Complications of hinged external fixation compared with cross-pinning of the elbow for acute and subacute instability

BACKGROUND

Elbows that are unstable after injury or reconstructive surgery often are stabilized using external fixation or cross-pinning of the joint supplemented by cast immobilization. The superiority of one approach or the other remains a matter of debate.

QUESTIONS/PURPOSES

We compared patients treated with external fixation or cross-pinning in terms of (1) adverse events, (2) Broberg and Morrey scores, and (3) ROM.

METHODS

Between 1998 and 2010, 19 patients (19 elbows) had hinged external fixation and 10 patients (11 elbows) cross-pinning and casting for subacute or acute posttraumatic elbow instability. Our general indications for both techniques were persistent elbow instability after usual treatment. Initially, we used external fixation for delayed treatment of fracture-dislocations and cross-pinning for simple elbow dislocations in patients who could not tolerate surgery, but more recently we have used cross-pinning for both indications. Adverse events, elbow scores, and ROM were retrospectively evaluated by chart review, with the latter two end points being calculated at a mean of 31 months (range, 5-83 months) and 10 months (range, 5-21 months) after index procedure for the patients treated with external fixation and cross-pinning, respectively.

RESULTS

Seven of 19 patients treated with external fixation experienced nine device-related adverse events: three pin tract infections, two nerve problems, one broken pin, one residual subluxation, one suture abscess, and one pin tract fracture of the ulna resulting in a nonunion. Of the 10 patients (11 elbows) treated with cross-pinning, one patient had pin tract inflammation that resolved with pin removal. Mean Broberg and Morrey score was 90 (95% CI, 84-95) after external fixation and 90 (95% CI, 84-96) after cross-pinning (p = 0.88). There were no differences between the external fixation and cross-pinning groups in mean flexion (123° versus 128°, p = 0.49), extension (29° versus 29°, p = 0.97), forearm pronation (68° versus 74°, p = 0.56), and forearm supination (47° versus 68°, p = 0.15).

CONCLUSIONS

When the elbow remains unstable after reduction and usual treatment for fractures and dislocations or has been out of place for more than 2 weeks, both cross-pinning and external fixation can help maintain elbow alignment while structures heal. Hinged external fixation is associated with more adverse events related to the device, but Broberg and Morrey score and ROM are similar between techniques.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Patient activation and disability in upper extremity illness

PURPOSE

To determine if higher patient activation (active involvement in one's health care) correlates with fewer symptoms and less disability in patients with hand and upper extremity illness.

METHODS

We enrolled 112 patients presenting to our department for the first time. Before meeting with the surgeon, subjects completed a demographics questionnaire, the short form Patient Activation Measure; Quick Disabilities of the Arm, Shoulder, and Hand; Patient Health Questionnaire-2; Pain Self-Efficacy Questionnaire; and an 11-point ordinal rating of pain intensity. We contacted patients 1 to 2 months after enrollment. Seventy-five subjects completed the second evaluation over the telephone, on a secure data-collection web site, or in an office visit, which included the Patient Activation Measure; Quick Disabilities of the Arm, Shoulder, and Hand; numerical rating scale for pain; and ordinal rating of treatment satisfaction.

RESULTS

Patient activation at enrollment correlated with disability, pain intensity, and satisfaction with treatment but was only retained in the multivariable model for pain intensity. Pain self-efficacy at enrollment was the factor that best accounted for variation in disability, pain, and satisfaction with treatment.

CONCLUSIONS

Given the consistent relationship between effective coping strategies (eg, pain self-efficacy) and symptoms and disability and the independent influence of patient activation on pain intensity in this study, future research should address the ability of interventions that improve self-efficacy and patient activation to improve upper extremity health.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Intra-articular osteotomy for malunited articular fractures of the distal end of the humerus

BACKGROUND

The precarious anatomy of the articular surface of the distal humerus, as well as its meager subchondral bony support and limited soft-tissue attachments, presents enormous challenges for the operative correction of post-traumatic intra-articular deformities. This study presents 8 patients who underwent articular osteotomy with a mean follow-up period of 10.6 years, with an emphasis on functional, patient-rated, and radiographic outcomes.

METHODS

Eight patients (mean age, 39 years; range, 17-60 years) were followed up for a mean period of 10.6 years. The original fracture was a type C variant in 4 patients, a type B unicondylar fracture in 2, and a type B articular shearing fracture in 2. The initial injury was treated operatively in 5 patients and nonoperatively in 3. The osteotomy and reconstruction were performed on average 8 months after injury (range, 6-11 months). The mean preoperative elbow arc of motion was 37°. Two patients had ulnar nerve dysfunction.

RESULTS

All the osteotomies healed after the index procedure without evidence of avascular necrosis. Two patients required a second procedure for stiffness. At follow-up, the mean arc of elbow motion improved to 104° (P = .001), with a mean flexion contracture of 26°. The mean Disabilities of the Arm, Shoulder and Hand score at follow-up was 13 (range, 1-37); the mean patient satisfaction rating on a Likert scale (from 0 to 10) was 9.1; and the mean Mayo Elbow Performance Index score was 83 points (range, 70-100 points). Grade II osteoarthritic changes were seen in 3 patients, grade I in 3, and grade 0 in 2.

CONCLUSIONS

In selected patients with a defined intra-articular malunion, the results of our experience support corrective osteotomy.

Temporary presence of myofibroblasts in human elbow capsule after trauma

BACKGROUND

Elbow stiffness is a common complication after elbow trauma. The elbow capsule is often thickened, fibrotic, and contracted at the time of surgical release. The limited studies available suggest that the capsule is contracted because of fibroblast-to-myofibroblast differentiation. We hypothesize that myofibroblasts are absent in normal elbow capsules and in acute trauma and that they are subsequently elevated in patients with posttraumatic elbow contracture.

METHODS

We obtained twenty-one human elbow joint capsules within fourteen days after an elbow fracture and/or dislocation and thirty-four elbow joint capsules in thirty-four patients who had undergone operative release of posttraumatic contractures more than five months after injury. Myofibroblasts in the joint capsules were quantified with use of immunohistochemistry. Alpha-smooth muscle actin was used as a marker for myofibroblasts. Samples were characterized and were scored by an independent pathologist blinded for clinical data.

RESULTS

Eleven capsules were associated with the acute phase after trauma (hours to less than seven days), and staining for alpha-smooth muscle actin was negative in all but one capsule. Ten capsules were associated with a later posttraumatic phase with myofibroblasts staining positive for alpha-smooth muscle actin in all but two capsules. Thirty-two long-standing contractures showed a histological pattern consistent with chronic stages of fibrosis, characterized by increased fibroblast-like cell proliferation and higher cellular density of fibroblast-like cells with highly unstructured collagen. Two joint capsules showed an earlier phase of fibrosis. Only two of the long-standing contractures had staining of alpha-smooth muscle actin in fibroblast-like cells; the lack of staining in the other contractures suggested an absence of myofibroblasts.

CONCLUSIONS

This study presents negative results on the hypothesis that myofibroblast numbers are elevated in long-standing (more than five months) human posttraumatic elbow capsules. The absence of myofibroblasts in long-standing elbow contracture capsules is in contrast to most other studies on human tissue in the literature to date.

Galeazzi fractures: our modified classification and treatment regimen

While diaphyseal fractures of the forearm are a common orthopedic injury, Galeazzi fractures are difficult to treat. The current knowledge on pathobiomechanics and modified therapeutic decisions implicate the need to devise an updated classification and treatment regimen of Galeazzi fractures. We challenge the concept that isolated fractures of the radius should be considered as a Galeazzi fractures as long as stability of the distal radioulnar joint is not proven. Contrary to others we demonstrate that the fracture location alone is not sufficient to determine the stability of the distal radioulnar joint.

Evaluation of the scratch collapse test for the diagnosis of carpal tunnel syndrome

This prospective study measured and compared the diagnostic performance characteristics of various clinical signs and physical examination manoeuvres for carpal tunnel syndrome (CTS), including the scratch collapse test. Eighty-eight adult patients that were prescribed electrophysiological testing to diagnose CTS were enrolled in the study. Attending surgeons documented symptoms and results of standard clinical manoeuvres. The scratch collapse test had a sensitivity of 31%, which was significantly lower than the sensitivity of Phalen's test (67%), Durkan's test (77%), Tinel's test (43%), CTS-6 lax (88%), and CTS-6 stringent (54%). The scratch test had a specificity of 61%, which was significantly lower than the specificity of thenar atrophy (96%) and significantly higher than the specificity of Durkan's test (18%) and CTS-6 lax (13%). The sensitivity of the scratch collapse test was not superior to other clinical signs and physical examination manoeuvers for CTS, and the specificity of the scratch collapse test was superior to that of Durkan's test and CTS-6 lax. Further studies should seek to limit the influence of a patient's clinical presentation on scratch test performance and assess the scratch test's inter-rater reliability.

History of operative treatment of forearm diaphyseal fractures

Diaphyseal fractures of the forearm have accompanied humanity throughout its history. Nonsurgical techniques dominated the treatment for centuries, and complications including nonunion and malunion were common. The 19th century featured the recognition of distinct injury patterns. With the development of anesthesia and antisepsis, the operative treatment became widespread. In 1878, Heine described fixation of the diaphyseal nonunion of the distal ulna using an intramedullary ivory peg. Parkhill reported on the application of external fixation for forearm fractures in 1897-1898. Hansmann published the case of plate osteosynthesis of an acute fracture of the radius in 1886. In 1913, Schöne published the technique of closed intramedullary fixation of diaphyseal fractures of the forearm using a silver wire. During the first 2 decades of the 20th century, plate osteosynthesis quickly spread across Europe and North America owing to the influence of Lambotte and Lane. After the World War II, plate osteosynthesis became the surgical treatment of choice for forearm diaphyseal fractures.

Determinants of disability after proximal interphalangeal joint sprain or dislocation

BACKGROUND

Sprain or dislocation of the proximal interphalangeal joint may be a useful example of the counterintuitive aspects of recovery as the prognosis is excellent, but protectiveness in response to discomfort often hinders the stretching exercises that are a key component of the recovery process.

OBJECTIVE

The aim of this study was to investigate the relationship between disability and pain self-efficacy in this context.

METHODS

A total of 82 patients (54 men and 28 women) were enrolled in this prospective study. Finger motion was measured, and the patients completed measures of upper limb-specific disability (the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire), symptoms of depression (Patient Health Questionnaire-9), effective coping strategies in response to pain (the Pain Self-Efficacy Questionnaire), and a pain scale at enrollment.

RESULTS

Patients were enrolled a mean of 48 days after injury. The final multivariable model accounting for greater disability included lower self-efficacy, greater symptoms of depression, and gender (women have more disability). Lower self-efficacy was also the strongest predictor of pain intensity and finger stiffness.

CONCLUSIONS

Effective coping strategies such as self-efficacy facilitate recovery (less disability, pain, and stiffness) after proximal interphalangeal joint sprain/dislocation.

LEVEL OF EVIDENCE

Prognostic level I.

Distal radius fractures: strategic alternatives to volar plate fixation

Volar locking plates have provided surgeons with enhanced capability to reliably repair both simple and complex fractures and avoid the hardware-related complications associated with dorsal plating. However, there have been an increasing number of published reports on the frequency and types of complications and failures associated with volar locked plating of distal radius fractures. An informed, critical assessment of distal radius fracture characteristics will allow surgeons to select an individualized treatment strategy that maximizes the likelihood of a successful outcome. Knowledge of the anatomy, patterns, and characteristics of the diverse types of distal radius fractures and the complications and failures associated with volar locked plating will be helpful to orthopaedic surgeons who treat patients with these injuries.

Non-union in forearm fractures

Non-union in forearm fractures is an uncommon but complex problem. This is especially given the unique anatomical structure and function of the forearm, making treatment distinctly different to that of other long bone fractures. Anatomical restoration of length, alignment, rotation and the radial bow maintains the optimal stabilising effects of the forearm muscles and interosseous membrane, as well as maximising the range of movement, particularly pronation and supination. Contemporary plate osteosynthesis using variations of the dynamic compression plate (DCP) developed by the AO group combined with established techniques of internal fixation have revolutionised the treatment of diaphyseal forearm fractures. Non-union rates have been minimised to below 5% and good to excellent functional outcomes are achieved. Non-union of the forearm is also intimately associated with a significant pain experience, marked pre-operative functional disability and physical and psychosocial morbidity. This review examines the literature and presents a guide to management as well as the current controversies and future directions related to this challenging problem.

Minimum 6-year follow-up after ulnar nerve decompression and submuscular transposition for primary entrapment

PURPOSE

To retrospectively evaluate patients with 6-year minimum follow-up after submuscular transposition of the ulnar nerve for primary entrapment.

METHODS

From 1992 to 2005, 142 patients were treated surgically for ulnar neuropathy at the elbow by 2 senior surgeons using a technique that preserved nerve vascularity. A total of 99 cases were eligible, and 82 elbows in 76 patients, average age 48 years, were followed for at least 6 years (average, 8.3 y). Thirty-two (42%) were male, and the dominant limb was involved in 49 (64%). The average duration of symptoms before surgery was 25 months. Clinical records were reviewed, and sensory (S0-2) and motor (M0-5) testing was performed. Dellon scores were determined, and visual analog scale and modified questionnaires from Novak et al and Kleinman and Bishop were completed. Preoperatively, 48 elbows were Dellon grade III, 33 were grade II, and one was grade I.

RESULTS

There were clinically and statistically significant improvements in patient and surgeon-reported data regardless of the preoperative disease severity. Visual analog scale questionnaires, sensory scale, and motor strength all improved, with at least antigravity strength in all subjects. Dellon scores also improved, and 38 elbows had normalized to Dellon 0. Of the 33 preoperative elbows that were grade III, 15 improved to grade II, 13 to grade I, and 5 normalized. Of the 48 preoperative elbows that were grade II, 16 improved to grade I and 32 normalized. Preoperative Dellon III elbows had more residual symptoms than grade II elbows. A total of 73 elbows (89%) had a good or excellent outcome. There were no reoperations or infections.

CONCLUSIONS

Submuscular transposition is a safe and durable option for primary ulnar neuropathy at the elbow. Overall, good or excellent results were achieved in 89% of patients with a low complication rate.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Recurrent bizarre parosteal osteochondromatous proliferation of the ulna with erosion of the adjacent radius: case report

Bizarre parosteal osteochondromatous proliferation is an unusual entity that should be considered when evaluating a patient with a surface-based bone lesion. The aggressive features of bizarre parosteal osteochondromatous proliferation have occasionally led to misdiagnoses as malignant neoplasms and subsequent aggressive treatment. We present a case of a recurrent forearm bizarre parosteal osteochondromatous proliferation with unique radiographic features. This report serves to illustrate the importance of both radiographic and histopathologic review for correct diagnosis and discusses the successful management of a recurrent forearm lesion.

Improvement of research quality in the fields of orthopaedics and trauma: a global perspective

The international orthopaedic community aims to achieve the best possible outcome for patient care by constantly modifying surgical techniques and expanding the surgeon's knowledge. These efforts require proper reflection within a setting that necessitates a higher quality standard for global orthopaedic publication. Furthermore, these techniques demand that surgeons acquire information at a rapid rate while enforcing higher standards in research performance. An international consensus exists on how to perform research and what rules should be considered when publishing a scientific paper. Despite this global agreement, in today's "Cross Check Era", too many authors do not give attention to the current standards of systematic research. Thus, the purpose of this paper is to describe these performance standards, the available choices for orthopaedic surgeons and the current learning curve for seasoned teams of researchers and orthopaedic surgeons with more than three decades of experience. These lead to provide an accessible overview of all important aspects of the topics that will significantly influence the research development as we arrive at an important globalisation era in orthopaedics and trauma-related research.

Correspondence between clinical presentation and electrophysiological testing for potential carpal tunnel syndrome

The diagnosis of carpal tunnel syndrome (CTS) is often applied in the absence of objectively verifiable pathophysiology (i.e. electrophysiologically normal carpal tunnel syndrome). The primary purpose of this study was to determine whether depressive symptoms, heightened illness concern, and pain catastrophizing are associated with an absence of electrophysiological abnormalities. The secondary purpose was to examine the correspondence between the Levine scale, the CTS-6, and electrophysiological abnormalities. Ninety-eight participants completed validated questionnaires assessing psychosocial factors at the initial visit, and surgeons recorded clinical data and their confidence that the diagnosis was carpal tunnel syndrome. Symptoms and signs that are characteristic of carpal tunnel syndrome (e.g. the CTS-6 and Levine scale) significantly, but incompletely coincided with electrophysiological testing. Psychological factors did not help distinguish patients with normal and abnormal objective testing and it remains unclear if symptoms that do not coincide with abnormal tests represent very mild, immeasurable median nerve dysfunction or a different illness altogether. Future studies should address whether outcomes are superior and resource utilization is optimized when surgery is offered based on symptoms and signs (e.g. the CTS-6) or when surgery is offered on the basis of measurable pathophysiology.

Bone loss in the hand

Traumatic bone loss in hand surgery is challenging for the patient as well as the doctor. Whereas the patient is threatened with a possible amputation or severe disability, the hand surgeon focuses on reconstruction, restoration of the function, bony union, and appearance of the injured hand. Both are confronted with a long-standing and staged treatment coupled with a high risk of complications. This review encompasses the classifications and treatment options of bone loss in hands. The optimal treatment is still prevention of the trauma itself.

A prospective randomized comparison of neoprene vs thermoplast hand-based thumb spica splinting for trapeziometacarpal arthrosis

OBJECTIVE

In patients with trapeziometacarpal arthrosis, we tested the hypothesis that there is no difference in arm-specific disability 5-15 weeks after prescription of a pre-fabricated neoprene or a custom-made thermoplast hand-based thumb spica splint with the metacarpophalangeal joint included and the first interphalangeal joint free.

METHOD

One hundred nineteen patients with a diagnosis of trapeziometacarpal arthrosis were prospectively randomized to wear either a neoprene or a thermoplast hand-based thumb spica splint. At enrollment, patients completed a set of validated questionnaires. An average of 9 weeks later, patients returned for a second visit. Bivariable analyses assessed factors associated with disability, pain and satisfaction. Analysis was by intention-to-treat.

RESULTS

Sixty-two patients (32 with a neoprene and 30 with a thermoplast splint) completed the study, 51 patients (43%) did not return for the second visit, and six did not complete the protocol for other reasons. Non-completers were significantly younger than completers (P < 0.00044). On average completers rated the neoprene splint as more comfortable (P = 0.048), but there were no detectable differences in Disabilities of the Arm, Shoulder and Hand (DASH), change in DASH, pain, satisfaction, pinch or grip strength between the two splint types in our sample.

CONCLUSION

When compared to custom-made thermoplast splints, pre-fabricated neoprene hand-based thumb spica splints are, on average, more comfortable, less expensive, and as effective in treating trapeziometacarpal arthrosis. This trial was registered at Clinicaltrials.gov (NCT00438763).

Scaphoid waist nonunion with humpback deformity treated without structural bone graft

PURPOSE

Conventional treatment of scaphoid nonunion with collapse deformity and bone loss involves the use of a structural corticocancellous bone graft. With internal screw fixation, we propose that length and alignment can be restored and maintained using only cancellous interposition graft.

METHODS

We describe 12 patients with established scaphoid waist nonunions. Average patient age was 22 years, all were male, and 8 cases involved the dominant wrist. Time from injury to treatment averaged 11 months. We performed open reduction through an anterior approach with correction of the deformity and placement of a distal to proximal screw. We then simply filled the resultant defect with cancellous autograft obtained from the ipsilateral distal radius. All patients underwent postoperative computed tomographic imaging to document union and degree of correction.

RESULTS

At a minimum 2-year follow-up, all patients had a united scaphoid with significant improvement in wrist extension compared with preoperative values. Grip strength also improved significantly. Disabilities of the Arm, Shoulder, and Hand scores at follow-up averaged 4 ± 3 (range, 0-9), the Mayo wrist score averaged 88 ± 6 (range, 80-100), and the average lateral intrascaphoid angle improved from 49° to 32° (normal, < 35°). Pain at follow-up as measured on a 10-point visual analog scale averaged 0.3 (range, 0-2).

CONCLUSIONS

With stable internal screw fixation, scaphoid waist nonunion with collapse and bone loss can be successfully treated using only cancellous bone graft. Advantages include marked simplification of surgical carpentry, the use of local autograft, and rapid incorporation of cancellous bone without compromise of scaphoid reduction and carpal alignment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Fractures of the radial head and neck

The majority of simple fractures of the radial head are stable, even when displaced 2 mm. Articular fragmentation and comminution can be seen in stable fracture patterns and are not absolute indications for operative treatment. Preservation and/or restoration of radiocapitellar contact is critical to coronal plane and longitudinal stability of the elbow and forearm. Partial and complete articular fractures of the radial head should be differentiated. Important fracture characteristics impacting treatment include fragment number, fragment size (percentage of articular disc), fragment comminution, fragment stability, displacement and corresponding block to motion, osteopenia, articular impaction, radiocapitellar malalignment, and radial neck and metaphyseal comminution and/or bone loss. Open reduction and internal fixation of displaced radial head fractures should only be attempted when anatomic reduction, restoration of articular congruity, and initiation of early motion can be achieved. If these goals are not obtainable, open reduction and internal fixation may lead to early fixation failure, nonunion, and loss of elbow and forearm motion and stability. Radial head replacement is preferred for displaced radial head fractures with more than three fragments, unstable partial articular fractures in which stable fixation cannot be achieved, and fractures occurring in association with complex elbow injury patterns if stable fixation cannot be ensured.

Intermediate-term outcomes for floating elbow and floating elbow variant injuries

BACKGROUND

There are limited outcome studies describing floating elbow injuries. The purpose of this report is to describe patient outcomes after floating elbow injury using the American Shoulder and Elbow Surgeons (ASES) elbow assessment form.

MATERIALS AND METHODS

From 1994 to 2004, 19 patients were retrospectively identified at 3 Level I trauma centers and returned for follow-up evaluation after treatment of their floating elbow injury. Patient outcomes were assessed based on physical examination and the ASES elbow form.

RESULTS

The 19 patients were evaluated at a mean of 6.7 years (range, 2.3-13.4 years) after treatment of their floating elbow injuries. The mean ASES elbow score was 89 (range, 13-99), and the mean visual analog scale satisfaction with elbow surgery was 8.7 (range, 7-10). Fifteen of 19 patients reported continued pain in the elbow. Patient age, arm dominance, type of humeral fixation, type of forearm fixation, open fracture, multiple surgeries, and fracture pattern were not significantly associated with outcomes. Nerve injury was associated with lower ASES elbow scores (P = .03). There was also a significant correlation between the ASES elbow score and follow-up time, indicating that patients with a longer duration of follow-up had better subjective outcomes (Spearman coefficient = 0.55; P = .02).

CONCLUSION

Floating elbow fractures represent high-energy trauma and have significant associated injuries. Nerve injury is correlated with lower subjective outcomes. Patients continue to improve for several years with acceptable mid-term results.

Simultaneous reconstruction of both medial and lateral collateral ligament complexes for recurrent instability of elbow dislocation: a case report

The late sequela of a simple elbow dislocation includes loss of motion or recurrent instability. This case report involves a patient with a 4-year history of recurrent elbow instability following multiple closed traumatic posterior elbow dislocation, who underwent the simultaneous reconstruction of both medial and lateral collateral ligament complexes, for both varus and valgus instability. The patient was informed and consented that data concerning his case would be submitted for publication.

Current concepts review - fractures of the shaft of the humerus

Fractures of the shaft of the humerus are common injuries. Historically, the treatment of choice has been functional bracing. Recent technical advances such as angular stable plate and nail constructs lead to a shift in the treatment algorithm for this type of fracture. Surgical treatment is recommended in high grade open fractures, multilevel injury, polytrauma patients, nerve and serious vascular injuries, pathological fractures, and delayed or nonunions. This article aims to describe the published scientific data and current treatment modalities most suitable for each type of fracture.

Trapeziometacarpal arthrosis: predictors of a second visit and surgery

Trapeziometacarpal arthrosis is expected with advancing age and a limited percentage of people seek medical attention for it. We studied patients after their first appointment to address trapeziometacarpal arthrosis with a hand surgeon to determine factors associated with return for a second visit and eventual election of operative treatment. A billing database identified 306 patients in the practice of three hand surgeons with a new diagnosis of TMC arthrosis and no associated diagnoses. Bivariate and multivariable logistic regression analyses sought factors associated with a second visit and operative treatment among demographic and visit related factors. One hundred and forty-three patients (47 %) returned for one or more additional visits and 46 (15 %) eventually elected operative treatment within the study period. Independent predictors of a return visit included injection at first visit, splint at first visit, and doctor's recommendation for a return visit. The predictors of surgery were treating surgeon and prescription of a splint at the first visit, but splint at first visit was only predictive for one of the three surgeons. When patients first learn about their trapeziometacarpal arthrosis, the behavior of the hand surgeon may have a strong influence on return visits and eventual choice of operative treatment.