UNASSIGNED: Open reduction and internal fixation (ORIF) is an established surgical procedure for distal humeral fractures; however, total elbow arthroplasty (TEA) has become an increasingly popular alternative for elderly patients with these injuries. Using a large sample of recent patient data, this study compares the rates of short-term complications between ORIF and TEA and evaluates complication risk factors.
UNASSIGNED: Patients who underwent primary TEA or ORIF from 2012 to 2021 were identified by Current Procedural Terminology codes in the American College of Surgeons National Surgical Quality Improvement Program database. Propensity score matching controlled for demographic and comorbid differences. The rates of 30-day postoperative complications were compared.
UNASSIGNED: A total of 1539 patients were identified, with 1365 (88.7%) and 174 (11.3%) undergoing ORIF and TEA, respectively. Patients undergoing TEA were older on average (ORIF: 56.2 ± 19.8 years, TEA: 74.3 ± 11.0 years, P < .001). 348 patients were included in the matched analysis, with 174 patients in each group. TEA was associated with an increased risk for postoperative transfusion (OR = 6.808, 95% CI = 1.355 - 34.199, P = .020). There were no significant differences in any adverse event (AAE) between procedures (P = .259). A multivariate analysis indicated age was the only independent risk factor for the development of AAE across both groups (OR = 1.068, 95% CI = 1.011 - 1.128, P = .018).
UNASSIGNED: The risk of short-term complications within 30-days of ORIF or TEA procedures are similar when patient characteristics are controlled. TEA, however, was found to increase the risk of postoperative transfusions. Risks associated with increasing patient age should be considered prior to either procedure. These findings suggest that long-term functional outcomes can be prioritized in the management of distal humerus fractures.

UNASSIGNED: Identification of modifiable comorbid conditions in the preoperative period is important in optimizing outcomes. We evaluate the association between such risk factors and postoperative outcomes after upper extremity surgery using a national database.
UNASSIGNED: The National Surgical Quality Improvement Program (NSQIP) 2006-2016 database was used to identify patients undergoing an upper extremity principle surgical procedure using CPT codes. Modifiable risk factors were defined as smoking status, use of alcohol, obesity, recent loss of >10% body weight, malnutrition, and anemia. Outcomes included discharge destination, major complications, bleeding complications, unplanned re-operation, sepsis, and prolonged length of stay. Chi square and multivariable logistic regressions were used to identify significant predictors of outcomes. Significance was defined as P<0.01.
UNASSIGNED: After applying exclusion criteria, 53,780 patients were included in the final analysis. Preoperative malnutrition was significantly associated with non-routine discharge (OR=4.75), major complications (OR=7.27), bleeding complications (OR=7.43), unplanned re-operation (OR=2.44), sepsis (OR=10.22), and prolonged length of stay (OR=5.27). Anemia was associated with non-routine discharge (OR=2.67), bleeding complications (OR=13.27), and prolonged length of stay (OR=3.26). In patients who had a weight loss of greater than 10%, there was an increase of non-routine discharge (OR=2.77), major complications (OR=2.93), and sepsis (OR=3.7). Smoking, alcohol use, and obesity were not associated with these complications.
UNASSIGNED: Behavioral risk factors (smoking, alcohol use, and obesity) were not associated with increased complication rates. Malnutrition, weight loss, and anemia were associated with an increase in postoperative complication rates in patients undergoing upper limb orthopaedic procedures and should be addressed prior to surgery, suggesting nutrition labs should be part of the initial blood work.

UNASSIGNED: With a rapidly ageing population, the number of distal radius fractures (DRFs) in the elderly will increase dramatically. The aim of this retrospective register study was to examine the 1- and 5-year mortality in DRF patients aged 80 years or more and correlate the overall survival to factors not related to the fracture itself.
UNASSIGNED: Patients aged ≥80 diagnosed with DRFs in Lund University Hospital in Sweden in the period 2010-2012 were extracted from the prospective Lund Distal Radius Fracture register. One- and 5-year standardised mortality rates (SMRs) were calculated using the Swedish standard population as a reference. Medical records were searched for non-fracture-related factors including comorbidity, medications, cognitive impairment and type of living. Cox proportional hazard regression models were used to identify prognostic factors for all-cause mortality.
UNASSIGNED: The study cohort included 240 patients, with a mean age of 86. The overall 1-year mortality was 5% (n = 11/240) and the 5-year mortality was 44% (n = 105/240). The 1-year SMR was .44 (CI .18-.69, P < .01) when indirectly adjusted for age and gender and compared to the Swedish standard population. The 5-year SMR was .96 (CI .78-1.14). The patients\' ability to live independently in their own home had the highest impact on survival.
UNASSIGNED: The 1-year mortality rate among the super-elderly DRF patients was only 44% of that expected. Possibly, a DRF at this age could be a sign of a healthier and more active patient.
UNASSIGNED: The DRF patients aged 80 or more had a substantially lower mortality rate 1 year after fracture compared to the age- and gender-matched standard population. Patients living independently in their own homes had the longest life expectancy. Treatment should not be limited solely because of old age, but individualised according to the patient\'s ability and activity level.

OBJECTIVE: Multiple interventions have been implemented to reduce opioid prescribing in upper extremity surgery. However, few studies have evaluated pain relief and patient satisfaction as related to failure of these protocols. We sought to evaluate the efficacy of limited and nonopioid (\"opioid-sparing\") regimens for upper extremity surgery as it pertains to patient satisfaction, pain experienced, and need for additional refills/rescue analgesia.
METHODS: We aimed to systematically review randomized controlled trials of opioid-sparing approaches in upper extremity surgery. An initial search of studies evaluating opioid-sparing regimens after upper extremity surgery from the elbow distal yielded 1,320 studies, with nine meeting inclusion criteria. Patient demographics, surgery type, postoperative pain regimen, satisfaction measurements, and number of patients inadequately treated within each study were recorded. Outcomes were assessed using descriptive statistics.
RESULTS: Nine randomized controlled trials with 1,480 patients were included. Six of nine studies (67%) reported superiority or equivalence of pain relief with nonopioid or limited opioid regimens. However, across all studies, 4.2% to 25% of patients were not adequately treated by the opioid-sparing protocols. This includes four of seven studies (57%) assessing number of medication refills or rescue analgesia reporting increased pill consumption, refills, or rescue dosing with limited/nonopioid regimens. Five of six studies (83%) reporting satisfaction outcomes found no difference in satisfaction with pain control, medication strength, and overall surgical experience using opioid-sparing regimens.
CONCLUSIONS: Opioid-sparing regimens provide adequate pain relief for most upper extremity surgery patients. However, a meaningful number of patients on opioid-sparing regimens required greater medication refills and increased use of rescue analgesia. These patients also reported no difference in satisfaction compared with limited/nonopioid regimens.
METHODS: Therapeutic II.

Social determinants of health (SDOH) are linked to poor health care outcomes across the different medical specialties. We conducted a scoping review to understand the existing literature and identify further areas of research to address disparities within hand surgery.
A systematic search of PubMed, Scopus, and Cochrane was conducted. Inclusion criteria were English studies examining health disparities in hand surgery. The following were assessed: the main SDOH, study design/phase/theme, and main disease/injury/procedure. A previously described health disparities research framework was used to determine study phase: detecting (identifying risk factors), understanding (analyzing risk factors), and reducing (assessing interventions). Studies were categorized according to themes outlined at the National Institute of Health and American College of Surgeons: Summit on Surgical Disparities.
The initial search yielded 446 articles, with 49 articles included in final analysis. The majority were detecting-type (31/49, 63%) or understanding-type (12/49, 24%) studies, with few reducing-type studies (6/49, 12%). Patient factors (31/49, 63%) and systemic/access factors (16/49, 33%) were the most frequently studied themes, with few investigating clinical care/quality factors (4/49, 8%), clinician factors (3/49, 6%), and postoperative/rehabilitation factors (1/49, 2%). The most commonly studied SDOH include insurance status (13/49, 27%), health literacy (10/49, 20%), and social deprivation (6/49, 12%). Carpal tunnel syndrome (9/49, 18%), upper extremity trauma (9/49, 18%), and amputations (5/49, 10%) were frequently assessed. Most investigations involved retrospective or database designs (29/49, 59%), while few were prospective, cross-sectional, or mixed-methods.
Despite an encouraging upward trend in health disparities research, existing studies are in the early phases of investigation.
Most of the literature focuses on patient factors and systemic/access factors in regard to insurance status. Further work with prospective, cross-sectional, and mixed-method studies is needed to better understand health disparities in hand surgery, which will inform future interventions.

The supraclavicular block (SCB) and the infraclavicular block (ICB) are introduced to meet upper extremity surgery, where the transducer or the insertion point is placed superiorly and inferiorly at the approximate midpoint of the clavicle, respectively. These two approaches are highly appealing since they clearly exhibited each cord and its associated anatomy. In addition, it directed the needle accurately with real-time imaging by ultrasound guidance. Therefore, it brought higher success rates and fewer complications. Numerous trials have recently been conducted to examine the SCB and ICB regarding the new approach, injection techniques, block dynamics, and complication of hemidiaphragmatic paresis. It was found that both approaches could improve block effectiveness and postoperative analgesia for upper extremity surgery, according to recent studies at the level of the clavicular brachial plexus block. However, there is still a lack of work comparing the clinical performance and effectiveness of both approaches with ultrasonography. This review aims to outline the current available data from clinical trials along with case reports about these two approaches and to describe the findings published in the literature during the previous 5 years. Based on these findings, we attempt to determine whether there exists a one-size-fits-all approach that has the potential to meet upper extremity surgery.

Dexmedetomidine (DEX) provides a unique conscious sedation without respiratory depression. We examined the usefulness of intravenous (IV) DEX sedation combined with brachial plexus block for long-duration upper extremity surgery without an anesthesiologist.
We retrospectively reviewed 90 limbs of 86 patients and measured the actual operative time course in detail. The adverse events and the patient-reported outcomes regarding intraoperative pain and depth of sedation were evaluated.
The mean total time of the operation, tourniquet use, and the IV DEX sedation were 150 min, 132 min, and 117 min, respectively. The mean time between discontinuation of IV DEX sedation and completion of the operation was 51 min. The intraoperative adverse events involved bradycardia (21%), hypotension (18%), and oxygen desaturation (3%). The mean visual analog scale scores of pain during brachial plexus block, surgical site pain, tourniquet pain, and depth of the sedation were 23.4 mm, 0.14 mm, 4.2 mm, and 6.6 mm, respectively. Furthermore, 96% patients expressed a preference for receiving anesthesia as brachial plexus block with IV DEX sedation.
Long-duration upper extremity surgery, even longer than 2 h, was feasible under brachial plexus block combined with IV DEX sedation without an anesthesiologist. For patients with low blood pressure and/or low heart rate, it is recommended to adjust the continuous infusion of IV DEX to less than 0.4 µg/kg/h. To ensure that the patients are able to promptly leave the operating room fully awake, IV DEX infusion should be stopped at least 30 min before finishing the operation.

Background  Pneumatic tourniquets are widely used in hand surgery. Elevated pressures can be associated with complications, and thus, guidelines based on patient-specific tourniquet pressures have been recommended. The primary aim of this study was to determine whether lower tourniquet values based on systolic blood pressure (SBP) could be effectively applied in upper extremity surgery. Methods  A prospective case series of 107 consecutive patients undergoing upper extremity surgery with use of a pneumatic tourniquet was performed. Tourniquet pressure used was based on the patient\'s SBP. The tourniquet was inflated based on our predetermined guidelines: 60 mm Hg was added for SBP < 130 mm Hg, 80 mm Hg for SBP between 131 and 190 mm Hg, and 100 mm Hg for SBP > 191 mm Hg. The outcome measures included intraoperative tourniquet adjustment, surgeon-rated quality of bloodless operative field and complications. Results  The mean tourniquet pressure was 183 ± 26 mm Hg with a mean tourniquet time of 34 minutes (range: 2-120 minutes). There were no instances of intraoperative tourniquet adjustment. The surgeon-rated quality of bloodless operative field was excellent in all patients. No complications were associated with the use of a tourniquet. Conclusion  Tourniquet inflation pressure based on SBP is an effective method to provide a bloodless surgical field in upper extremity surgery at significantly lower inflation pressures than are the current standards.

Cervical spinal cord injury (SCI) causing tetraplegia is extremely disabling. In such circumstances, restoration of upper extremity (UE) function is considered the highest priority. The advent of early nerve transfer (NT) procedures, in addition to more traditional tendon transfers (TT), warranted in-depth consideration given the time-limited nature of NT procedures. Potential surgery candidates may not yet have come to terms with the permanence of their disability. A mixed methods convergent design was utilized for concurrent analysis of the Aotearoa/New Zealand upper limb registry data from the clinical assessments of all individuals considering UE surgery, regardless of their final decision. The International Classification of Functioning, Disability and Health (ICF) taxonomy guided data interpretation during the three-phased study series. It was the integration of the findings using the Stewart Model of care drawn from palliative health that enabled the interpretation of higher order messages. It is clear the clinical assessment and selection processes in use require reconsideration given the complexities individuals face following onset of SCI. We draw attention to the higher order cognitive demands placed on individuals, the requirement for SCI peer involvement in decision making and the need for acknowledgment of interdependence as a relational construct when living with tetraplegia.

Corticosteroid injection (CSI) has a relatively high benefit-to-risk ratio and is commonly administered to treat musculoskeletal conditions. However, perioperative CSI has been associated with an increased risk of postoperative infection. The literature suggests delaying surgery after CSI to minimize the risk of postoperative infection. We review the literature to summarize the most current knowledge on the association between perioperative CSI and infection rates for different hand and upper extremity procedures.
Two independent reviewers conducted a literature search using PubMed and Web of Science databases (through October 1, 2022). The database searches used were (((injection) AND (infection)) AND (risk)) AND ((hand) OR (wrist) OR (elbow) OR (shoulder)). English-language articles were screened for infection rates associated with CSI given temporally around upper extremity surgery, focusing between 6 months preoperatively and 1 month postoperatively.
Nineteen articles including database queries and retrospective case-control or cohort studies were used after screening 465 articles. Most infection rates were increased in hand, wrist, elbow, and shoulder surgery between 3 months preoperatively and 1 month postoperatively. Intraoperative injection during elbow arthroscopy demonstrated increased infection rate relative to other upper extremity surgeries.
Corticosteroid injection increased the risk of infection temporally around upper extremity surgeries; however, CSI provides benefits. The consensus regarding CSI timeline perioperatively has yet to be determined. The evidence supports an increased benefit-to-risk ratio when giving corticosteroids greater than 3 months preoperatively and greater than 1 month postoperatively for most upper extremity procedures, with relative contraindications within 1 month of upper extremity surgery.