HAND最新文献

High-velocity traumatic amputations of the proximal upper extremity are devastating to the patient and represent an extreme surgical challenge to the treatment team. The hand surgeon must simultaneously battle devascularization with timely microvascular anastomosis, gross contamination with meticulous debridement, and amputation with stable fixation. In restoring a functional extremity, many of these goals are in contention with each other. This case describes a novel management strategy for a left transhumeral amputation sustained by a 23-year-old man in a motorcycle accident. The amputated arm was temporized by ectopic banking via the lateral circumflex femoral artery to allow for thorough debridement and immediate open reduction internal plate fixation with coverage provided by a free omental flap and subsequent split-thickness skin graft. This strategy allows for a single-stage treatment of upper arm amputations with immediate microvascular anastomosis, stable internal fixation, and soft tissue coverage by the omentum providing immunogenic and lymphangiogenic properties to combat infection, lymphedema, and swelling. Functional reconstruction was then performed in a staged fashion with a free functional muscle transfer using the contralateral gracilis.

Background: Understanding the median nerve's position relative to surrounding anatomy is essential; however, there are many variations among individuals. This study assesses differences in median nerve position with or without palmaris longus (PL). We hypothesize that PL presence alters median nerve position, resulting in a greater distance to the skin volar surface, a decreased distance to the radius volar surface, and an increased distance to the flexor carpi radialis (FCR).

Methods: 1193 wrist magnetic resonance imaging (MRI) studies were retrospectively reviewed from 2019 to 2023. One hundred adults ages 18 to 50 meeting criteria were included for a power > 80%: 50 wrist axial plane MRIs (distal radial-ulnar joint level) with PL and 50 without PL. Measurements included the distance from the median nerve center to the skin volar surface, radius volar surface, and FCR center. Statistical analysis included Fisher exact tests and Mann-Whitney U Test (median, ranges), with significance at P-value < 0.05.

Results: Individuals with PL had a greater distance between the median nerve and skin volar surface. The presence of PL exhibited no discernable difference in the distance between the median nerve to the radius volar surface or the FCR center. Palmaris longus presence or absence did not affect the radial/ulnar positioning of the median nerve to the FCR center.

Conclusions: PL presence results in a deeper median nerve position within the wrist in relation to the skin volar surface. This knowledge is crucial for musculoskeletal specialists, especially during volar approach wrist surgeries and when administering anesthetic or therapeutic injections to the median nerve.

Background: Multiple approaches exist for operative fixation of metacarpal fractures; with common treatments including lag screw fixation or open-reduction internal fixation (ORIF) with plates and screws. Recently, the adaptation of intramedullary screw (IMS) placement has allowed for an essentially closed approach with stable fixation and theoretically improved outcomes. Thus, we sought to compare such approaches to ultimately determine the superior method for achieving the goal of return to normal function.

Methods: We performed a retrospective study of all patients in our institution with metacarpal fractures requiring operative fixation over a 10-year period, with at least 6 months follow-up. Preoperative demographics, fracture characteristics, and operative data were collected. First digit metacarpal fractures along with any occurring at the base of the bone were excluded, as IMS fixation is not typically performed in such cases. Postoperative outcomes, including range of motion, hand therapy requirements, and time to subjective recovery were also compared.

Results: A total of 154 metacarpals were included in this study. Patients treated via IMS experienced shorter operative and tourniquet times compared to ORIF, with a faster return to subjective normal function, a greater range of motion, and reduced need for hand therapy. Complication rates were similar. This held true in isolated metacarpal fractures as well.

Conclusions: Intramedullary screw exhibited improved functional outcomes when compared against ORIF, exhibiting improved patient outcomes with comparable complication rates and should be considered as a method for fixation of metacarpal fractures within appropriate settings.

Background: While concomitant opioid and benzodiazepine use is discouraged due to an increased risk of sedation/overdose, the extent of perioperative opioid utilization in hand surgery patients already using benzodiazepines is unknown.

Methods: Using an administrative claims database, we identified adults undergoing carpal tunnel, DeQuervain, or trigger finger release, palmar fasciectomies, ganglion/mucoid cyst removals, and hand/wrist soft tissue mass excisions from 2011 to 2021. We identified opioid-naive patients with a benzodiazepine prescription within 90 days before surgery. Outcomes included the percentage of patients prescribed opioids and the amount of opioids prescribed, new persistent opioid utilization, postoperative emergency department (ED) visits, hand therapy utilization, and opioid overdose. We used multivariable regression models to adjust for age, sex, region, insurance, procedure, and comorbidities.

Results: Patients with benzodiazepine utilization had a higher adjusted odds of perioperative opioid prescriptions, amount of opioids filled, and new, persistent opioid use compared with patients without benzodiazepine use (all P < .001). In the multivariable analysis, patients with benzodiazepine use received +30.8 (95% CI: 28.9-32.8) morphine milligram equivalents and had an odds ratio of 1.48 (95% CI: 1.44-1.52) for developing new, persistent opioid use compared with patients without benzodiazepine use. Patients with preoperative benzodiazepine use also had increased postoperative ED visits and hand therapy utilization.

Conclusions: Opioid-naive patients undergoing soft tissue hand surgery who are using benzodiazepines were prescribed opioids more frequently/at higher amounts and experienced an increased odds of developing new, persistent opioid use. Surgeons could consider reducing opioid prescriptions in patients already using benzodiazepines in favor of nonopioid pain strategies.

Background: Kirschner wire (K-wire) and intramedullary (IM) screw fixation are accepted techniques for treatment of unstable proximal phalanx fractures, but comparative reports are lacking. This study aimed to evaluate early clinical outcomes following treatment with K-wire or IM fixation.

Methods: A retrospective review of all proximal phalanx fractures treated surgically at a single center by multiple surgeons was performed from May 1, 2019 to March 1, 2024. Inclusion criteria consisted of patients above 18 years of age with transverse or short-oblique proximal phalanx fractures, without associated soft-tissue injury or involvement of multiple digits, who were treated with IM screw or K-wire fixation. Outcomes were available for 49 patients (27 K-wire, 22 IM nail). Chart review was performed to assess range of motion (ROM) and Quick Disabilities of the Arm, Shoulder, and Hand outcomes 6 and 12 weeks postoperatively.

Results: A significant difference was found in total active motion (TAM) (207.4° vs 150.8°, P = .03) and proximal interphalangeal (PIP) joint motion (71.8° vs 54.5°, P = .04) between the IM and K-wire cohorts 12 weeks after surgery. Proximal interphalangeal motion was also significantly different (57.6° vs 34.3°, P = .03) 6 weeks after surgery with no significant difference in TAM (176.6° vs 122.1°, P = .13) at that time point. Quick Disabilities of the Arm, Shoulder, and Hand scores 12 weeks after surgery were not significantly different between the IM (M: 15.8) and K-wire (M: 28.15) groups (P = .13).

Conclusions: Total active motion and PIP joint motion were found to be significantly higher 12 weeks postoperatively following IM fixation compared to K-wire fixation for extra-articular proximal phalanx fractures.

Background: Perilunate/lunate injuries are frequently misdiagnosed. We hypothesize that utilization of a machine learning algorithm can improve human detection of perilunate/lunate dislocations.

Methods: Participants from emergency medicine, hand surgery, and radiology were asked to evaluate 30 lateral wrist radiographs for the presence of a perilunate/lunate dislocation with and without the use of a machine learning algorithm, which was used to label the lunate. Human performance with and without the machine learning tool was evaluated using sensitivity, specificity, accuracy, and F1 score.

Results: A total of 137 participants were recruited, with 55 respondents from emergency medicine, 33 from radiology, and 49 from hand surgery. Thirty-nine participants were attending physicians or fellows, and 98 were residents. Use of the machine learning tool improved specificity from 88% to 94%, accuracy from 89% to 93%, and F1 score from 0.89 to 0.92. When stratified by training level, attending physicians and fellows had an improvement in specificity from 93% to 97%. For residents, use of the machine learning tool resulted in improved accuracy from 86% to 91% and specificity from 86% to 93%. The performance of surgery and radiology residents improved when assisted by the tool to achieve similar accuracy to attendings, and their assisted diagnostic performance reaches levels similar to that of the fully automated artificial intelligence tool.

Conclusions: Use of a machine learning tool improves resident accuracy for radiographic detection of perilunate dislocations, and improves specificity for all training levels. This may help to decrease misdiagnosis of perilunate dislocations, particularly when subspecialist evaluation is delayed.

Background: Aggressive digital papillary adenocarcinoma (ADPA) is a rare skin adnexal tumor with a predilection for the hand. The presentation, treatment, and outcomes of ADPA remain poorly defined due to the scarcity of reports and low-level evidence of published findings.

Methods: We performed a meta-analysis following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines with the intent to provide hand surgeons a better understanding of the diagnosis and treatment of the disease. Three additional cases of ADPA from our institution were combined with the results from the systematic review.

Results: A total of 238 cases were included in the meta-analysis. Most ADPAs were painful, evolving, and less than 2 cm in size. Regional sentinel lymph node biopsies were performed in 55 patients, of which 25.5% were positive. Overall cohort recurrence and distant metastasis rates were 24.3% and 18.1%, respectively. Patients who obtained clear margins within 6 months of diagnosis had significantly lower rates of recurrence, metastasis, and mortality (P < .001, P = .04, P = .003, respectively). There were no differences in recurrence or metastasis rates in those who obtained clear margins by excision or amputation (P = .27 and P = .07, respectively). In patients who died from disease (6.0%), 5.0 years was the average time to death.

Conclusions: Aggressive digital papillary adenocarcinoma should be included in the differential diagnosis of hand lesions with unusual presentations or lack of response to other therapies. Clear margins should be obtained within 6 months of diagnosis, and routine surveillance should be provided by an oncologic physician familiar with ADPA as these tumors have high recurrence rates.

Background: The work relative value unit (wRVU) system quantifies surgeons' effort and resources for procedures. Studies have shown its inaccuracy in capturing the complexity of certain plastic and upper extremity surgeries. Analysis for peripheral nerve surgery (PNS), a growing niche within hand and plastic surgery, has not been performed. The authors aim to evaluate the PNS wRVUs by correlation to their operative time.

Methods: A retrospective analysis with current procedure terminology (CPT) codes for PNS (2005-2021) from the American College of Surgeons National Surgical Quality Improvement Program database was performed. Efficiency was determined by wRVU per operative time. Correlation was performed between operative time with wRVU and wRVU/minute.

Results: A total of 2402 procedures across 21 CPT Codes were included and categorized into neuroplasty, nerve repair, and nerve grafting/transfers with the median operative time being 63.75, 100, and 153.78 minutes respectively. Nerve graft/transfer generated the maximum wRVU (mean 16.35). Neuroplasty generated the minimum wRVU (mean 7.24). Nerve grafts/transfers generated the least wRVUs per minute (0.09). Longer operative times were associated with higher wRVUs. Neuroplasty (R = .86) and nerve repairs (R = .84) had a strong correlation to the operative time. Nerve grafts/transfer had a positive but moderate correlation with the operative time (R = .67). All procedures had a negative correlation between operative time and wRVU/minute.

Conclusions: Nerve grafts/transfers had reduced compensation compared to neuroplasty or nerve repairs. Compensation did not reflect the procedure efficiency. This disparity in wRVU allocation for complex PNS underscores the need for remuneration reform.

Background: Intramedullary screw (IMS) fixation for metacarpal fractures is a relatively new fixation technique in comparison to plate and screw constructs. Our hypothesis evaluated whether IMS fixation for metacarpal fractures results in lower overall health care-associated costs in comparison to open reduction and internal fixation (ORIF).

Methods: A retrospective review of patients undergoing IMS fixation for metacarpal fractures at a single center during 2018 to 2022 was conducted. Health care-associated costs included primary operative costs (surgical time and implant(s)) and postoperative costs (therapy, splinting, and radiology). Costs were compared with age-matched and fracture pattern-matched controls who underwent ORIF with plate and screw construct. Subgroup analysis of cost outcomes excluding outliers was completed.

Results: Eight subjects met the inclusion criteria and matched with an ORIF group. Primary operative costs were significantly higher in the ORIF group (mean difference of $1830, 95% CI: $1006 to $2653) The cost of an IMS at our institution was $584, whereas the average cost for plate and screw construct was $2538 (mean difference of $1953, 95% CI: $1665 to $2243). Total surgical costs were on average $3784 more for the ORIF group (95% CI: $2869 to $4700). There was no significant difference in outpatient follow-up costs (95% CI: -$441 to $3180). Total overall costs were significantly lower for the IMS group (95% CI: $2693 to $6513).

Conclusions: Total primary operative costs and overall health care-associated costs for IMS fixation of metacarpal fractures is significantly lower than ORIF. There was no statistical difference in follow-up care costs. To better determine the indirect costs for patients, high-powered prospective studies will be required.