United States

Background: Osteochondritis dissecans of the capitellum is a common condition in adolescent overhead athletes, causing pain during physical activity, limited motion range, and functional impairments. While its exact cause is not fully understood, repetitive microtrauma and reduced blood supply are thought to contribute to lesion development. Traditional surgeries for unstable OCD lesions often fail to restore cartilage or subchondral bone, potentially leading to further joint problems. Osteochondral autograft transfers have emerged as a promising alternative that aims to both restore osteochondral structure and improve sports-related outcomes. This study examines the long-term impact of OATs on capitellar OCD lesions with the hypothesis that such interventions can prevent long-term elbow disability and facilitate a return to athletic activities
Hypothesis: We hypothesize osteochondral autologous transplantation surgery (OATS) provides long-term pain relief and maintains elbow function in adolescent athletes with capitellar osteochondritis dissecans (OCD) lesions.
Methods: A retrospective review of patients who underwent OATS between 2009 and 2023 was performed. Patients were identified by CPT code. Clinical assessment and surgeries were performed at a single institution by a single orthopaedic surgeon. Demographic data, preoperative clinical information, radiographic assessments, intraoperative findings, and postoperative outcomes were collected. Clinical and radiographic evaluations were performed, and preoperative MRI was analyzed. Intraoperative data, including graft dimensions and histopathology, were recorded. Postoperative data included MRI, complications, range of motion, return to sports, and patient satisfaction.
Results: 17 patients (15 males, 2 females) met inclusion criteria, with a mean follow-up duration of 62 months (range 12-170). The average age at time of surgery was 14 years old (±3, range 11-19). All but one patient presented with involvement of the dominant arm. All patients were athletes, with 15 competing at the elite level and 2 at the recreational level. Baseball was the most prevalent sport among these athletes. Preoperatively, every patient reported pain, and 6 of them present with a limited range of motion. The average passive pre-operative arc of motion increased from 127° ± 19 (range 80-150), with 136° of flexion and 8.9° of extension. All patients had undergone nonsurgical treatment involving rest and immobilization, and four had previously received surgical treatment at outside institutions. Intraoperatively, 4 patients had loose bodies. Synovial biopsies, performed in all cases, revealed papillary hypertrophy in 53% and mucoid/myxomatous degeneration in 59% of patients. A single osteochondral plug was used in each surgery. Postoperatively, there were no instances of instability or infections. The average passive arc of motion improved to 136.5°, consisting of 139° flexion and 3.2° extension. All athletes resumed sports activities, although one elite athlete did not return to the previous competitive level in the same sport. Additionally, one patient underwent a subsequent contracture release due to stiffness. No sign or evidence of decline in function was observed throughout the follow-up period.
Summary: 
• This study has identified synovial inflammation as a component of this disease process. 
• OATS has proven to be an effective treatment for capitellar OCD in adolescent athletes. 
• The restoration of osteochondral architecture provides both short-term and long-term elbow pain relief and restoration of high-level function.


AMA Research Challenge 2024 

Long-Term Outcomes of Osteochondral Autologous Transplantation Surgery in Adolescent Athletes with Capitellar Osteochondritis Dissecans

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Abstract Title
Nationwide Surgical Trends in Distal Radius Fixation in Medicare Beneficiaries: Increased Utilization by Plastic Surgeons and Subspecialty Hand Surgeons

Background
In recent years, several randomized controlled trials have been published concerning the treatment of distal radius fractures (DRFs) in elderly patients. It remains unclear to what extent these studies have influenced clinical practice among different surgical specialties. This study aims to investigate both overarching trends and specialty-specific patterns in the surgical management of DRFs within the Medicare population.

Methods
Utilizing data from the Centers for Medicare & Medicaid Services, between 2013 and 2022, all claims associated with surgical management of DRFs were identified (Current Procedural Terminology [CPT] codes: 25606, 25607, 25608, and 25609). The results were further categorized based on primary operator type (general orthopedist, general plastics, general surgeon, subspecialty hand surgeon) and place of service (inpatient, outpatient, other).

Results
A total of 101,857 DRFs requiring surgical intervention were identified. Over a span of 10 years, the overall rate of distal radius fracture interventions (DRFIs) declined from 29.5 to 26.1 per 100,000 individuals, representing a 12% decrease. During this period, the utilization of closed reduction percutaneous pinning experienced a substantial 63% decrease, dropping from 4.8 to 1.8 per 100,000. Conversely, open treatment for distal radial intra-articular fractures of three or more fragments saw an 11% increase in utilization, rising from 10.0 to 11.1 per 100,000. After correction for the number of claims, general orthopedic and general surgeons experienced a notable decrease in utilization for DRFIs, 22% and 6% respectively, However, plastic surgeons and hand surgeons saw an increase in utilization for DRFIs, 74% and 13% respectively, over the same 10-year period. Additionally, there was an increasing shift towards outpatient DRFIs, with an 11% increase, whereas inpatient and other experienced a 17% and 36% decrease, respectively.

Conclusion
Between 2013 and 2022, there has been a notable decline in surgical interventions for distal radius fractures (DRFIs) within the Medicare population. While general orthopedic surgeons traditionally led the provision of DRFIs, recent trends indicate a shifting landscape. We observe a diminishing procedure share among general orthopedic surgeons and general surgeons, accompanied by a rising utilization of plastic surgeons and hand surgeons in addressing DRFIs.


Nationwide Surgical Trends in Distal Radius Fixation in Medicare Beneficiaries: Increased Utilization by Plastic Surgeons and Subspecialty Hand Surgeons

Background: Ankle fractures are one of the most common fractures that occur in the United States with an estimated incidence of 4.22/10,000 per year. Trimalleolar ankle fractures make up about 7% of all ankle fractures, but these fractures traditionally have worse recovery outcomes as well as a risk of future osteoarthritis. Surgical repair of the ankle after this type of fracture requires the reduction of the malleoli and stabilization of the syndesmosis. However, postoperative complications from this type of fracture include restricted mobility, pain, swelling, and limitation to activities of daily living. Smoking and nicotine use are well described in the literature to increase the risk of bone loss, decrease bone mineral density, and delay the union of fracture sites. The purpose of this study is to evaluate specific postoperative complications between nicotine- and non-nicotine-dependent patients who had surgical open treatment of trimalleolar ankle fracture.

Methods: TriNetX, a global health database with de-identified patient information, was used and analyzed for this study. Cohort A was defined as patients who had surgical open treatment of trimalleolar ankle fractures with or without fixation (Current Procedural Terminology [CPT]: 27822, 27823) and had a dependence to nicotine (International Classification of Diseases, Tenth Revision, code: F17.2). Cohort B was defined as patients who had surgical open treatment of trimalleolar ankle fractures but did not have a dependence to nicotine. Data were gathered from healthcare organizations over the past 20 years. All post-diagnostic complications were analyzed between 1 and 120 days after the surgical open treatment of trimalleolar ankle fractures.

Results: 4,827 patients in cohort A were propensity matched with 25,467 patients in cohort B for age at the event, ethnicity, race, sex, type 2 diabetes mellitus, and body mass index. Nicotine-dependent patients who had surgical open treatment of trimalleolar ankle fractures experienced a higher associated risk for numerous post-operative complications. When compared to non-dependent patients, nicotine-dependent patients had an increased risk for wound disruption (risk ratio [RR] 1.656, 95% confidence interval [CI] 1.28 – 2.14) and infection (RR 1.836, 95% CI 1.5 – 2.25) following a procedure within 120 days post open treatment of trimalleolar ankle fractures. Instances of avascular necrosis, deep vein thrombosis, pulmonary embolism, and revision surgeries were found not to be statistically different between the two cohorts.

Conclusion: This propensity-matched study showed that nicotine-dependent patients who were surgically treated with open treatment of trimalleolar ankle fractures were correlated with an increased risk for wound disruption and infection compared to their non-nicotine-dependent counterparts.

Nicotine Dependence on Postoperative Complications in Trimalleolar Ankle Fractures

Background
Body mass index (BMI) cutoffs are frequently implemented for total knee arthroplasty (TKA) candidates. However, recent data in primary TKA suggest obese patients have greater improvement in patient-reported outcome measures (PROMs) and no difference in postoperative complications when utilizing standardized medical optimization protocols. This study evaluated the influence of BMI on PROMs following revision TKA using these optimization protocols. The null hypothesis of the study was there would be no difference in PROMs based on BMI following revision TKA.

Methods
Between 2010 and 2022, 572 consecutive revision TKAs were retrospectively reviewed. All patients underwent risk assessment and medical clearance prior to surgery by a designated internal medicine specialist. Cases were dichotomized into two BMI groups, ≥35kg/m2 and <35kg/m2 (range, 20 to 65kg/m2). Activity level, pain, function, and satisfaction were compared between groups, controlling for multiple comorbidities and case characteristics. The BMI ≥35kg/m2 group was younger; had a higher prevalence of depression/anxiety and pre-revision narcotics; and worse pre-revision PROMs (P≤0.090). Multivariate statistical analysis was performed with P<0.05 as significant.

Results
Patients with a BMI ≥35 demonstrated greater improvement in their Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and experienced less pain when walking and climbing stairs (P≤0.071) over an average of 2.0 years. A higher percentage of patients in the BMI ≥35 group also achieved Minimal Clinically Important Differences (MCIDs) for PROMs (46-67% compared to 59-70%). Moreover, the BMI ≥35 group reported higher satisfaction levels (72.2% versus 66.5%, P=0.254), and more patients indicated that their knee 'always' feels normal (28.4% versus 19.8%, P=0.149). 
The groups did not differ by the indication for revision surgery or the number of components revised (P≥0.108). However, those who needed revision due to aseptic loosening showed significantly greater improvements in PROMs. There was no difference in the rate of re-revisions between the two groups for aseptic loosening or infection.

Conclusion
Despite being more debilitated preoperatively, revision TKA patients with a BMI ≥35 experienced greater improvements in PROMs compared to patients with lower BMIs, independent of revision indication. Given the significant improvements in PROMs with appropriate perioperative optimization, obese patients should not be restricted access to revision TKA when appropriately indicated.

Obesity is Associated With Greater Improvement in Patient-Reported Outcomes Following Revision Total Knee Arthroplasty

Background
The safety of outpatient versus inpatient total hip arthroplasty (THA) in the higher BMI population has not been described. The current study compared 90-day complications and 5-year revisions in patients following primary THA in the outpatient versus inpatient settings with BMI ≥ 35 kg/m2, a “high-risk” group as defined by prior studies.

Methods 
In this case-control study, adult patients with BMI ≥ 35 kg/m2 undergoing primary THA from 2010 to October 2022 were identified in the PearlDiver Mariner165 orthopedics database. Patients diagnosed with infection, trauma, or neoplasm of the hip within 90 days prior to surgery were excluded. Patients were categorized by service location of THA: inpatient or outpatient. 90-day postoperative adverse events were compared between groups with multivariable logistic regression controlling for age, sex, and Elixhauser Comorbidity Index (ECI). With Bonferroni correction, significance was established at P < 0.004. 5-year revision rates were compared with logrank test.

Results
Of high-BMI patients undergoing THA, 39,396 were inpatient and 11,505 were outpatient. These groups were exact matched 1:1 on age, sex, and ECI, yielding 11,455 patients in each matched group. Multivariate analysis demonstrated that outpatient THA was associated with lower 90-day odds ratios (ORs) for: deep vein thrombosis (OR: 0.47), pulmonary embolism (OR: 0.63), surgical site infection (OR: 0.69), and readmissions (OR: 0.40), in addition to multiple minor adverse events (P < 0.001 for each). Outpatient THA in the study population was not associated with differences in 90-day hip-related adverse events (dislocation, fracture) or 5-year all-cause revisions (P = 0.5).

Conclusion
Compared to inpatient THA, outpatient THA for those with BMI ≥ 35 kg/m2 was associated with lower odds of various severe and minor 90-day adverse events, with similar short-term hip-related outcome measures and 5-year revision rates. These findings are encouraging when considering performing outpatient THA in obese patients.

Outpatient Total Hip Arthroplasty Is Safe in High BMI Patients

Background
Total hip arthroplasty (THA) utilization is increasing significantly. Despite this, it is unknown whether patients have increasing interest in THA, and what patients search online regarding THA. Google Trends provides the relative search volume (RSV) regarding any search term. Therefore, we performed this study utilizing Google Trends to determine whether public interest in THA is increased, and to identify which THA search terms have the most engagement.

Methods
A longitudinal study on United States public interest in THA was performed with Google Trends from January 2013 – December 2022. 50 Google search terms were identified, for which the mean RSV was obtained and compared. RSV ranges from 0 – 100 and represents interest in a search term during at a specific point during the selected timeframe; 0 indicates negligible interest while 100 indicates maximal interest. Linear regression was used with yearly volume to determine if RSV increased significantly over time. We compared the rates of change for various pairs of search terms using an interaction model.

Results
Between 2013–2022, the mean RSV for “hip replacement” increased significantly [2013: 57; 2022: 92; p < 0.001], indicating increasing public interest in THA. Additionally, when comparing 50 search terms about THA, “hip replacement pain” and “hip replacement recovery” had significantly higher mean RSVs than other terms, and the ten highest mean RSV terms also included “hip replacement cost”, “hip replacement therapy”, “hip replacement precautions”, “hip replacement approach”, “how long does hip replacement take”, “hip replacement fracture”, “hip replacement infection”, and “hip replacement rehab” (65 vs 61 vs 20 vs 15 vs 14 vs 12 vs 11 vs 11 vs 10 vs 8; p < 0.001). The mean RSV significantly increased over the last decade for “hip replacement pain” [2013: 44; 2022: 88; p < 0.001] and “hip replacement recovery” [2013: 50; 2022: 73; p < 0.001]. The rate of change of these two terms was significantly more positive over time than all other terms.

Conclusion
Public interest in THA has significantly increased during the past decade, correlating with the increasing volume of THA being performed. Patients have interest in many topics about THA, with pain and recovery having the largest increase in search volume over time. Other topics such as cost, therapy, surgical length/approach, and complications were also commonly searched. Patient information resources should ensure to include these variety of topics to meet changing patient interests.

Patients Have Increasing Interest In Total Hip Arthroplasty In The United States

Introduction. Postoperative pain control is critical in orthopedic surgery. While efficacious analgesics, opiates have rapid tolerance and addictive potential. Metamizole is a non-opioid analgesic primarily inhibiting COX-3, commonly used in Europe and South America, but banned in the U.S. due to concerns about agranulocytosis risk. However, large meta-analyses have not shown significant agranulocytosis when compared to other analgesics. The purpose of this review is to assess the analgesic efficacy of metamizole and potential use in orthopedic surgery.
Methods. An electronic review was conducted of PubMed, Web of Science, Cochrane, Embase, and OVID Medline in October 2023. Studies for inclusion were limited to those in which metamizole use was a primary focus, patients were undergoing orthopedic surgery, studies in human patients, and studies reporting in the English language.
Results. 1,112 studies were identified and 15 (1.3%) met inclusion criteria. The use of metamizole as a single agent or in combination therapy was described to be superior or non-inferior to alternative analgesics in 10 (66.7%) studies. Metamizole decreased rescue analgesia in 5 (33.3%) articles. No patients experienced agranulocytosis.
Conclusions. Metamizole was efficaciously non-inferior to other non-opioid analgesics by demonstrating an opioid sparing effect in over a third of included studies. Metamizole did not have significant differences in incidence or severity of side effects and no cases of agranulocytosis were seen across all studies. These results indicate the potential for metamizole as analgesia in the setting of orthopedic surgery. Future studies should focus on larger cohorts to continue to assess efficacy and risk of agranulocytosis.


Postoperative Pain Management with Metamizole after Orthopedic Surgery: A Systematic Review

Background
Congenital cervical stenosis (CCS) is a rare condition involving a narrowed spinal canal due to developmental anomalies. CCS heightens the risk of neurologic deficits and acute spinal cord injury post-trauma, influencing return-to-play decisions for contact athletes. Additionally, CCS patients are prone to cervical myelopathy as degenerative changes progress with age. Limited evidence-based literature exists on the epidemiology of CCS, including racial effects. We sought to investigate the incidence of CCS as it pertains to race and ethnicity.
Methods
We screened 5395 cervical MRIs from a single institution and identified CCS by a sagittal canal diameter (SCD) of less than 10 mm at 2 or more vertebral levels (C3-7) at the pedicle. Exclusion criteria included patients under 18 and over 50 years, prior cervical spine surgery, congenital fusions, spinal column malignancy, or active smoking history. For each patient, axial measurements were taken at each level, including coronal vertebral body length, anteroposterior vertebral body length, pedicle width, pedicle length, laminar length, anteroposterior lateral mass length, posterior canal distance, apex-to-vertebral body, lamina-disc angle (LDA), lamina-pedicle angle, and anteroposterior spinal cord diameter.
Results
A total of 343 patients met the criteria for CCS: 100 White, 98 Black, 70 Asian, and 75 Hispanic. CCS prevalence varied significantly among ethnic groups; Black (39.3%), Asian (33.6%), and Hispanic (22%) patients had higher CCS rates than White patients (7.5%) [x2 (3, N=343) = 30.04, p <0.05]. The Interrater Correlation Coefficient for the SCD measurements across all levels and patients demonstrated excellent reliability (ICC = 0.926, 95% CI: 0.91-0.94). Black and Asian patients showed consistently smaller SCDs at all pedicle levels compared to White patients, who had the largest SCDs overall (p<0.001). Average SCDs were 11.4 mm (White), 10.4 mm (Black), 10.5 mm (Asian), and 11 mm (Hispanic). Additionally, LDAs were larger in Asians, Blacks, and Hispanics compared to Whites, reducing cross-sectional canal area (p<0.001).
Conclusion
Our study indicates a significant correlation between race/ethnicity and CCS prevalence. Black and Asian patients had the highest CCS rates, smallest SCDs, and largest LDAs. These anatomical differences suggest an increased risk of cervical myelopathy and neurological issues, particularly for contact sport athletes. This emphasizes the need for personalized clinical management and early intervention to address healthcare disparities and improve outcomes in vulnerable populations.

Racial Differences in Congenital Cervical Stenosis

ABSTRACT

Background: Midshaft clavicle fractures are often subject to increased complications when treated nonoperatively, so surgical treatment with open reduction and internal fixation (ORIF) is a favored alternative. Despite safer outcomes, adverse events such as surgical site infections may still persist, particularly in the presence of certain patient characteristics. The objective of this study was to determine risk factors for and the frequency of adverse events following ORIF for clavicle fractures. 

Methods: A retrospective review of the National Surgical Quality Improvement Program (NSQIP) database from 2012 to 2021 identified patients undergoing isolated ORIF for clavicle fractures. Patient demographics and 30-day complications were collected. Bivariate analyses with a student’s t-test or chi-square test were used to identify possible predictor variables for either AAE or SSI, and demographic metrics with P<0.2 were included in a multivariable regression model. Multivariable analyses identified significant independent patient risk factors for any adverse event (AAE) or SSI within 30-days of surgery. Adjusted odds ratios were reported for each variable included in the model. Statistical significance was set a prior at P<0.05.

Results: The 6,753 selected patients who underwent ORIF for clavicle fractures between 2012 and 2021 were 38.1±15.3 years of age, BMI 26.2±4.9 kg/m2, and 77.3% male. Of this cohort, 88.4% received treatment on an outpatient basis. Postoperative adverse events were experienced by 128 (1.9%) patients within 30 days of surgery, and SSI were prevalent in 0.77% of patients, followed by wound dehiscence in 0.12% of patients. After controlling for patient demographics and comorbidities, notable risk factors for adverse events included current smoking status (OR=2.036; P<0.001) and patient age (OR=1.025; P<0.001). Outpatient status (OR=0.528; P=0.004) was protective. 

Conclusion: The present study noted significantly increased risk of postoperative adverse events in older patients, as well as patients who smoke. Outpatient setting was significantly protective for adverse events. These findings help to provide further clinical context to guide surgical decision making and inform surgeons on current risks and outcomes.

Risk Factors for Adverse Events after Clavicle Fracture Open Reduction and Internal Fixation: A NSQIP Study

Title: 
Subsequent Total Shoulder Arthroplasty Following Common Shoulder Stabilization and Reconstructive Procedures

Background:
Shoulder stabilization and reconstructive surgeries are indicated based on a variety of pathologies including instability, impingement, and rotator cuff tears. Surgery to restore anatomic and biomechanical normalcy may reduce pain, restore function, or may slow the progression of osteoarthritis. This study analyzes common shoulder stabilization and reconstructive surgeries and compares their odds of future total shoulder arthroplasty (TSA) development.

Methods:
The TriNetX database patient data was queried from the period of May 2004 to May 2024 using ICD10 and CPT codes. Cohorts were built by including patients who underwent a procedure of interest, while the control group used a combination of patients from other procedural cohorts not undergoing the procedure of interest. Cohorts were then propensity matched for age, race, sex, and co-morbidities. Laterality was assessed separately to ensure ipsilateral index procedure and TSA. The primary outcome measured was TSA at 5 and 10 years postoperatively for 13 different shoulder procedures.


Results:
A total of 355,960 patients were divided into procedural cohorts and analyzed. The procedure with the highest rate of subsequent TSA was the Latarjet procedure (3.99% at 5 years; 4.23% at 10 years); whereas the procedure with the lowest rate was arthroscopic capsulorrhaphy (0.91% at 5 years; 0.95% at 10 years. Compared to propensity-matched controls, procedures associated with increased odds of subsequent TSA were the Latarjet procedure (OR 3.34, P<0.0001 at 5 years; OR 3.56, P<0.0001 at 10 years), arthroscopic capsulorrhaphy (OR 1.47, P=0.0042 at 5 years; OR 1.43, P=0.0066 at 10 years), open rotator cuff repair, chronic (OR 1.39, P=0.0005 at 5 years), arthroscopic extensive debridement (OR 1.31, P<0.0001 at 5 years; OR 1.26, P<0.0001 at 10 years), and open biceps tenodesis (OR 1.28, P=0.0003 at 5 years; OR 1.20, P=0.0053 at 10 years). Procedures associated with decreased odds of subsequent TSA were arthroscopic distal clavicle resection (OR 0.56, P<0.0001 at 5 years; OR 0.56, P<0.0001 at 10 years), arthroscopic subacromial decompression (OR 0.65, P<0.0001 at 5 years; OR 0.63, P<0.0001 at 10 years), arthroscopic rotator cuff repair (OR 0.78, P<0.0001 at 5 years; OR 74, P<0.0001 at 10 years), and arthroscopic biceps tenodesis (OR 0.78, P<0.0001 at 5 years; OR 0.76, P<0.0001 at 10 years).

Conclusion:
In general, arthroscopic procedures had decreased associated odds of subsequent TSA when compared to their open counterparts. However, arthroscopic capsulorrhaphy and arthroscopic extensive debridement had increased odds of subsequent TSA. The Latarjet procedure had the highest odds of all procedures for future TSA.

Subsequent Total Shoulder Arthroplasty Following Common Shoulder Stabilization and Reconstructive Procedures 


Background: Achilles tendon rupture is a common orthopedic injury presenting to the clinic and emergency room. Patients with comorbidities are not ideal surgical candidates and often must be treated with cast or boot immobilization. The risk of complications includes pressure sores, skin infections, and joint stiffness. Recently, 3D-printed (3DP) casting has become popular due to customizability and inexpensiveness. This study performs a systematic review on the clinical application of 3D-printed (3DP) for conservative management of injuries.

Methods: The search phrase “(3d printed cast) AND ((fracture) OR (injury) OR (tendon))” was entered into PubMed, yielding 50 results published between 2015 and 2024. 15 articles were included in this review.

Results: 3 studies showed proof-of-concept in a non-clinical setting for 3DP casting using biomechanical and materials testing in both UE and LE models. 5 clinical studies without a control group reported overall patient satisfaction and good to excellent clinical healing of UE fractures with 3DP but also reported incidents of cast breakage. 7 studies in a clinical setting showed that 3DP casting is superior to conventional fiberglass in patient satisfaction and non-inferior in clinical efficacy.

Discussion: Based on the current literature, this study proposes a novel 3D-printed cast that provides immobilization at the maximum plantar flexion required for Achilles tendon healing and eliminates the need for constant cast changes in a non-surgical treatment plan. The proposed device will act to maintain stability and reapproximation for healing at the injury site, whilst providing easy access for hygiene and wound care, thus mitigating the risk of infections and promoting optimal healing. Future direction will establish proof-of-concept using finite element analysis for customization of stress distribution and biomechanical testing for load-bearing analysis. By extending its usage to acute Achilles tendon injuries, 3DP casting has the potential to enhance outcomes for non-surgical candidates.

Next from AMA Research Challenge 2024

Nationwide Surgical Trends in Distal Radius Fixation in Medicare Beneficiaries: Increased Utilization by Plastic Surgeons and Subspecialty Hand Surgeons

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