HAND最新文献

Background: While diagnosis of ganglion cysts of the wrist in the pediatric population is common, data on management are limited. This study describes a nationwide analysis of the incidence and treatment of pediatric ganglion cysts.

Methods: Patients who were diagnosed with a wrist ganglion cyst were identified from the PearlDiver database. Exclusion criteria included age over 18 years, incidence of different cyst diagnosis codes, fewer than 6 months of records prior to first diagnosis, and fewer than 2 years of follow-up. The use of imaging and common treatments for ganglion cysts including bracing, aspiration/injection, and surgery were noted. Patients were followed for 2 years, and factors associated with undergoing surgery were analyzed. Trends in the diagnosis and surgical management of ganglion cysts by age were observed.

Results: A total of 33 884 patients with a ganglion cyst on the wrist were identified. Diagnoses increased exponentially with age, while the percentage of patients who underwent surgery increased linearly with age. Those who underwent surgery tended to be older and were more likely to be female. These patients were also more likely to have undergone ultrasound or magnetic resonance imaging. There was a statistically significant difference in prior use of nonoperative management between patients that did and did not undergo surgery.

Conclusion: This study offers a nationwide analysis of pediatric ganglion cysts. These findings are important to consider during longitudinal patient counseling and surgical planning.

Background: The treatment of scaphoid nonunion is challenging, with one approach aiming to provide vascularized bone to encourage union. While the iliac crest and medial femoral condyle are well-described donor sites for osseous flaps, they require violation of a separate limb and confer particular donor site morbidities. We investigate the viability of using a proximal olecranon osseous free flap in the setting of scaphoid nonunion.

Methods: Ten proximal olecranon free flaps were harvested in cadaveric specimens, and the length of the pedicle, diameter of the pedicle, number of perforators and quality of bone graft harvested were recorded. Furthermore, a volar approach to the scaphoid was performed, and the shortest distance from the scaphoid to the radial artery noted, to determine whether utilization of the olecranon free flap was possible without grafting.

Results: The posterior ulnar recurrent artery [PURA] was present in all specimens. The median pedicle length from take-off of the PURA to the olecranon flap was 65 (62.2-71.0) mm. The number of visible periosteal perforators varied between 1 and 2 per specimen. The median diameter of the main perforator before dividing into subperiosteal branches was 2 (2.1-2.5) mm. The quality of the bone graft harvested was mainly assessed as good (n = 5) or moderate (n = 4). The mean shortest distance from scaphoid to radial artery was 10 mm.

Conclusions: The olecranon free flap is a suitable alternative source of vascularized bone for scaphoid nonunion.

Background: Carpal tunnel syndrome (CTS), affecting approximately 8% of the population, is treated with open (oCTR) or endoscopic (eCTR) carpal tunnel release. Previous literature compares outcomes within 1 to 2 years; this study evaluated >5-year reoperation rates and short-term complications using a large electronic health record database.

Methods: A retrospective analysis using data from the TriNetX Research Network (2007-2024) identified patients with unilateral CTS who underwent either oCTR or eCTR within 1 year of diagnosis, using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Propensity score matching and multiple logistic regression calculated adjusted risk and odds ratios (ORs) with 95% confidence intervals (95% CIs) to assess reoperation rates at 2, between 2 and 5, >5 years after operation and 90-day postoperative complications (wound dehiscence, surgical site infection [SSI]).

Results: Within 2 years of CTR, reoperation rate was higher for eCTR than that for oCTR (relative risk [RR] = 1.15, 95% CI = 1.09-1.22; OR = 1.36, 95% CI = 1.21-1.53). Beyond 5 years, the revision rate of the two approaches was similar (RR = 0.85, 95% CI = 0.74-1.01; OR = 0.76, 95% CI = 0.58-1.00). The number needed to treat to prevent one reoperation within 2 years was 67, and beyond 5 years, it was 473. Within 90 days of surgery, eCTR was associated with decreased wound dehiscence (RR = 0.67, 95% CI = 0.53-0.85; OR = 0.50, 95% CI = 0.36-0.71) and SSI (RR = 0.77, 95% CI = 0.65-0.91; OR = 0.63, 95% CI = 0.48-0.81).

Conclusion: This study demonstrates the clinical insignificance of the difference in early CTR revision rate between approaches and that eCTR necessitates a similar reoperation rate at long term, supporting eCTR to remain an appropriate intervention for CTR.

Salter-Harris II (SH2) proximal/middle phalanx fractures are common injuries in children and heal well with immobilization. We conducted a systematic review of nonsurgical treatments for SH2 proximal/middle phalanx fractures. The constructed search strategy used descriptors that included synonyms for "phalanx fracture," "proximal/middle phalanx," and "fracture treatment." All steps of the process were performed by 2 independent reviewers. Articles of any study design that included children treated for SH2 proximal/middle phalanx fractures were included. Results were analyzed for summary statistics and interobserver agreement. Findings were reported in keeping with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The initial search yielded 3511 studies. Five studies met the final criteria: 1 randomized controlled trial (RCT), 3 prospective studies, and 1 retrospective study. Three studies employed a combination of taping and splinting strategies. All fractures healed with no reported complications. At the final follow-up, all studies reported full or nearly full range of motion and high rates of patient comfort and satisfaction. The RCT found lower rates of secondary displacement in the taping (6%) versus splinting (23%) group. Due to small sample sizes and heterogeneous study designs, conclusive recommendations cannot be drawn. More research is needed to determine the feasibility, compliance, safety, and effectiveness of taping these injuries.

Background: Metacarpal fractures are common injuries that can lead to debilitating outcomes if not treated appropriately. Intramedullary fixation has gained popularity as a treatment option, allowing for earlier mobilization with few reported complications.

Methods: A retrospective chart review of all patients treated with intramedullary implants for a metacarpal fracture between August 2018 and February 2024 at a single center was performed. Medical records and radiographs were reviewed to identify instances of hardware failure/bent implant. In patients with bent implants, the mechanism of re-injury was recorded.

Results: 648 total metacarpal fractures were surgically treated during the study period, with 90 patients receiving intramedullary fixation (56 ExsoMed INnate, 31 Acumed acutrak, 3 Arthrex headless compression screw). Five patients (7 screws) experienced postoperative hardware failure/bending of the implant, all resulting from a punching mechanism. Furthermore, all patients with postoperative hardware failure sustained their initial metacarpal fracture as a result of a punching mechanism. Additionally, 1 patient initially treated at an outside hospital presented with a bent implant following a punching-related reinjury. All affected patients were male, and the time from initial surgery to implant failure ranged from 4 weeks to 7 months.

Conclusion: This series highlights a notable complication (bent implant) associated with intramedullary fixation of metacarpal fractures and includes our strategy for implant removal. Furthermore, we now consider patients with a history of closed-fist striking as a mechanism of injury as a contraindication to intramedullary metacarpal fixation due to this complication.

Background: Metacarpal neck fractures are frequently encountered by hand surgeons. Certain operative metacarpal neck fractures are amenable to both retrograde intramedullary screw (IMS) fixation and closed reduction percutaneous pinning (CRPP). The purpose of this study was to compare functional outcomes and complications following these two techniques.

Methods: All patients with metacarpal neck fractures treated with either IMS or CRPP from 2015 to 2021 at a large private academic institution were retrospectively identified. Electronic medical records were reviewed for demographics, Quick Disabilities of Arm, Shoulder, and Hand (qDASH) scores, metacarpophalangeal joint range of motion (ROM), and complications.

Results: A total of 113 patients, consisting of 57 in the IMS cohort and 56 in the CRPP cohort, were included. The CRPP cohort was significantly younger, otherwise demographics were similar between both groups. Both cohorts had similar preoperative (47.5 IMS vs 43.9 CRPP), postoperative (17.6 IMS vs 9.9 CRPP), and delta (35.5 IMS vs 34.0 CRPP) qDASH scores. Retrograde IMS allowed for greater flexion at 4 to 6 weeks (81° vs 65°) postoperatively. The overall incidence of complications was similar among IMS and CRPP (21.1% vs 17.9%), although IMS had significantly more major complications (8.8% vs 0%).

Conclusions: Despite earlier return to ROM, operative fixation of unstable metacarpal neck fractures with retrograde IMS may be at higher risk of major hardware complications and extensor lag.

Background: There are many factors that may influence patient recovery following triangular fibrocartilage complex (TFCC) foveal repair surgery. This study aimed to retrospectively analyze patient records following TFCC foveal repair surgery to identify characteristics that predict patient outcomes.

Methods: A multicenter, retrospective case-series was conducted. Informed written consent was obtained from participating hand therapy clinics, who provided deidentified patient records for adult patients following TFCC foveal repair surgery between January 1 2015 and December 31 2020. Predictors of outcomes were identified using Linear Mixed Effects Regression and Logistic Regression models.

Results: A total of 210 patients were included. The most notable improvements in range of motion (ROM) and grip strength, and pain reduction, were observed in the first 10 weeks postsurgery. Longer forearm immobilization duration predicted poorer ROM for pronation, flexion, and extension. Workcover (compensable) patients demonstrated poorer ROM progression compared with private patients. Forty-two patients (20%) required further surgery, of which was due to postoperative TFCC rupture for 22 patients (10%). Patients who received a shorter wrist immobilization period were more likely to experience TFCC rupture. The duration of time between injury and operative treatment did not predict ROM, grip strength, or pain progression.

Conclusions: Longer forearm immobilization predicted poorer ROM and grip strength progression, whereas shorter wrist immobilization predicted an increased risk of TFCC rupture. These findings support a staggered commencement of wrist and forearm ROM exercises, whereby forearm rotation exercises could commence earlier than wrist exercises. The duration of time between injury and operative treatment did not predict ROM, grip strength, or pain progression.

Background: Extensor pollicis longus (EPL) rupture is a well-described complication after volar plate fixation of distal radius fractures. Although protrusion of screw tips through the dorsal cortex of the distal radius is likely the cause of a substantial proportion of EPL ruptures, it is probably not the sole cause for EPL rupture after distal radius fracture. The purpose of this study was to evaluate preoperative computed tomography (CT) scans of distal radius fractures to characterize the incidence of EPL damage at the time of injury.

Methods: This retrospective study included adults with operatively treated distal radius fractures and a preoperative CT scan within 2 weeks of injury between January 1, 2017 and July 31, 2018. The cohort consisted of 96 wrists in 95 patients. The median age was 54 (interquartile range, IQR 38-64) years, 68% (65/95) were women, and median follow-up was 56 (IQR 22-61) months.

Results: The fracture involved Lister's tubercle in 75% (72/96) of fractures. Of these 72 fractures, 11 had an EPL tendon entrapped by fracture fragments (18%). Within the cohort, two EPL injuries manifested clinically.

Conclusion: We present evidence that not all EPL ruptures after Open reduction and internal fixation (ORIF) of the distal radius are related to prominent dorsal screws. Extensor pollicis longus entrapment in Lister's tubercle fracture fragments is relatively frequent and may be a potential contributor to tendon rupture. When a CT scan is obtained for the treatment of distal radius fractures, attention to the EPL and its relation to Lister's tubercle may be helpful to characterize the risk of late rupture.

Background: The integration of artificial intelligence (AI) into health care witnessed significant advancements, particularly with AI-driven tools like ChatGPT. Initial evaluations indicated that ChatGPT 3.5 did not perform as well as humans on specialized hand surgery self-assessment examinations. The purpose of this study is to evaluate the performance of ChatGPT 4o on American Society for Surgery of the Hand (ASSH) self-assessment questions and whether using enhanced techniques such as better prompts and file search improve accuracy.

Methods: Using data from the ASSH self-assessment examinations (2008-2013), we explored the impact of ChatGPT model version, prompt, and file search on the accuracy of AI-generated responses. We used OpenAI's application programming interface to automate question input and response scoring. Statistical analysis was conducted using one-way analysis of variance. KR-20 was used to assess the reliability of the test.

Results: Results indicate that the latest AI models, particularly ChatGPT 4o with enhanced prompting and access to peer-reviewed literature, can achieve performance levels comparable to human examinees, particularly on text-based questions. ChatGPT 4o performed significantly better than ChatGPT 3.5 and showed marked improvement with better prompts and file search capabilities. The KR-20 for the 2013 examination was 0.946, indicating a very reliable test.

Conclusions: These findings highlight AI's potential to support medical education and practice, demonstrating that ChatGPT can perform at a human-equivalent level on hand surgery self-assessment examinations. Our results suggest potential utility as a supplementary tool in educational settings and as a supportive resource in clinical practice.

Background: Surgical patient hospital readmissions are costly to the health care system. The Affordable Care Act Hospital Readmissions Reduction Program introduced penalties for high hospital readmission rates. We performed a retrospective study evaluating factors associated with readmission in hand surgical inpatients.

Methods: We performed a retrospective chart review on 566 patients admitted to a level 1 trauma center for hand trauma or infection from January 1, 2016, to December 31, 2019. Data included demographics, social history, medical problems, comorbidities, procedure details, and admission and readmission details. A multivariable regression analysis was performed to identify factors associated with hospital readmission within 30 days.

Results: Cigarette smoking (P = .048), bite wound (P = .038), laceration wound (P = .028), laceration repair (P < .01), open reduction internal fixation (P = .041), and disposition to a skilled nursing facility (P = .017) were significantly associated with readmission to the hospital within 30 days. For patients who underwent emergency department interventions, alcohol use (P = .034), houselessness (P = .046), and malnutrition (P = .036) were additional factors associated with readmission.

Conclusions: Immediately irremediable factors such as tobacco and alcohol abuse, malnutrition, and houselessness should be considered as exemptions for penalties levied on health care systems for readmissions. Initiating targeted interventions, such as detoxification, smoking cessation, housing assistance, and improved nutrition, may reduce readmission risk and could improve patient outcomes.