulnar nerve stability in 4 cases.

Conclusions: Preoperative dynamic ultrasound can be used to accurately predict the degree of ulnar nerve instability following in situ decompression.

Type Of Study/level Of Evidence: Diagnostic II.
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http://dx.doi.org/10.1016/j.jhsa.2018.10.013DOI Listing
January 2019

Incidence and Reason for Readmission and Unscheduled Health Care Contact After Distal Radius Fracture.

Hand (N Y) 2020 03 27;15(2):243-251. Epub 2018 Jul 27.

Geisinger Medical Center, Danville, PA, USA.

Understanding risk factors for readmission may help decrease the rate of these costly events. The purpose of this study is to define the incidence of 30-day readmission and unscheduled health care contact (UHC) after distal radius fracture (DRF). In addition, we aim to define risk factors for readmission and UHC. A retrospective review of patients who sustained a DRF at our trauma center was performed. We recorded baseline demographics, fracture characteristics, and treatment. Any UHC or readmission (including emergency department [ED] visits) was documented. Reasons for readmission and UHC were stratified by cause. We utilized a case-control design comparing patients readmitted within 30 days after DRF versus those who were not, as well as patients with and without UHC. About 353 patients were identified. The 30-day incidence of readmission after DRF was 7% with 2% of patients readmitted for reasons related to their fracture. Twenty percent of patients had UHC within 30 days, most frequently due to pain. Patients with anxiety or depression and those with open fractures were more likely to be readmitted. Patients with UHC were younger, more likely to have depression or anxiety, and more likely to have undergone operative treatment. For patients sustaining DRF, we report a 30-day readmission rate of 7% with 20% of patients having UHC. Patients with depression or anxiety were more likely to be both readmitted and have UHC. Identifying risk factors for readmission during initial presentation may help reduce readmissions. Improving pain relief strategies early may aid in decreasing the burden of UHC.
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http://dx.doi.org/10.1177/1558944718788687DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7076622PMC
March 2020

The Management of Persistent and Recurrent Cubital Tunnel Syndrome.

J Hand Surg Am 2018 10 8;43(10):933-940. Epub 2018 Jun 8.

Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH.

Cubital tunnel syndrome (CuTS) is the second most common compressive neuropathy in the upper extremity. There are considerable diagnostic and therapeutic challenges associated with treating patients after a failed primary procedure for CuTS. Distinguishing cases of recurrence versus persistence and identifying concomitant pathology can guide treatment. Conditions that mimic CuTS must be carefully ruled out and coexisting dysfunction of the medial antebrachial cutaneous nerve needs to be addressed. Results of revision procedures are not as reliable as primary procedures for CuTS; however, improvements in pain and paresthesias are noted in approximately 75% of patients. Nerve wraps represent a promising adjuvant treatment option, but long-term outcome data are lacking. External neurolysis and anterior transposition after failed CuTS procedures are supported by case series; multicenter, prospective randomized trials are needed to guide treatment further and improve outcomes.
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http://dx.doi.org/10.1016/j.jhsa.2018.03.057DOI Listing
October 2018

Comparison of Radiographic and Intraoperative Visual Assessment of Scaphotrapezoid Joint Arthritis in Patients With End-Stage Carpometacarpal Arthritis of the Thumb Base.

Hand (N Y) 2019 09 20;14(5):609-613. Epub 2018 Mar 20.

Geisinger Medical Center, Danville, PA, USA.

The purpose of this investigation is to compare the radiographic and intraoperative assessment of scaphotrapezoid (ST) joint arthritis in patients with end-stage carpometacarpal (CMC) arthritis of the thumb base. We aim to define the incidence of ST arthritis in this population and determine whether radiographic features such as lunate morphology, dorsal intercalated segment instability (DISI), and scapholunate (SL) diastasis are associated with the incidence of ST arthritis. We retrospectively reviewed consecutive patients with end-stage CMC arthritis of the thumb treated operatively with trapeziectomy. Preoperative wrist radiographs were reviewed, and the presence of ST arthritis was determined using the Sodha classification. Lunate morphology, DISI, and SL diastasis were noted. Intraoperative grading of ST arthritis was assessed using a modified Brown classification. The specificity and sensitivity of radiographic assessment was compared with the gold standard of intraoperative direct visualization. In total, 302 thumbs met inclusion criteria. End-stage ST joint arthritis determined by intraoperative visual inspection was noted in 31% of cases. No radiographic or demographic variables were found to be risk factors for ST arthritis. Plain radiographs were 47% sensitive and 94% specific in their ability to detect end-stage ST joint arthritis. We report a 31% incidence of end-stage ST joint arthritis in surgically treated patients with CMC arthritis based on visual inspection which is lower than previous literature. Wrist radiographs demonstrate a 47% sensitivity and 94% specificity in predicting end-stage ST joint arthritis. It is imperative to directly visualize the ST joint after trapeziectomy, as radiographs demonstrate poor sensitivity.
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http://dx.doi.org/10.1177/1558944718765246DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6759968PMC
September 2019

Anatomic Assessment of K-Wire Trajectory for Transverse Percutaneous Fixation of Small Finger Metacarpal Fractures: A Cadaveric Study.

Hand (N Y) 2018 01 14;13(1):86-89. Epub 2017 Feb 14.

1 Geisinger Medical Center, Danville, PA, USA.

Background: The purpose of this cadaveric study is to evaluate the trajectory of percutaneous transverse Kirschner wire (K-wire) placement for fifth metacarpal fractures relative to the sagittal profile of the fifth metacarpal in order to develop a targeting strategy for the treatment of fifth metacarpal fractures.

Methods: Using 12 unmatched fresh human upper limbs, we evaluated the trajectory of percutaneous transverse K-wire placement relative to the sagittal profile of the fifth metacarpal in order to develop a targeting strategy for treatment of fifth metacarpal fractures. The midpoint of the small and ring finger metacarpals in the sagittal plane was identified at 3 points. At each point, a K-wire was inserted from the small finger metacarpal into the midpoint of the ring finger metacarpal ("center-center" position).

Results: The angle of the transverse K-wire relative to the table needed to achieve a center-center position averaged 20.8°, 18.9°, and 16.7° for the proximal diaphysis, middiaphysis, and the collateral recess, respectively. Approximately 80% of transversely placed K-wires obtained purchase in the long finger metacarpal.

Conclusions: These results can serve as a guide to help surgeons in the accurate placement of percutaneous K-wires for small finger metacarpal fractures and may aid in surgeon training.
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http://dx.doi.org/10.1177/1558944717691128DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5755863PMC
January 2018
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