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Background: Cubital tunnel syndrome (CuTS) is a lifestyle-altering peripheral neuropathy lacking a consensus for optimal surgical management. We describe creation of a fascial "V-sling" without ulnar nerve transposition, which is associated with increased surgical morbidity compared with decompression. The purpose of this study is to evaluate a novel technique with effective ulnar nerve decompression and subluxation prevention by creating a fascial sling in patients with CuTS and ulnar nerve subluxation.

Methods: We reviewed records of 39 elbows in 35 patients who underwent in situ ulnar nerve decompression and creation of a fascial sling in a "V" configuration to stabilize the nerve in its native position. We examined patient demographics, Single Assessment Numeric Evaluation (SANE) scores, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, and patient outcomes. Chi-square and student's t test were used for all analysis.

Results: A total of 37 extremities in 33 patients undergoing nerve decompression had nerve subluxation confirmed intraoperatively. There was a statistically significant change in preoperative and postoperative SANE scores of 64.5 and 82.3, respectively. Mean QuickDASH scores decreased significantly from 49.3 preoperative to 10.8 postoperative. The long-term QuickDASH scores obtained at mean of 564 days were maintained at 10.76.

Conclusions: This study describes a novel technique for treating CuTS by achieving in situ nerve decompression and addressing ulnar nerve subluxation with creation of an intermuscular septal sling. The technique improved functional outcomes and provided symptomatic relief, while avoiding risks commonly associated with nerve transposition.

Background: Open A1 pulley release for trigger finger has generally been considered a minor procedure with infrequent complications. Most reported complications are minor, including scar pain and tenderness, mild extension lag, and recurrence of triggering. Rates of major complications, such as bowstringing, neurovascular bundle injury, and infection requiring reoperation, are less than 1% to 4%. We aimed to describe the potentially devastating sequelae of these major complications and the subsequent consequences.

Methods: Three patients underwent open trigger finger release, which were all complicated by severe postoperative surgical site infection requiring multiple subsequent procedures. We review our initial management, subsequent reconstructive options, and outcomes with up to 19 years follow-up.

Results: All 3 adult patients who underwent open A1 pulley release for trigger finger developed a surgical site infection, leading to flexor tenosynovitis requiring urgent operative debridement and multiple subsequent procedures. Two patients were poorly controlled diabetics, and the third patient was otherwise healthy. Each patient ultimately developed distinct consequences from their postoperative course-finger stiffness and contracture, disabling bowstringing requiring the use of a pulley ring, and flexor tendon rupture requiring staged tendon reconstruction, respectively. All 3 patients at final follow-up had a permanent functional deficit.

Conclusions: Major complications after trigger finger release are infrequent. However, if left untreated, particularly in diabetic patients, there can be disastrous consequences, resulting in permanent loss of function. This case series highlights the importance of accurate diagnosis of postoperative infections and expedient treatment thereafter.

Background: The purpose of this study was to gather information regarding current practices in the care of carpometacarpal (CMC) arthroplasty including the use of hand therapy, immobilization, and surgical technique, and to determine which factors influence these patterns.

Methods: We conducted a survey from February 24, 2022, through March 26, 2022, of 3648 currently practicing members of the American Society for Surgery of the Hand. We developed an 11-item questionnaire that contained questions about surgical technique, immobilization, and postoperative therapy utilization. Results were analyzed using chi-square analysis and a Bonferroni correction was applied to account for multiple comparisons. Statistical significance was set at a P-value of less than .05.

Results: A total of 811 hand surgeons completed the survey (22% response rate). Surgeons who are employed by the same medical center as their hand therapist use more in-person hand therapy than surgeons with other types of business relationships. Surgeons with more than 25 years of experience are less likely to recommend therapy routinely, more likely to use ligament reconstruction and tendon interposition, and less likely to be an employee of the same medical center as their hand therapist. The length of immobilization and the time at which hand therapy began were related to surgical technique.

Conclusions: Variability in hand therapy usage after CMC arthroplasty is at least partially explained by business relationships with hand therapists and surgeon experience. Variability in the length of immobilization and the beginning of hand therapy postoperatively was more associated with surgical technique.

Background: Achieving bony union in scaphoid nonunion fractures is challenging. Various bone grafts have been studied using headless compression screws (HCS) fixation. However, the impact of bone graft choice on bone healing with volar locking plates (VLP) use is less clear. This study evaluates osseous bridging using packed cancellous grafting versus corticocancellous grafting when used during scaphoid waist nonunion repair with volar plating.

Methods: A retrospective case series was performed of 22 consecutive patients with a scaphoid waist fracture nonunions that were treated with VLP fixation and bone autografts. Inclusion criteria required ≥90-day follow-up clinical examination and postoperative computed tomography (CT) scan. Graft types included corticocancellous or packed cancellous autograft harvested from the radius or iliac crest. Amount of bone healing and presence of residual dorsal intercalated segmental instability were determined by 3 fellowship-trained hand surgeons.

Results: Twenty-two patients with scaphoid fracture nonunions that met study inclusion criteria were evaluated. Postoperative CT scan showed osseous bridging in 95% (21/22) of patients. Despite less time between surgery and the final follow-up CT scan (102.7 ± 59 days for packed cancellous autografts vs 133.6 ± 73 days for corticocancellous autografts), the packed cancellous autograft group displayed higher osseous bridging percentages compared with the corticocancellous graft (80.7% ± 17% vs 47.8% ± 35%, P = .013).

Conclusion: Nearly all patients displayed osseous bridging on postoperative CT scan with VLP and autograft use. However, study findings suggest that packed cancellous autograft use displayed more robust early healing.

Background: Currently, there is no recommended standard set of outcomes to report in Dupuytren disease treatment studies, nor are there guidelines on how the outcomes themselves should be reported. This study aimed to elicit the most salient issues for patients living with and undergoing treatment for Dupuytren disease, as well as for the hand surgeons, occupational therapists, and physical therapists caring for these patients.

Methods: A qualitative, interpretive description study employing one-on-one semi-structured interviews was conducted. Ten surgeons, 12 occupational and physical therapists, and 10 patients were interviewed.

Results: Priorities related to Dupuytren disease treatment and recovery differed by stakeholder group. Surgeons prioritized range of motion, recovery time, and recurrence. Physical and occupational therapists frequently mentioned range of motion, grip strength, activities of daily living, return to meaningful activities, wound healing, edema, lack of sensation, and pain as important treatment outcomes. Patients described extension deficit, activities of daily living, holding objects, and lack of sensation.

Conclusions: Through the present study, we have identified outcomes of high importance to patients, hand surgeons, occupational therapists, and physical therapists. These results can be used to inform the development of a core outcome set for Dupuytren contracture.

Background: There is debate regarding nonoperative versus surgical treatment of thumb ulnar collateral ligament (UCL) tears with avulsion fractures. The aim of this study was to evaluate the fragment size in relation to the UCL footprint size in patients with an avulsion fracture injury and to find risk factors associated with surgical treatment.

Methods: In a cohort of avulsion fracture injury patients, the largest side of the fragment was divided by the average reported UCL footprint size (ff-ratio), and a logistic regression was performed to find variables associated with surgery.

Results: The mean ff-ratio was 1.1 in 114 patients with an avulsion fracture injury. Metacarpophalangeal (MCP) joint instability, rather than the largest fragment side, was a significant risk factor for surgery.

Conclusions: An avulsion fracture fragment associated with thumb UCL injury approximates the dimensions of the UCL footprint. In addition, MCP joint instability was associated with surgery in patients with avulsion fracture injuries.

The purpose of this review is to examine the literature regarding episode-based bundled payment models for hand surgery. Health care and productivity costs associated with the surgical management of hand and wrist pathologies represent a substantial burden on the United States health care system. Traditional fee-for-service models fail to incentivize interdisciplinary collaboration and optimization of resources. More recently, the concept of episode-based bundled payments has evolved as a potential solution to rising health care costs by encouraging care coordination, streamlining billing processes, and linking reimbursement to quality metrics and patient outcomes as opposed to the volume of services rendered. Although episode-based bundled payments have demonstrated the potential to reduce health care costs in various medical specialties, their feasibility in hand surgery remains relatively unexplored. The transition to episode-based bundled payments in hand surgery hinges on the ability to incentivize physicians to work cohesively with other members of the care team to reduce low-value preoperative testing, optimize patients preoperatively, and establish treatment guidelines, especially for patients undergoing high-volume, low-complexity procedures. By fostering collaboration among stakeholders, leveraging data-driven insights, and prioritizing patient-centered care, episode-based bundled payments have the potential to enhance the value and efficiency of hand surgery services while improving patient outcomes. The current literature regarding episode-based bundled payments in hand surgery highlights various avenues for cost savings, including alternative sites of service, surgical approaches, use of anesthesia, and the elimination of low-value tests, and demonstrates that there is sufficient evidence to proceed to a trial phase for episode-based bundled payments in hand surgery.

Introduction: Managing open distal radius fractures (DRFs) poses challenges. While preventing surgical site infection (SSI) involves prompt antibiotic administration and thorough irrigation and debridement, the impact of urgent intervention on reducing postoperative infection rates is debated. We hypothesize that timing of surgery does not significantly affect the incidence of SSI in open DRF treated within or after 24 hours from time of injury.

Methods: We retrospectively analyzed the American College of Surgeons Trauma Quality Improvement Program from 2011 to 2021. We focused on outcome variables, including superficial SSI and deep SSI or osteomyelitis. To evaluate the relationship between time to operative intervention and SSI rates, we employed least absolute shrinkage and selection operator and multivariate regression models, adjusting for patient-specific factors and injury severity.

Results: A total of 14 486 patients were included. Regression modeling demonstrated a 23% increase in the odds of deep SSI with each 1-day delay in surgery (P = .010). However, no association was found between time to surgery and superficial SSI (odds ratio [OR] = 0.96, P = .768). Injury severity score (ISS) was associated with increased odds of superficial SSI (OR = 1.06, P < .001) and deep SSI (OR = 1.06, P < .001) while diabetes (OR = 3.56, P = .013) was significantly associated with increased rates of superficial SSI.

Conclusions: Extended time to surgery correlates with a modest rise in deep SSI incidence in open DRF. However, there was no heightened risk of superficial SSI in patients with delayed surgery. Polytrauma, alcohol use disorder, and diabetes were linked to elevated SSI rates in open DRF.

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: Distal radius fractures (DRFs) are some of the most common injuries suffered by the elderly; however, there are varied opinions on management. As there is limited research on patient factors affecting functional outcomes in conservatively managed patients with DRFs, this study aimed to find predictive factors for functional outcomes in such patients.

Methods: Patients with DRFs satisfying the inclusion criteria were managed with closed reduction and slab followed by cast application. Radiological parameters (radioulnar angulation, dorsal tilt, radial height, and ulnar variance) and functional scores (patient-rated wrist evaluation [PRWE] score, Short Form 8 questionnaire [SF-8], and QuickDASH [Disabilities of the Arm, Shoulder, and Hand]-9) were recorded prereduction, postreduction, at the time of cast removal, and in follow-up visits. Patient factors such as underlying diseases were also recorded, and correlations were analyzed using appropriate software.

Results: Patients with diabetes (43.33% of patients) and those with loss in radial height through the course of treatment were found to have poorer functional outcomes (P-values less than .05 for all functional scores-PRWE, QuickDASH-9, SF-8-except SF-8 at 12 weeks). Patients younger than 60 years were also found to have better functional outcomes at 24 weeks (for PRWE: P-value = .048, for QuickDASH-9: P-value = .032, and for SF-8: P-value = .026).

Conclusion: Conservative management plays a major role in the treatment of DRFs, despite the increasing trend of operative management. Diabetes was found to be a predictor of poorer functional outcomes; however, further research is needed to determine the role of these and other factors in detail.