Archive | Hand and Wrist RSS for this section

Is It Time to Use Ultrasound in Diagnosing Zone-II Flexor Tendon Injuries?

OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent article in Ultrasound in Medicine and Biology by Bekhet et al., this commentary comes from Christopher Dy, MD, MPH.

In their study from Cairo, Egypt, Bekhet et al. report their experience using ultrasound (US) to examine tendon integrity in the setting of suspected flexor tendon injury. A single musculoskeletal radiologist performed diagnostic US in 35 patients with trauma to the ventral surface of the hand or wrist; a total of 50 tendons were evaluated, with zone-II injuries being the most common.

US correctly identified all complete tendon disruptions, with no false positive or false negative results. US identified partial tendon injuries with 98% accuracy, with 1 false positive result and no false negatives. In comparison, clinical examination alone had a diagnostic accuracy of 88%. The diagnostic performance of US in this study is impressive, and suggests that US may have a role in the diagnostic workup of patients with suspected flexor tendon injury.

While many surgeons still rely on physical examination, it is clear that clinical assessment alone is imperfect. An accurate, objective diagnostic test is desirable for determining the need for (and extent of) surgical treatment as well as in counseling patients. MRI has been suggested to fill this role, but it can be expensive and time-consuming. US is a natural alternative, but its usage in most practice settings (including North America) has been limited because of its operator-dependent nature. That is a key acknowledgment made by the authors of this study, which limits the generalizability and impact of their findings. As only 1 highly specialized radiologist performed the US examinations in the study, it is unclear whether US performed by a less-experienced sonographer would provide the level of detail needed to directly affect clinical management.

Further validation studies (both within the authors’ institution as well as in other centers) would provide important information to determine the utility of US in accurately diagnosing the location and extent of flexor tendon injuries.

In my practice, if there is doubt regarding the integrity of a flexor tendon, I have used US performed by a musculoskeletal (MSK) radiologist or a US-trained physiatrist to provide diagnostic clarity. Admittedly, if the US results do not match my clinical impression, I will either order an MRI or discuss surgical exploration with the patient. This bias in my decision-making process clearly demonstrates my belief that further work is needed to show that US can be used accurately and reliably. While the findings of Bekhet et al. are intriguing, the single-sonographer limitation leads me to question the external validity of their findings. Because of this, the findings of this study are not practice-changing. But I hope to be proven wrong!

Christopher Dy, MD, MPH is a hand and wrist surgeon, an assistant professor of orthopaedic surgery at Washington University School of Medicine in St. Louis, and a member of the JBJS Social Media Advisory Board.

What’s New in Hand and Wrist Surgery 2021

Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 14 specialty areas. Click here for a collection of all such OrthoBuzz Guest Editorial summaries.

This month, author Christopher J. Dy, MD, MPH summarizes the 5 most compelling findings from the 40 studies highlighted in the most recent What’s New in Hand and Wrist Surgery.”

Carpal Tunnel Syndrome

–Corticosteroid injection is one modality for managing carpal tunnel syndrome, and a recent study examined the accuracy of needle placement1. Of 756 simulated injections, correct placement was noted for 572 (76%). The needle was placed in the median nerve 66 times (8.7%), and the carpal tunnel was missed 118 times (15.6%). As noted by the study authors, “safety of carpal tunnel injection remains an important concern.”

Cubital Tunnel Syndrome

–One recent study evaluating patient-reported outcomes of in situ decompression for cubital tunnel syndrome found that 66 (86%) of 77 patients were satisfied2. All of the patients who were not satisfied had preoperative weakness of the muscles innervated by the ulnar nerve.

Distal Radial Fracture

–A retrospective radiographic analysis of 273 uninjured adult distal radii found that the volar cortical angle (VCA) ranged from 23° to 43° (mean, 32°)3. With most volar locking plates having a fixed angle of 18° to 30°, there is a strong possibility of a mismatch between the patient’s VCA and the implant. If the patient’s VCA exceeds the implant’s fixed angle, undercorrection of sagittal tilt may result if the plate is used to guide reduction in treating a distal radial fracture.

Dupuytren Contracture

–A recent report presented a single surgeon’s experience over an 11-year time frame with 3 common treatments of Dupuytren contracture4. The rates of reintervention after needle aponeurotomy were 24% at 2 years and 61% at 5 years; after collagenase injection at the same time points, 41% and 55%; and after surgical fasciectomy, 4% at both 2 and 5 years. When factoring in cost, needle aponeurotomy appeared to be a high-value intervention.

Scapholunate Dissociation

–Among 203 patients who underwent  3-ligament tenodesis for scapholunate injury, improvement in patient-reported outcomes at 1 year was noted for 79%, but 10% had no change, and 11% had worse patient-reported outcomes5. Indications for 3-ligament tenodesis may need further clarification.

References

  1. Green DP, MacKay BJ, Seiler SJ, Fry MT. Accuracy of carpal tunnel injection: a prospective evaluation of 756 patients. Hand (N Y). 2020 Jan;15(1):54-8. Epub 2018 Jul 13.
  2. Yeoman TFM, Stirling PHC, Lowdon A, Jenkins PJ, McEachan JE. Patient-reported outcomes after in situ cubital tunnel decompression: a report in 77 patients. J Hand Surg EurVol. Vol 2020 Jan;45(1):51-5. Epub 2019 Oct 30.
  3. Gandhi RA, Hesketh PJ, Bannister ER, Sebro R, Mehta S. Age-related variations in volar cortical angle of the distal radius. Hand (N Y). 2020 Jul;15(4):573-7. Epub 2018 Dec 31.
  4. Leafblad ND, Wagner E, Wanderman NR, Anderson GR, Visscher SL, Maradit Kremers H, Larson DR, Rizzo M. Outcomes and direct costs of needle aponeurotomy, collagenase injection, and fasciectomy in the treatment of Dupuytren contracture. J Hand Surg Am. 2019 Nov;44(11):919-27. Epub 2019 Sep 17.
  5. Blackburn J, van der Oest MJW, Poelstra R, Selles RW, Chen NC, Feitz R; Hand-Wrist Study Group. Three-ligament tenodesis for chronic scapholunate injuries: short-term outcomes in 203 patients. J Hand Surg EurVol. Vol 2020 May;45(4):383-8. Epub 2019 Nov 11.

 

Mouse Paws Good for Investigating Pyogenic Flexor Tenosynovitis

Although an infected finger may not sound like a big deal, the closed-space bacterial infection known as pyogenic flexor tenosynovitis (PFT) has been described as “one of the most devastating infections in the upper extremity.” PFT can rapidly spread from one digit to another, and the incidence of posttreatment complications—including adhesions and tendon tears—has been reported to be as high as 38%.

In a recent issue of JBJS, Qiu et al. report on a mouse model that could help us better understand the pathophysiology of PFT—and more efficiently test established and novel ways of treating it. Previous basic-science investigations into PFT have relied on avian models, but those have proven to be expensive and hard to scale and maintain.

What the Researchers Did:

  • Inoculated the tendon sheath of 36 male mouse hind-paws with bioluminescent forms of either Staphylococcus aureus or sterile saline
  • Monitored the infected and control cohorts for bioluminescence values and clinical signs such as digit swelling and body-weight reduction
  • Performed histological analysis of control and infected paws

What the Researchers Found:

  • A significant increase in bioluminescence in the infected group for the first 2 days after infection
  • Significantly lower weights in the infected animals compared with controls
  • Swelling, scar formation, collapse of the intrasheath space, and thickening of the tendon sheath itself in the infected group

Qiu et al. say this mouse model “could serve as a platform in further understanding the pathophysiology of PFT” and could help evaluate therapies aimed at reducing scarring and stiffness.

Click here to read the JBJS Clinical Summary on Infections of the Hand by Ryan Calfee, MD.

Cost-Effectiveness of Endoscopic vs Open Carpal Tunnel Release

Carpal tunnel release (CTR) is one of the most common upper-extremity procedures, with excellent outcomes and lasting benefits. When comparing the surgical options of open versus endoscopic CTR, studies have noted higher rates of transient nerve injury but lower risk of wound problems after endoscopic release. Long-term clinical outcomes appear to be similar between the 2 techniques.

What about the associated costs? This is a multidimensional question of particular relevance given the high economic impact of carpal tunnel syndrome, a leading cause of lost work time. Barnes et al. shed new light on the cost-effectiveness of endoscopic versus open CTR in a recent JBJS report, offering a look from societal and payer perspectives. In this cost-effectiveness analysis, the authors developed a Markov model to evaluate unilateral open versus endoscopic CTR in an office setting with local anesthesia and an operating room (OR) setting under monitored anesthesia care. Comprehensive outcomes data from published meta-analyses helped to inform the modeling, while the costs of CTR, performed from 2012 to 2016, were obtained from a large Medicare claims database.

The authors note that, with complications rates being relatively balanced between the 2 techniques, and differences in quality-adjusted life-years being small (<1 quality-adjusted life-day), “procedural and lost-productivity costs primarily drove the results.” (The model assumed 8.21 fewer days of missed work after endoscopic CTR.) Health-care costs are larger for endoscopic CTR, but “the impact of lost productivity was important.” For instance, endoscopic release in the OR setting becomes cost-effective if the patient’s expected return to work is even 1.2 days earlier than that following open CTR in the OR. However, because of the lower costs of performing open CTR in the office setting, endoscopic CTR in the OR is cost-effective only if the expected return to work is at least 3.9 days earlier than that following open CTR in the office.

Overall, the authors concluded that, from a payer perspective, endoscopic CTR is more expensive than open CTR and only becomes truly cost-effective if performed in an office setting under local anesthesia. However, from a societal perspective, earlier return to work may help tip the scales in favor of endoscopic release. The authors caution that additional research is needed to confirm their findings based on the latest surgical techniques and return-to-work protocols.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

Click here for a JBJS Clinical Summary on the treatment of carpal tunnel syndrome.

Patient Misperception of Musculoskeletal Disease Onset

Often when I ask patients about the reason for their visit, I inquire about specific events. For example, “What were you doing when you hurt your knee?” For acute injuries, they can usually describe the exact moment they tore their ACL or dislocated their shoulder. In an adolescent sports clinic, where I spend much of my time, this acute scenario is the norm, but what about patient conversations regarding gradual-onset disease processes such as carpal tunnel syndrome (CTS) or osteoarthritis? These pathologies develop over many years, but patients with such conditions may fixate on when their disease became symptomatic–and may therefore mistakenly attribute a chronic condition to an acute injury.

Lemmers et al. investigate this complex body-mind concept in the December 16, 2020 issue of The Journal. The authors sought to analyze factors associated with the misperception of disease onset due to the recent experience of symptoms in 121 adult patients with CTS, cubital tunnel syndrome, upper-extremity osteoarthritis, or rotator cuff tendinosis. The patients filled out questionnaires for depression, anxiety, pain catastrophizing, self-efficacy, and upper-extremity physical function, in addition to supplying basic demographic information.

Based on the responses, most patients understood that their problem was not new but was instead “age-appropriate.” However, 18% of patients perceived the sudden onset of symptoms as a “new” disease, and 24% felt the problem was related to at least 1 injury or event. After multivariable analysis, Lemmers et al. found that Hispanic ethnicity and publicly funded or no insurance were independently associated with the perception that an event/injury caused the problem. The authors candidly admit that this area needs much more research, but they surmise that this latter finding could be related to lower health literacy.

This work highlights that we need to make sure our patients understand exactly what is happening with their musculoskeletal system. Because misperception of a disease’s cause and onset could affect patient decision-making, it is incumbent upon us as surgeons to be vigilant for possible misconceptions during our shared decision-making discussions with patients. As Lemmers et al. conclude, “Patients who do not understand what is happening to their body might choose different health strategies than they would if their understanding were accurate.”

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

Using Registries to Investigate Rare Diseases

There has been a huge worldwide effort over the last 2-plus decades to establish arthroplasty registries. Among the many advantages of such registries, advocates emphasize the potential detection of early failures associated with new implant designs and biomaterials. The large number of patients enrolled in most registries and the methodical capturing of data yield substantial statistical and research benefits.

Based on the successes of arthroplasty registries, parallel registries have been established for sports medicine (especially for shoulder and knee conditions and treatments), fractures, musculoskeletal tumors, and others. Although the focus has been on enrolling large numbers of patients with relatively common disorders or procedures, there have been less well-publicized efforts to create smaller registries of rarer diseases.

In the October 21, 2020 issue of The Journal, Forman et al. use the 8-site Congenital Upper Limb Differences (CoULD) registry to report on associations between congenital deficiency of the radial aspect of the forearm in 259 patients (383 involved limbs) and thumb hypoplasia. Two findings stood out to me:

  • The severity of radial deficiency was correlated with the severity of thumb deficiency.
  • Compared with subjects who had no diagnosed syndromes, patients with concomitant syndromes (such as VACTERL and Holt-Oram) were twice as likely to have bilateral deficiency and 2.5 times as likely to have radial and thumb deficiencies as opposed to thumb deficiency alone.

In addition to reinforcing findings from previous single-institution studies, these data from Forman et al. will help surgeons counsel parents, determine treatment approaches, and establish frameworks for following patient outcomes after both surgical and nonsurgical treatment. It is my hope that other clinician-researchers with interest in understanding and managing rare conditions will establish similar registries to benefit these smaller but no-less-important groups of patients and families.

Click here to read the JBJS Clinical Summary on Congenital Hand Differences.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

What I Learned at the ASSH 2020 Virtual Annual Meeting

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes Christopher Dy, MD, MPH in response to his recent participation in the virtual Annual Meeting of the American Society for Surgery of the Hand.

The year 2020 has brought with it many “firsts.” For example, due to the COVID-19 pandemic, the Annual Meeting for the American Society for Surgery of the Hand (ASSH) was moved from San Antonio to a virtual platform. Kudos to the Annual Meeting chairs (Dawn Laport, MD and Ryan Calfee, MD), ASSH president Martin Boyer, MD, and the ASSH staff for constructing an amazing experience. Here are some general take-homes from my first-ever virtual conference experience:

  • A virtual conference provides attendees with a ton of flexibility and customization. While there are often “conflicting,” concurrent sessions during an in-person meeting where I have to decide between 2 sessions, the virtual ASSH meeting format offered the ability to go back and watch prior courses and lectures. When we (hopefully) go back to in-person meetings, it would help if more sessions were recorded and made available to attendees on demand.
  • The virtual conference requires a lot more pre-meeting preparation for all parties involved, especially presenters. Because the sessions that would normally occur in the large, main halls were hosted on a professionally run platform with A/V engineers, presenters were required to attend more than a few “tech” rehearsals, as well as submit their presentation slides 4 to 6 weeks in advance. I admit that it was harder for me to present from slides that didn’t feel as fresh, since I couldn’t revise them the night before!
  • While it was convenient to view most of the meeting from my couch (or exercise bike), I really miss the in-person interactions with colleagues and friends that you get while moving between sessions. It’s also harder to pull yourself away from your family and your practice when you are “participating” in a meeting from home or office.

Here are 4 technical things I learned from the sessions I attended, largely biased toward my personal interests. I encourage readers to leave comments by clicking on the “Leave a Comment” button in the box next to the title.

  • Innovation continues for distal nerve transfers to treat peripheral nerve palsy. Professor Jayme Bertelli from Brazil gave talks demonstrating both technical aspects and his own results following transfers such as ECRL [extensor carpi radialis longus]-to-AIN [anterior interosseous nerve], distal AIN to distal PIN [posterior interosseous nerve], and opponens pollicis to adductor pollicis. I am eager to read more about these transfers and get into the cadaver lab to refine my surgical technique. (Precourse 03 and Symposium 18)
  • The debate about “supercharging” (reverse end-to-side) nerve transfers continues. There is laboratory evidence supporting the role of a supercharged nerve transfer in preserving the distal muscle unit and the distal nerve stump. However, there is controversy regarding whether it is benign and/or beneficial to have 2 “competing” sources of muscle innervation, in cases where the “native” nerve reaches the distal target after the axons coming from the supercharged transfer have been placed. While many surgeons have adopted supercharged nerve transfer into their practice, there is far more laboratory and clinical research needed to substantiate this practice and refine the indications for use. (Precourse 03 and Symposium 11)
  • Utilization of wide-awake, local-anesthesia, no-tourniquet (WALANT) hand surgery continues to grow. Surgeons are performing a growing number of different surgeries (including fracture cases and complex tendon transfers) with WALANT, and some are doing these cases in procedure rooms or offices rather than in a formal operating room. These changes are driven by both surgeon and patient preference, as well as potential cost advantages for both parties. For surgeons, there is a potential for increased revenue with WALANT, but this can come with logistical challenges such as stocking sterile trays and making sure that medications are available. The trend toward increasing utilization of WALANT in procedure rooms and in surgeons’ offices is likely to continue. (Instructional courses 24 and 56 and related OrthoBuzz post)
  • Teaching in the operating room has shifted. Many current trainees prefer to use videos for case preparation rather than focusing on book chapters, technique articles, or primary literature. Consequently, there is a growing embrace of video among hand-surgeon educators. Videos that are short, discuss indications, and provide rationale for technique-related decisions are favored. Today’s trainees are also less likely to respond well to the classic Socratic method of teaching and may need more overtly delivered feedback. (Instructional courses 10 and 36)

Christopher Dy, MD, MPH is a hand and wrist surgeon, an assistant professor of orthopaedic surgery at Washington University School of Medicine in St. Louis, and a member of the JBJS Social Media Advisory Board.

Is It Safe to Drive After WALANT Hand Surgery?

Most everyone has seen the auto-insurance TV ad where the deep-voiced man asserts, “Safe drivers save 40%.” Insurance savings notwithstanding, patients frequently ask orthopaedic surgeons when they can return to safe driving after surgery. Of course, the answer depends partly on the patient’s ability to drive safely before surgery, but most of the orthopaedic research on this topic has focused on lower extremities. In the September 16, 2020 issue of The Journal, Orfield et al. take a detailed look at the driving question after wide-awake, local-anesthetic, no-tourniquet (WALANT) surgery of the hand.

Twelve right-handed patients drove 18 miles under baseline conditions and completed various parking tasks during the first 45- to 55-minute test. The instrumented vehicle they drove obtained kinematic data automatically, and behavioral responses were recorded on video cameras. Then the same subjects completed the same driving exercise in the same vehicle—but this time after having their right hand injected with 10 mL of 1% lidocaine over the volar wrist, and another 10 mL into the carpal tunnel. To further simulate WALANT conditions, researchers applied a bulky hand dressing to each participant’s right hand. The WALANT-modeled driving test included a simulated “surprise event” that required avoidance maneuvers. Researchers analyzed before-and-after data on a variety of kinematics, including braking, acceleration, right and left turning, and proportion of time spent driving with each or both hands.

Overall, Orfield et al. found no evidence of a negative impact on driving fitness in the simulated WALANT state. In fact, the subjects braked harder and steered more smoothly in the WALANT-modeled state, an indication that they perceived they might be impaired. Not surprisingly, participants in the WALANT-modeled state spent decreased time using both hands (from 72% to 62%), while left-hand-only driving increased from 2% to 16% of the time. All participants reported that they felt safe to drive with a numb, bandaged right hand.

These noninferiority findings suggests that WALANT patients are no worse off with immediate driving after the surgical procedure than they were beforehand. The authors are quick to point out that these findings should not be generalized beyond right-handed people driving a passenger car with an automatic transmission in the United States. Still, this study gives us some evidence-based data to better inform patients undergoing common hand procedures now frequently performed under WALANT conditions, such as trigger-finger and carpal-tunnel release. However, we can’t guarantee they will save on their auto insurance.

Click here to view a 3-minute “Author Insight” video with study co-author Peter J. Apel, MD, PhD.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

Reoperation Rates for Wrist-Arthritis Treatments

With contemporary teaching and advanced-imaging diagnostic protocols, the incidence of advanced wrist arthritis related to scaphoid nonunion and carpal instability seems to be decreasing. When this condition does present, the longstanding debate about treatment pits preserving the carpal bone mass with a 4-corner arthrodesis (FCA) against resecting the proximal row of carpal bones (proximal row carpectomy, or PRC) to provide better motion. At issue have been concerns about the durability and reoperation rates for these two treatment approaches.

In the June 17, 2020 issue of The Journal, Garcia et al. tap into the Veterans Health Administration  data warehouse to help clarify this treatment dilemma. The authors identified 1,168 patients with stage-II SLAC (scapholunate advanced collapse) or SNAC (scaphoid nonunion advanced collapse) patterns of wrist arthritis. The outcomes of interest were subsequent conversion to total wrist arthrodesis and secondary surgical procedures after FCA and PRC.

Using propensity score analysis, the authors established matched cohorts of 251 cases of each procedure. The rate of conversion to total wrist arthrodesis was virtually identical in both matched groups, but far fewer patients who underwent FCA avoided a subsequent nonarthrodesis operation compared with those who underwent PRC (83.5% vs 99.7%, respectively).

Based on these findings and the evidence in previously published literature, the authors say, “We believe that PRC may be preferable to FCA in patients with symptomatic stage-II SLAC/SNAC wrist arthritis.” I think this choice should always be the result of shared decision making that itemizes the pros and cons of both procedures—especially taking into account patient preferences related to expected functional outcomes.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

What’s New in Hand and Wrist Surgery 2020

Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of OrthoBuzz summaries of these “What’s New” articles. This month, author Christopher J. Dy, MD, MPH selected the 5 most clinically compelling findings from the more than 50 studies summarized in the March 18, 2020 “What’s New in Hand and Wrist Surgery.

Scaphoid Nonunion
—A retrospective case series investigating 3 treatments for scaphoid nonunion among >100 patients1 found the following:

  • Those receiving iliac crest bone graft (n=31), most of whom had carpal collapse with preserved proximal pole vascularity, had a union rate of 71%, a time-to-union of 19 weeks, and a reoperation rate of 23%.
  • Those receiving an intercompartmental supraretinacular artery flap (n=33), most of whom had osteonecrosis of the proximal pole and half of whom had carpal collapse, had a union rate of 79%, a time-to-union of 26 weeks, and a reoperation rate of 12%.
  • Those receiving a free vascularized medial femoral condyle flap (n=45), most of whom had carpal collapse, osteonecrosis, and prior surgery, had a union rate of 89%, a time-to-union of 16 weeks, and a reoperation rate of 16%.

—Among 13 patients with scaphoid nonunion and osteonecrosis who were treated with cancellous autograft packing and volar-plate fixation,2 there was 100% fracture union, with most achieving union within 18 weeks. However, preoperative carpal-collapse rates were not reported, making it difficult to assess the role of this procedure.

Finger Replantation: Financial Issues
—The frequency and success rates of finger replantation have been decreasing in the US. A review of physician reimbursement for these procedures3 found that replantation has lower reimbursement per work relative value unit (RVU) than many other common hand surgeries, including revision amputation, carpal tunnel release, and trigger finger surgery. This “relative devaluation” may help explain the decline in frequency and success of finger replantation.

Socioeconomics of Carpal Tunnel Syndrome
—Among patients seeking treatment for carpal tunnel syndrome, those from areas of “increased social deprivation” had worse physical function, pain interference, anxiety, and depression than patients from more affluent areas.4

Cubital Tunnel Syndrome
—A study of preoperative dynamic ultrasound in patients with cubital syndrome5 found that ultrasound was far more reliable than preoperative clinical examinations in predicting ulnar nerve stability within the cubital tunnel (88% match with intraoperative findings vs 12% match, respectively). Preoperative ultrasound may therefore help surgeons counsel patients about the possible need for nerve transposition.

References

  1. Aibinder WR, Wagner ER, Bishop AT, Shin AY. Bone grafting for scaphoid nonunions: is free vascularized bone grafting superior for scaphoid nonunion?Hand (N Y). 2019 Mar;14(2):217-22. Epub 2017 Oct 27.
  2. Putnam JG, DiGiovanni RM, Mitchell SM, Castañeda P, Edwards SG. Plate fixation with cancellous graft for scaphoid nonunion with avascular necrosis. J Hand Surg Am.2019 Apr;44(4):339.e1-7. Epub 2018 Aug 10.
  3. Hooper RC, Sterbenz JM, Zhong L, Chung KC. An in-depth review of physician reimbursement for digit and thumb replantation. J Hand Surg Am.2019 Jun;44(6):443-53. Epub 2019 Apr 17.
  4. Wright MA, Beleckas CM, Calfee RP. Mental and physical health disparities in patients with carpal tunnel syndrome living with high levels of social deprivation. J Hand Surg Am.2019 Apr;44(4):335.e1-9. Epub 2018 Jun 23.
  5. Rutter M, Grandizio LC, Malone WJ, Klena JC. 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;44(1):35-8. Epub 2018 Nov 27.