HAND最新文献

Background: Abundant literature exists on the morphology of the carpal tunnel. Despite this, the shape of the carpal tunnel has been reported erratically, and most studies did not attempt to correlate findings with measurements taken from cadavers. The objective of this study was to perform a morphological analysis, determine the shape and mean dimensions of the carpal tunnel, determine the level of the narrowest area of the tunnel, and establish a set of values capable of serving as a reference for carpal tunnel release.

Methods: The carpal tunnels of 20 fresh cadaveric hands were dissected, and acrylic casts were created and measured using industrial computed tomography.

Results: Of the 20 casts, 19 were shaped like elliptic cylinders, with little variation in their measurements along the length. The location of the narrowest section of the carpal tunnel is very different among casts, and the length of the roof of the carpal tunnel ranged from 21.26 to 29.86 mm.

Conclusions: The most common shape of the carpal tunnel is an elliptic cylinder. Because of the unpredictability of the location of the narrowest area of the carpal tunnel, carpal tunnel release must continue through all extension of its roof. We advise that the release should rarely be extended distally more than 30 mm from the distal palmar wrist crease, which corresponds, in most cases, to the middle of the pisiform.

Background: Small proximal pole scaphoid nonunions present a clinical challenge influenced by fragment size, vascular compromise, deforming forces exerted through the scapholunate interosseous ligament (SLIL), and potential articular fragmentation. Osteochondral autograft options for proximal pole reconstruction include the medial femoral trochlea, costochondral rib, or proximal hamate. This study reports the clinical outcomes of patients treated with proximal hamate osteochondral autograft reconstruction.

Methods: A retrospective review identified patients treated with this surgery from 2 institutions with a minimum 6-month follow-up. Clinical outcomes included the Visual Analog Dcale pain score, 12-item Short-Form survey, abbreviated Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, wrist and forearm range of motion (ROM), radiographic assessment, and complications. We reviewed and compared these outcomes with those of the current published literature.

Results: Four patients (mean age: 24 years, 75% men) with a 12.8-month average follow-up (range: 6-20 months) were included. Radiographic union was identified in all cases by 12 weeks (range, 10-12). The average wrist ROM was 67.5% flexion/extension and 100% pronation/supination compared with the contralateral side at the final follow-up. The mean QuickDASH score was 17.6 (SD, 13). No complications were identified.

Conclusions: Proximal pole scaphoid nonunion reconstruction using autologous proximal hamate osteochondral graft demonstrated encouraging clinical and radiographic outcomes. Proximal hamate harvest involves minimal donor site morbidity without a distant operative site, uses an osteochondral graft with similar morphology to the proximal scaphoid, requires no microsurgical technique, and permits reconstruction of the SLIL using the volar capitohamate ligament.

Background: The purpose of this study was to evaluate the incidence of lymphedema onset or exacerbation in patients undergoing upper extremity interventions, both nonoperative and operative, after breast cancer surgery.

Methods: The study inclusion criteria were the following: (1) prior history of breast cancer surgery or lymphedema from the cancer; (2) upper extremity intervention, ipsilateral to the breast cancer side; and (3) follow-up of at least 1 month. Patients were evaluated for demographic information, type of breast cancer procedure and hand intervention, number of lymph nodes dissected, preexisting lymphedema, exacerbation of lymphedema, and new-onset lymphedema.

Results: A total of 161 patients undergoing 385 hand interventions (300 injections, 85 surgeries) were reviewed. Median follow-up was 31 months (range: 1-110). Nineteen patients had preexisting lymphedema ipsilateral to the hand procedure and none experienced an exacerbation of their lymphedema. Three patients developed new-onset lymphedema ipsilateral to their hand intervention at an average follow-up of 30 months (range: 4-67). One patient had a single injection and developed lymphedema over 5 years later. One had 2 injections in the same hand on the same date and developed lymphedema 3 months later. The third patient had 2 injections in the right hand, 1 injection and 1 surgery in the left hand, and developed either lymphedema or swelling due to rheumatoid arthritis in the right hand 1 year after the injections.

Conclusions: Patients who have undergone breast cancer surgery can safely undergo upper extremity intervention with low risk of lymphedema exacerbation or onset.

Background: The purpose of this study was to determine the perioperative complication rate of surgical fasciectomy following previous treatment with collagenase clostridium histolyticum (CCH) treatment in patients with Dupuytren disease.

Methods: A retrospective review of all patients at a large health system undergoing CCH treatment and subsequent limited surgical fasciectomy for recurrence on the same digit between 2010 and 2020 was performed. Fifty-two patients with 62 affected digits met inclusion criteria, and cases were reviewed for preoperative demographics, treatment characteristics, clinical outcomes, and perioperative complications.

Results: Fifty-five digits in 48 patients were treated with CCH and underwent subsequent limited surgical fasciectomy. Of all digits in the present study, 3 (6.3%) had a documented surgical complication following open surgical fasciectomy. There were zero postoperative infections, vascular injuries, or tendon injuries. The rate of nerve injury was 2.1%. The rate of postoperative skin necrosis was 4.2%. These rates were comparable or lower than those of historical published data.

Conclusions: The rate of perioperative complications in patients undergoing limited surgical fasciectomy after previous CCH treatment is low. The findings of this study will aid the counseling of Dupuytren patients in deciding whether to pursue treatment with CCH versus open surgical fasciectomy.

Restoring elbow joint motion is paramount for upper extremity optimum function. In end-stage elbow disease and stiffness, total elbow arthroplasty is the recommended option for older patients; however, for younger, highly demanding patients, interposition arthroplasty (IPA) is the management option of choice. We report a case of an 16-year-old female patient who presented after she had an open-grade IIIA, type AO 13C2.2 distal humerus fracture, which was managed initially by debridement and a cross-elbow external fixation. The decision was made to manage the fracture by open reduction and internal fixation through a posterior approach, and after performing an olecranon osteotomy, the surgeon found that the distal humerus segment was denuded of articular cartilage, so a decision was made after consulting the patient's parents to perform an IPA using fascia lata. At the final follow-up after 16 months, the fracture united completely, and the elbow ROM was from 15° to 120°. Interposition arthroplasty is a valid option to manage unexpected denuded distal humerus articular cartilage while managing distal humerus fractures.

Background: Patients with carpal tunnel syndrome (CTS) may also have cervical radiculopathy (CR) or vice versa, potentially requiring carpal tunnel release (CTR) and anterior cervical discectomy and fusion (ACDF). This study evaluates whether there is an increased risk of complications following CTR or ACDF in patients with concurrent CTS and CR (CTS-CR) compared with those with only CTS or CR.

Methods: A multipayer database was used to identify patients with CTS-CR. From this cohort, patients who underwent CTR and/or ACDF were identified. Patients with CTS-CR undergoing surgery were compared with those undergoing surgery with only CTS or CR. Multivariable logistic regression was used to compare matched populations to assess postoperative complications and risk of undergoing both procedures.

Results: A total of 110 379 patients with CTS-CR were identified. Carpal tunnel release was performed in 21 152 patients (19.2%) with CTS-CR, from which 835 (0.76%) underwent ACDF. Anterior cervical discectomy and fusion was performed in 6960 patients (6.31%) with CTS-CR followed by CTR in 1098 patients (0.99%). Patients with CTS-CR were at greater risk of reoperation and complex regional pain syndrome following CTR. In ACDF, patients with CTS-CR were at greater risk of reoperation. Obesity and tobacco use were significant risk factors in patients with CTS-CR who underwent both CTR and ACDF rather than a single surgery.

Conclusions: Examination of more than 100 000 patients with CTS-CR found a greater likelihood of reoperation and perioperative complications following surgery than those without concurrent diagnoses. Obesity and smoking increased the risk for patients undergoing both procedures. Patients presenting with CTS-CR are high risk and should be counseled on risk of complication and reoperation and optimized to reduce risk of undergoing both CTR and ACDF.

Background: Unstable fractures of the base of the middle phalanx are notorious for causing chronic loss of proximal interphalangeal (PIP) joint function, and they remain a challenge for the hand surgeon. We report on a temporary intraoperatively constructed internal joint stabilizer for unstable PIP joint injuries.

Methods: Across 2 institutions, a retrospective chart review was performed for cases with acute presentation of pilon fracture or fracture-dislocation of the base of the middle phalanx which were surgically treated with an internal joint stabilizer. Information collected included time from injury to surgical intervention, time from implantation to device removal, complications, and preoperative and postoperative range of motion.

Results: Seven patients met the inclusion criteria with a mean age of 51 (range: 24-72) years and a mean follow-up of 29 (range: 11-72) months. After removal of the fixator, the mean arc of PIP joint motion was 8° to 88° (range: 0°-100°). There were no infections, no hardware loosening or failures, and no revision procedures.

Conclusion: The current findings are comparable to the results for dynamic external fixators. An internal joint stabilizer for unstable injuries to the base of the middle phalanx provides satisfactory functional outcomes, allows early postoperative motion, and mitigates the routine complications which may arise with external fixation.

Background: Brachial plexus block for hand and upper extremity procedures in the obese presents a unique set of technical challenges. The authors examined how obesity affects procedural success, quality of anesthesia, and patient satisfaction.

Methods: Secondary analysis of a randomized control trial comparing the retroclavicular versus supraclavicular brachial plexus block for distal upper extremity surgery was conducted. Patients were randomized to supraclavicular or retroclavicular brachial plexus block groups in the original trial. In this study, the authors dichotomized patients by obesity to compare differences in outcomes.

Results: Sixteen of 117 patients (13.7%) were obese. The groups were statistically well balanced in terms of baseline and operative variables. Obese patients had increased imaging time 2.7 minutes (95% confidence interval [CI], 1.44-3.92) versus 1.9 minutes (95% CI, 1.64-2.16), P value = .05; needling time 6.6 minutes (95% CI, 5.17-7.95) versus 5.8 minutes (95% CI, 5.04-5.74), P = .02; and procedure time 9.3 minutes (95% CI, 7.04-11.46) versus 7.3 minutes (95% CI, 6.79-7.79), P = .01. Block success and complications were not statistically significant. The visual analog scores during the block, at 2 hours, and 24 hours after were not statistically different. Patient satisfaction score among obese patients was 9.1 (95% CI, 8.6-9.6) versus 9.2 (95% CI, 9.1-9.4), P = .63.

Conclusion: Findings from this trial suggest that despite an increased procedural difficulty, the use of both supraclavicular and retroclavicular brachial plexus blocks is associated with comparable quality of anesthesia, similar complication profile, equal opioid requirements, and similar patient satisfaction in the obese.