HAND最新文献

Background: There are knowledge gaps about postsurgical utilization and spending after hand trauma, which has implications for outcomes and access to care.

Methods: Using 2019-2022 national claims, we examined 30-, 60-, and 90-day postsurgical health care utilization and out-of-pocket (OOP) expenses of flexor tendon repairs, open reduction internal fixation (ORIF) of a distal radius fracture, and digital replantation/revascularization. Multivariable regression models were used to examine the association between characteristics and postsurgical utilization and OOP expenses.

Results: Among 22 170 patients, a large proportion of patients had utilization within 30 days (19 188; 87%), 60 days (20 022; 91%), and 90 days (20 170; 92%) after surgery, translating to OOP expenses of $41 at 30 days versus $107 at 90 days with substantial procedural variation (eg, 90-day OOP expenses after ORIF of a distal radius fracture of $98 vs $211 for flexor tendon repair). Patients undergoing flexor tendon repair had greater odds of reoperation/hospitalization at 30 days (adjusted odds ratio [aOR] = 1.8, 95% confidence interval [CI] = 1.5-2.1), 60 days (aOR = 1.8, 95% CI = 1.5-2.0), and 90 days (aOR = 1.6, 95% CI = 1.4-1.8) compared with ORIF of distal radius fractures. Flexor tendon repair was associated with 52% greater OOP expenses at 30 days (95% CI = 1.4-1.6) and 33% greater OOP expenses at 90 days (95% CI = 1.2-1.4) compared with ORIF of distal radius fractures.

Conclusions: There was substantial variation in utilization and patient OOP expenses 30, 60, and 90 days postoperatively. These findings can help inform policy and practice leaders as they implement strategies to minimize patient financial burden of health care.

Background: Painful digital neuromas are disorganized nerve proliferations that develop following traumatic or iatrogenic digital nerve injury, often resulting in debilitating allodynia, hypersensitivity, and impaired hand function. While conservative therapies such as desensitization, splinting, and pharmacological agents may offer temporary relief, over 50% of patients ultimately require surgical intervention. However, surgical strategies remain highly heterogeneous, and no consensus exists regarding the most effective operative technique.

Methods: A comprehensive search of 4 databases through May 2025 identified 30 studies encompassing over 600 adult patients who underwent surgical treatment for digital neuromas. Techniques assessed included neuroma excision with nerve stump transposition, direct end-to-end neurorrhaphy, nerve capping, regenerative peripheral nerve interface (RPNI) surgery, and targeted muscle reinnervation (TMR) surgery.

Results: Excision with transposition relieved pain in up to 80% of cases but demonstrated inconsistent sensory recovery. Neurorrhaphy was associated with superior functional outcomes and a reduced recurrence rate. Nerve capping and polyglycolic acid-collagen conduits significantly improved pain scores and protective sensation. RPNI and TMR surgery, though reported in small series, provided over 80% pain relief with minimal complications. Meta-analysis was precluded by outcome heterogeneity.

Conclusion: urgical treatment of painful digital neuromas provides meaningful pain relief and functional improvement, particularly when techniques restore physiologic targets for regenerating axons rather than relying on excision alone. Continuity-restoring and reinnervation-based approaches, including neurorrhaphy, nerve capping, RPNI, and TMR, demonstrate favourable outcomes with lower recurrence rates, although comparative evidence remains limited. Standardised outcome measures and higher-quality comparative studies are required to guide optimal, patient-specific surgical decision-making.

Background: Hand Surgery Fellowship is the mainstay for training of hand surgeons globally. Despite this, a standardized curriculum for hand surgeons has yet to be established, and discrepancies between Hand Fellowship offerings, including operative exposure and program requirements, persist. The purpose of this study was to characterize what Fellowship programs globally promise to teach their Fellows, and how they do this.

Methods: An Internet search for Hand Surgery Fellowship programs was conducted between March 3, 2024 and February 8, 2025. In addition to the primary search, programs were found through the International Federation of Societies for Surgery of the Hand and affiliate society websites. Only Fellowships that were recognized by national regulatory bodies were included.

Results: A total of 218 program websites were identified across the United States, the United Kingdom, Canada, Europe, Australia/New Zealand, Asia, Africa/Middle East, and South America. Mentorship/apprenticeships and rotation-based programs were the most common training approaches. Trauma surgery was a universal focus of Hand Fellowships globally. Programs supervised by orthopedic faculty were more likely to offer training in shoulder, elbow, and arthroscopic surgery, whereas programs supervised by plastics/mixed departments were more likely to include peripheral nerve, congenital, microsurgery, and replantation surgery.

Conclusions: Program websites in various regions globally possess different levels of detail and emphasize different aspects of surgical training in their descriptions. The United States had the most programs and included the greatest level of detail in their program descriptions. Reported obtainable clinical competencies varied with geographical region and faculty specialization. Recommendations are suggested.

Background: Thumb carpometacarpal (CMC) joint osteoarthritis is a debilitating degenerative condition that primarily afflicts older adults. Traditional surgical interventions are effective but require prolonged recovery and potential loss of strength. Carpometacarpal joint denervation has emerged as an alternative due to its minimal recovery time and low morbidity. However, its conversion rate to arthroplasty and ideal patient selection criteria remain unclear.

Methods: We retrospectively reviewed patients undergoing thumb CMC joint denervation from January 2019 to November 2023, excluding those with concurrent procedures or follow-up shorter than 6 months. We collected and analyzed demographic and clinical data, with primary functional outcomes assessed via Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores. Statistical analyses included Wilcoxon signed-rank tests for preoperative and postoperative comparisons and assessments of factors associated with achieving minimal clinically important difference (MCID).

Results: Among 37 patients (mean age 56.4 ± 11.3 years, 70.3% female), 20 had complete preoperative and postoperative QuickDASH data. The median follow-up was 1.1 years. Although median QuickDASH scores improved from 39.8 to 14.8, the difference was not statistically significant (P = .073). Younger age (52.9 vs 63.8 years, P = .015) and dominant hand surgery (80% vs 20%, P = .023) were significantly associated with achieving MCID. Common complications included transient paresthesia (21.6%) and conversion to arthroplasty (13.5%).

Conclusions: Thumb CMC joint denervation provides greater benefit for younger patients and those undergoing surgery on their dominant hand. The favorable complication profile and low conversion to arthroplasty support the role of denervation in the treatment algorithm for first CMC osteoarthritis.

Background: The transition to volar locking plates for the treatment of distal radius fractures has improved patients' range of motion, reduced extensor tendon issues, and hastened return to activity compared to older fixation methods or nonoperative treatment. One drawback to volar plating is the potential for flexor tendon ruptures due to aberrant plate or screw placement. This study aims to describe the reconstruction options and patient outcomes after flexor tendon rupture due to volar plating.

Methods: This is a single-institution, retrospective review of patients who presented with flexor tendon rupture from 2014 to 2023 after a distal radius fracture previously managed with a volar plate. Patient demographics, operative details, range of motion, complications, and patient-reported outcomes were collected.

Results: Ten patients presented with flexor tendon ruptures after volar plating for distal radius fractures from 2014 to 2023. The most common rupture was flexor pollicis longus (FPL) in 7 patients, followed by index finger flexor digitorum profundus (FDP) in 2 patients, and small and ring finger FDP rupture in 1 patient. Flexor pollicis longus (FPL) was reconstructed with a palmaris longus (PL) graft in 4 patients, ring finger flexor digitorum superficialis transfer in 2 patients, and repaired primarily in 1 patient. All patients with FPL ruptures regained functional thumb interphalangeal flexion except for 1 patient who reruptured 4 weeks after surgery.

Conclusions: Flexor tendon ruptures can occur following volar plating of distal radius fractures, even years after fixation of the fracture. These are attritional ruptures and generally reconstructed with tendon grafting of transfer, providing functional flexion of the affected digit.

Background: The impact of social determinants of health on patients' access to medical care and health outcomes is increasingly recognized. Telemedicine's rapid and widespread adoption altered the delivery of care. This study describes the characteristics of patients undergoing telemedicine visits with hand surgeons, without COVID-19 pandemic-related restrictions.

Methods: All telemedicine encounters for 4 hand surgeons at a single institution between September 2022 and September 2023 were retrospectively reviewed. Patient demographics were recorded as well as the encounter type. The distance of the patients' residential address and the area deprivation index (ADI) were recorded.

Results: Sixty patient encounters were recorded. Forty-seven percent were male and 53% were female, 5 (8.3%) were new patients, 44 (73.3%) were established patients, and 11 (18.3%) were postoperative. The mean age was 43, and the mean and median distances from the clinic were 72 and 18 miles, respectively. Forty-three patients (72%) were from high ADI residences. Upon comparison of low ADI (0-50th percentile) and high ADI (50th-100th percentile) patients, no statistically significant differences in age, sex, distance from clinic, or encounter type were found.

Conclusions: Telemedicine in hand surgery at this single institution is most frequently used for follow-up encounter types in patients living in high ADI communities, far from clinic sites. Low or high ADI did not correlate with seasonal changes in the use of telemedicine, encounter type, or patient demographics. Telemedicine may improve patient access to hand surgery follow-up care. This may particularly benefit patients facing geographic and economic challenges to healthcare access.

Level of evidence: Prognostic Level IV.

In response to the widespread occurrence of limb loss and the transformative potential of extremity vascularized composite allotransplantation (VCA), we examine the impact of warm and cold ischemia duration on limb survival and functional recovery. Our insights into warm ischemia are largely derived from relevant literature on replantation and revascularization. Studies indicate that achieving reperfusion within 5 to 6 hours of warm ischemia is critical for limb survival, and within 3 hours for curbing significant functional deficits. For limbs preserved in static cold conditions, as is standard practice in VCA, reperfusion should be attained within 10 to 12 hours of cold ischemia. However, our analysis exposes a lack of data on extremity functional recovery following cold ischemia, particularly in humans or large animal models. This underscores a gap in the literature that could guide clinical ischemia management in VCA if addressed. We anticipate optimal functional recovery between 3 and 6 hours of cold ischemia, as supported by outcomes in rats. Prolonged ischemia times are also associated with graft rejection, posing unique challenges to VCA. Tissues exhibit diverse responses, with muscle and nerve being highly susceptible to ischemic damage, and skin acquiring heightened immunogenicity. Ischemia management emerges as a focus for future policy and research initiatives. On the horizon, exploring updated transplantation protocols, vascular shunts, stabilizing perfusion solutions, and subnormothermic machine perfusion could mitigate ischemic damage and enhance clinical outcomes in extremity VCA.

Background: Determining accurate intraoperative screw length in complex distal radius fractures may pose difficulties. With volar plate fixation, excessive screw length may result in extensor pollicis longus injury and this can be challenging to determine via intraoperative imaging. This study aims to identify the precise anatomic location and parameters of Lister's tubercle on the dorsal aspect of the radius.

Methods: The anatomy and location of Lister's tubercle was evaluated in 26 cadaveric arms, of which 27% were female, with a mean age of 73.6 years. Additionally, Lister's tubercle was evaluated on 198 computed tomography (CT) scans using a quantitative distal radius surface map. Median age was 28 years, and 28% of the patients were female.

Results: As measured in cadaveric arms, the mean Lister's tubercle length was 12.6 mm, and width was 5.4 mm. The distance from the radial styloid to the distal and proximal border of Lister's tubercle averaged 23.0 and 10.4 mm, respectively. Of the total distal radial width, Lister's tubercle begins 43% from the radial border and spans to 42% of the ulnar border, encompassing 16% of the entire width of the dorsal distal radius. On CT mapping, the distance between the peak of Lister's tubercle and the ulnar and radial border of the radius was 46% and 54%, respectively. Female sex was associated with a smaller distal radius width, but not with a smaller Lister's tubercle.

Conclusions: Knowledge of Lister's tubercle anatomy may assist in more precise screw placement in volar locked plating of distal radius fractures.

Level of evidence: IV-Therapeutic.

Background: Cannabinoids are a diverse group of compounds under investigation for various medical purposes, including analgesia. Given the evolving landscape of cannabinoid use, we aimed to analyze their prevalence and effect in pain management among urban orthopedic hand patients.

Methods: An electronic survey was administered to 122 new patients presenting to the orthopedic hand clinic of a major urban academic hospital. Demographic data, numerical rating scale pain scores, cannabinoid usage, and other concomitant pain regimens were recorded.

Results: Approximately half of the new patients were dissatisfied with current pain management for their hand pathology. Prescription (Rx) and over-the-counter (OTC) pain medications were used by 58% (71/122) of patients, while cannabinoids were used by 15% (18/122) of patients. Compared with pre-usage pain scores, both cannabinoids and Rx/OTC medications induced significant reductions in pain associated with patients' hand pathologies (Cannabinoid: Δ4.4, P = .002; Rx/OTC: Δ3.0, P < .001). Cannabinoids induced a larger analgesic effect, but this difference was not statistically or clinically significant (P = .06). Subjectively, cannabinoid users either preferred their cannabinoid over Rx/OTC medications or liked both equally. Opioid use was higher among cannabinoid users (22.2% vs 12.5%), although this was not statistically significant (P = .28).

Conclusion: Approximately 15% of new urban hand patients use cannabinoids for pain control, and these compounds have similar analgesic efficacy in hand pathologies as Rx/OTC medications. Cannabinoids are equally liked or preferred relative to traditional medications in this cohort, and they may play an important role in pain management for hand patients.

Avascular necrosis or osteonecrosis of the scaphoid following fracture is extremely rare in the pediatric population with no concrete treatment protocol established in the literature. In this case report, we present an 11-year-old boy with a scaphoid waist fracture nonunion complicated by proximal pole osteonecrosis. Due to the severe fragmentation of the scaphoid, fixation across the nonunion site was not feasible, and we instead used temporary scaphocapitate fixation. The patient ultimately had radiographically confirmed bony union and full wrist range of motion at 3 months post-op.