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Background: The recent trend in administering postoperative oral corticosteroids has proven effective in alleviating pain and improving surgical outcomes for hand and upper extremity procedures. However, concerns persist regarding potential infection risks despite a lack of supporting evidence in the current literature. We propose that a 6-day regimen of low-dose postoperative oral corticosteroids is safe and does not increase the likelihood of surgical site infections (SSIs) in adult upper extremity surgeries.

Methods: A retrospective study of all adult patients who underwent clean, upper extremity surgery, including both soft tissue and hardware implantation cases, between November 2021 and November 2023, performed at a single institution were included in the study. Primary outcome measures were diagnosis of SSI by 14 days and 30 days. Categorical variables were compared using χ² tests, and continuous variables were compared using Wilcoxon rank-sum tests. A P value less than .05 was considered statistically significant.

Results: A total of 813 cases were included for analysis-196 received a 6-day course of postoperative oral steroids (methylprednisolone) and 617 did not. Both groups had similar SSI rates of 4.1% and 3.1%, respectively, with no statistical differences between the groups at any postoperative time. Subgroup analysis of patients diagnosed with an SSI identified no statistically different demographic factors or medical comorbidities when comparing patients who received postoperative oral corticosteroids versus those who did not.

Conclusions: Low-dose, postoperative oral steroid use following adult upper extremity surgery is safe and does not increase the risk of SSI. Further investigations with prospective studies on postoperative oral corticosteroids would prove advantageous.

Background: Revisionary digital amputations are often performed after partial or full traumatic digital amputation to minimize complications while preserving as much length and functionality as possible. Many surgeons attempt revisionary procedures swiftly after initial injury. The aim of this study was to investigate the effects of time from injury to surgery on rate of complications and reoperation in revisionary traumatic digital amputations.

Methods: This was a retrospective chart review of all patients undergoing revisionary digital amputation for initial traumatic amputation at a single hospital from January 1, 2007 to December 31, 2021. Demographics, comorbidities, surgical details, complications, and time from injury to surgery were collected. Five-factor modified fragility index scores were also computed for each patient. Primary outcomes of interest included complications and need for additional procedures. Secondary outcomes of interest included development of neuroma, phantom limb, and referral to a long-term pain specialist.

Results: A total of 97 patients were identified as meeting all inclusion criteria. The average time to surgery was 14.4 days. Body mass index, comorbidities, and time to surgery were not associated with increased risk of complication. Increasing time to surgery was not significantly associated with increased risk of complications, development of neuroma, phantom limb, or a referral to long-term pain service. The only factors which were significantly associated with reoperation were absence of diabetes and hypertension.

Conclusion: Increasing time to surgery after initial injury was not significantly associated with increased risk of complications or reoperation. Surgeons should consider this when assessing urgency of surgery in patients after traumatic digital amputation.

The diagnosis and optimal management of radial tunnel syndrome (RTS) is controversial with little consensus among the many possible pathophysiological mechanisms and surgical approaches. Thus, we performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines on studies reporting outcomes of surgical treatment for RTS. PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases were queried. Patient demographics, surgical approach, intraoperative findings, postoperative patient-reported outcomes, and complications were recorded and synthesized. We included 11 studies comprising 401 upper extremities (381 patients). Of the included forearms, 54% (n = 155) were approached dorsally, and 46% (n = 130) were approached volarly. Studies that utilized a dorsal approach between the extensor carpi radialis brevis and extensor digitorum communis had the most favorable Roles and Maudsley scores and patient satisfaction when compared with volar approaches. However, volar approaches identified a greater number of constrictions at the arcade of Frohse (19% vs 7%) when compared with dorsal approaches. Wide variability of surgical approaches used for treatment of RTS is present in the literature. Compared with volar approaches, dorsal approaches are associated with favorable reported outcomes. However, in RTS secondary to vascular constriction, volar approaches may be better suited for release.

Diagnostic suspicion of Chiari I malformations (CM-I) can be challenging in the pediatric population due to highly variable neurologic symptoms and cognitive immaturity impairing symptom identification. Especially in an atypical presentation without obvious central neurological abnormalities, the diagnosis can often be missed. We present a case of a left-hand-dominant 14-year-old boy presenting to an orthopedic hand clinic with right-hand weakness, tingling, and impaired grip strength. The medical history was notable for mild scoliosis and acute lymphoblastic leukemia in remission treated with chemotherapy. The patient denied headaches, neck pain, or balance dysfunction on initial presentation. Neurodiagnostic studies were consistent with C7 and C8 radiculopathies, and magnetic resonance imaging of the brain and entire spine revealed herniation of the cerebellar tonsils with expansive syrinx extending into the lower thoracic spine. After successful posterior fossa decompression, upper extremity strength and hand clawing improved, which was corroborated with postoperative imaging. The patient met his physical therapy goals 6 months after surgery. A thorough history and neurologic examination are essential for earlier detection of pediatric CM-I and a favorable prognosis, particularly in patients with an unclear neurologic cause.

Background: Although it is well established that antibiotic prophylaxis is not needed in soft tissue upper extremity cases, there is still no definitive consensus when hardware implantation is involved. We hypothesize that antibiotic prophylaxis is not necessary and there is no difference in postoperative surgical site infection rates regardless of preoperative antibiotic administration.

Methods: A retrospective cohort analysis was performed on upper extremity surgical cases with hardware implantation performed at a single institution amongst 5 hand surgeons between November 2021 and November 2023. Implants included plates, screws, Kirschner wires, and suture anchors. Primary outcome measures were diagnosis of surgical site infection by 14 and 30 days postoperatively. Secondary outcomes included the type of management used to treat infection. Categorical variables were compared using Fisher exact test, and continuous variables were compared using Wilcoxon rank-sum test.

Results: A total of 232 patients were included for analysis-152 received antibiotic prophylaxis and 80 did not. There were no differences between the 2 groups in terms of demographic factors, comorbidities, or smoking status. There was no difference in infection rates between the group who received antibiotic prophylaxis and the group who did not. Infection rate in the antibiotic prophylaxis group was 4.6% and in the sans antibiotics group was 2.5%. All infections were treated with antibiotics, and there were no differences in the rates of operative washout and hardware removal between the 2 groups.

Conclusions: Antibiotic prophylaxis is not necessary in upper extremity surgical cases even when implantation of hardware is involved.

Background: Our objective is to evaluate the utilization fraction (UF) of surgical instruments during a commonly performed ambulatory hand surgery case as an avenue for cost reduction, increased operating room efficiency, and systems quality improvement.

Methods: The total number of instruments opened at the start of the case was recorded followed by instruments being divided into those used and not used during the procedure. Total sterile processing costs were estimated at $1.56 per instrument according to data from our institution's central sterilization processing (CSP) department.

Results: Nineteen hand procedures performed by 2 surgeons were included in this study. An average of 120.1 ± 10.9 instruments were opened at the start of each case, while an average of 12.6 ± 5.4 instruments were used per case (Figure 1). This yielded an UF of 10.7% ± 4.8%. Using our internal CSP estimate, we calculated an annual cost of $16 863 to reprocess the current hand tray (Figure 2). Using literature data, this cost ranged from $5 513 to $34 484 annually. The same cost calculations were performed for the theoretical optimized tray (incorporating instruments used at least 20% of the time when opened) containing 23.2 instruments. The annual reprocessing cost of this new tray according to CSP data was $3 260, demonstrating a cost-reduction of $13 603 or 80.7% (Figure 2).

Conclusions: Evaluation of pre- and peri-operative processes is a valuable technique to mitigate increasing healthcare costs and reduce unnecessary healthcare spending, with broad applicability to multiple surgical subspecialties and procedures.

Background: Cold intolerance following digital nerve injury burdens patients significantly. To better understand how cold intolerance evolves in the setting of digital nerve injuries, a sub-analysis of a trial comparing conduit-based (CONDUIT) and processed nerve allograft (PNA) repairs was conducted. It was hypothesized that PNA repairs would alleviate cold intolerance more effectively, especially for longer nerve gaps.

Methods: A multicenter trial across 20 US-based medical centers was undertaken of patients 18- to 69-year-old presenting with 5 to 25 mm digital nerve gaps within 24 weeks of injury. Patients were randomized (1:1) to PNA or collagen CONDUIT repairs. Cold Intolerance Symptom Severity (CISS) scores and sensory function testers were assessed at first patient visit (FPV), 1-, 3-, 6-, 9-, and 12-months post-surgery, with patients and assessors blinded to treatment.

Results: In total, 220 patients were enrolled, with 183 patients included in final analysis with ≥6 months follow-up. At the last evaluable visit (LEV), mean CISS score decreased from FPV for both PNA (from 31.2 ± 27 to 20.8 ± 19) and CONDUIT (from 31.2 ± 30 to 25.9 ± 24). On sub-analysis, more patients converted from severe/extremely severe cold intolerance to mild cold intolerance for PNA compared with CONDUIT at 1 month and LEV (P < 0.05). The CISS scores correlated significantly with sensory function testing.

Conclusions: Although no correlation was demonstrated with nerve gap size, digital nerve gap repaired with PNA had significantly improved cold tolerance outcomes for patients with more severe cold intolerance at FPV relative to nerves repaired with CONDUIT.

Background: The purpose of this study was to determine the clinical outcomes of mucous cystectomy and osteophytectomy using a random nonadvancement flap technique.

Methods: This was a therapeutic outcomes study of patients who underwent mucous cystectomy under local anesthesia by 1 of 2 hand fellowship-trained surgeons between 2012 and 2022. The key features of the surgical technique include designing a random nonadvancement flap with the cyst at its base; transecting the cyst pedicle as the flap is elevated; resecting the cyst wall from the undersurface of the reflected flap; decompressing the distal joint by removing marginal osteophytes; and insetting the flap without advancement. Patient demographic and disease-specific data were extracted from medical records and compiled in an electronic database. At minimum 1-year follow-up, patients were queried by telephone regarding wound complications, cyst recurrence, and satisfaction with outcome.

Results: The study cohort included 64 cysts in 61 patients, mean age 63 ± 10 years. The index or middle finger was affected in 63% of cases. At early postoperative follow-up, digital pain improved or resolved in 97% of cases. There were no complications of wound dehiscence or infection. At median 5-year follow-up in 34 cases, all patients except 1 were satisfied with the surgical outcome. There were 2 cyst recurrences in the study cohort (3%) and only 1 secondary procedure.

Conclusions: Our study demonstrated that mucous cystectomy and distal joint osteophytectomy using a random nonadvancement flap is an effective surgical technique with low procedure complication and cyst recurrence rates and high patient satisfaction.

Acute flaccid myelitis (AFM) is a rare, debilitating neurological disease resulting in pure motor deficits in school-aged children. Unfortunately, 90% of patients do not experience complete spontaneous recovery, and medical therapy has not proven efficacious. Herein, we report the course of 2 patients with AFM who underwent upper extremity nerve transfers to treat persistent upper extremity paralysis after failing roughly 6.5 months of conservative treatment. Objective comparisons were made between preoperative and postoperative examinations using the Active Movement Scale and Mallet Classification. Patient 1 underwent transfers of spinal accessory to suprascapular nerve, medial pectoral to axillary nerve, flexor carpi radialis motor fascicle to motor fascicles of the biceps and brachialis musculocutaneous nerve, and anterior interosseous transfer to deep motor branch of the ulnar nerve. Patient 2 underwent transfers of the left spinal accessory to suprascapular nerve and motor nerve of the long head of the triceps to axillary nerve. Both patients experienced significant improvement in muscle strength and ability to complete activities of daily living, with near complete recovery of function. Nerve transfers in the upper extremity within 1 year of symptom onset appear to be beneficial for children with persistent weakness.

Background: Peripheral intravenous (PIV) infiltration and extravasation are common complications of intravenous fluid administration. Here, we aim to investigate risk factors associated with major adverse events following PIV infiltration, which may help risk stratify those who require early surgical consultation.

Methods: Retrospectively, patients were identified who had a documented PIV infiltration or extravasation event at 3 academic hospitals between 2015 and 2022. A major adverse advent was defined as a full-thickness injury requiring operative management (deep infection, compartment syndrome). A minor adverse event was defined as superficial injury (cellulitis, superficial thrombosis).

Results: In total, 160 patients with PIV infiltration events were included (37.5% men), with an average age of 64.1 years. A surgical consult for a hand specialist was placed 35% of the time: orthopedic surgery in 46.4% of cases and plastic surgery in 42.9%. Among these consults, 87.5% recommended supportive treatment (elevation, warm/cold compresses, serial examinations). Major adverse events occurred in 4.4% (n = 7) of patients, and minor adverse events occurred in 11.3% (n = 18). Both intensive care unit (ICU) admission and current intubation status (ie, intubated, sedated, and nonexaminable) at the time of infiltration were significantly associated with adverse events (P = .02 and P = .03, respectively). Current intubation status was significantly associated with operative management (P = .001).

Conclusion: Robust characterization of PIV infiltration events may facilitate early identification of patients at risk of serious complications. We found ICU admission and current intubation both to be associated with adverse events following PIV infiltration. Further work should be done to evaluate the risk of infiltration with different fluid types (vesicant, nonvesicant).