HAND最新文献

Background: The Darrach procedure, comprising distal ulna resection, has been used to treat numerous wrist and distal radioulnar joint pathologies. Extensor tendon rupture from the proximal ulnar stump is a recognized, but lesser known postoperative complication. We present this case series of extensor tendon ruptures following Darrach procedures and their subsequent reconstructions to share different surgeon experiences with this complication.

Methods: Patients with extensor tendon rupture after Darrach procedure were identified from contributing hand surgeon case logs. The treating surgeons shared demographic data and surgical case details pertinent to this study. A single patient experience is presented as the representative case, with the remaining patient experiences summarized in a table.

Results: Seven patients were included. Nearly all patients underwent intraoperative capsular closure following distal ulna resection, and their extensor tendon ruptures were treated with revision surgeries.

Conclusion: While rarely reported in the literature, treating surgeons should be aware of extensor tendon rupture as a possible complication after Darrach procedure.

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.

Upper extremity reconstructive surgeries in patients with cervical spinal cord injury (SCI) can significantly improve function, but anesthesia planning and postoperative pain management are complex. Continuous peripheral nerve blocks (CPNBs) may offer intraoperative anesthesia and postoperative analgesia benefits, yet literature on their safety and patient tolerance in those with cervical SCI is limited. This case series reviewed the records of 18 patients with cervical SCI who underwent upper extremity tendon transfer, nerve transfer, or reconstructive surgery and received an ultrasound-guided brachial plexus CPNB maintained for up to 7 days postsurgery. The retrospective chart review focused on CPNB-related neurological symptoms, patient experiences with a new insensate limb, postsurgical opioid use up to postoperative day (POD) 7, and the return of bowel function. The mean duration of CPNB infusion was 3.5 days. No patients exhibited new neurological symptoms or unpleasant experiences necessitating removal of the CPNB. Most patients returned to baseline opioid use by POD 5 and had a bowel movement by POD 1. The findings suggest that brachial plexus CPNB infusions are well tolerated in patients with cervical SCI, providing effective pain relief and minimizing opioid usage without causing distress related to a new insensate limb.

Traumatic dislocation of the thumb carpometacarpal (CMC) joint is relatively rare. Although there are scattered reports of such dislocations, they are all in the dorsoradial direction. We report a very rare case of an ulnar dislocation of the CMC joint of the thumb. The patient fell while on a motorcycle and was presented with an ulnar dislocation of the CMC joint of the left thumb. Manual reduction failed to provide stability, and surgery was performed. The CMC joint was temporarily wired, and the posterior oblique ligament and dorsoradial ligament were repaired with a suture anchor. One year after surgery, the CMC joint was stable and pain-free.

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: Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome. The thread carpal tunnel release (TCTR) is an incision-less ultrasound-guided approach to divide the transverse carpal ligament. This retrospective case series aims to identify and assess the bleeding risks associated with continuing anticoagulation or antiplatelet therapy during TCTR.

Methods: Retrospective chart review with follow-up questionnaires/surveys. One hundred and fourteen adult patients who were using antiplatelet or anticoagulation medication underwent 164 TCTR procedures during 2018 to 2023 at a single institution (tertiary care hospital) from June 29, 2018, and August 11, 2023. A chart review was performed to identify patients on antiplatelets or anticoagulants at the time of the procedure and to determine if there were any adverse events associated with continuing or holding their antiplatelet or anticoagulant therapy.

Results: There were no significant complications associated with continuing or holding anticoagulation or antiplatelet therapy during TCTR.

Conclusions: Continuing antiplatelet therapy during TCTR appears safe. The decision to continue antiplatelet or anticoagulation therapy should be made on a case-by-case basis.

Distal radius fractures (DRFs) are common, especially in elderly populations, and often occur alongside scapholunate (SL) ligament injuries (SLIs), which can progress to scapholunate advanced collapse if untreated. There is no standardized treatment for SLIs with DRFs, with options ranging from conservative management to surgical interventions. This review aims to evaluate functional, radiographic, and clinical outcomes of surgical and nonsurgical treatments for SLIs associated with DRFs. A systematic search was conducted across PubMed, ScienceDirect, and Embase according to International Prospective Register of Systematic Reviews and Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Studies comparing surgical and nonsurgical management in adults (≥18 years) with SLIs and DRFs were included. Outcomes assessed included Disabilities of the Arm, Shoulder, and Hand (DASH) scores, QuickDASH scores, Mayo Wrist Scores, mean grip strength, SL gap, SL angle, and wrist range of motion (ROM). Thirteen studies involving 4315 DRF patients (423 with SLIs) were analyzed. Surgical treatment showed better functional outcomes, with lower DASH scores (P = .0011) and improved radiographic alignment, indicated by lower SL angles (P = 7.5 × 10^-20). However, wrist ROM was lower in surgically treated patients, particularly in flexion (P = .00031) and extension (P = .0080). Pain was the most commonly reported complication across both groups. Surgical treatment for SLIs with DRFs may lead to functional and radiographic outcomes similar to nonsurgical options, but is associated with reduced wrist mobility. Nonsurgical management remains effective for patients with milder symptoms. Further research is necessary to refine treatment protocols and optimize outcomes for these complex injuries.

Background: There are no large studies describing patient-reported outcomes after ulnar tunnel release (UTR). The aims of this study are to describe the causes of ulnar tunnel syndrome (UTS), the incidence of UTR, and identify factors associated with long-term patient-reported outcomes after UTR.

Methods: We reviewed the medical charts of 76 adult patients who had an UTR for UTS at 1 of 5 academic medical centers between January 1, 2003 and January 1, 2017. Of these patients, 30 completed a follow-up questionnaire including the PROMIS Upper Extremity (PROMIS-UE), Numerical Rating Scale for Pain Intensity (NRS Pain), the Global Rating Scale of Change, and a custom questionnaire about satisfaction and current UTS-specific symptoms.

Results: Approximately 3% of the patients who underwent a decompression surgery of the ulnar nerve at one of our centers between 2003 and 2017 had a UTR. The most frequent described cause of compression was ganglion cyst (16%). The 30 patients who completed the follow-up survey had a mean ± SD PROMIS-UE score of 46.0 ± 12 and a median (interquartile range) NRS Pain score of 0.5 (0-4). Twenty-five patients (83%) described themselves improved compared to before UTR. Bivariate analysis showed that patients who had a preoperative electromyography and nerve conduction velocity study (EMG/NCV) positive for UTS had a higher mean ± SD PROMIS-UE score compared to patients who had a negative EMG/NCV for UTS, respectively 48 ± 12 versus 37 ± 7.6, P = .04.

Conclusion: Diagnosis of UTS is challenging and made with substantial variation among surgeons. We observed that most patients improve after UTR, but patients with a negative EMG/NCV have a lower PROMIS Upper Extremity score at long-term follow-up.

Background: Understanding peripheral ulnar nerve anatomy is necessary to refine surgical treatment of ulnar nerve injuries. This study topographically mapped the ulnar nerve and its distal branch points from a well-defined surgical landmark and assessed for variations in interfascicular motor arrangement and branch size.

Methods: Fifty-four cadaveric upper extremities were dissected to expose the distal ulnar nerve and its branches (dorsal cutaneous (DCB), volar sensory (VSB), and motor branches). The motor branch underwent internal neurolysis to record the topographic orientation of abductor digiti minimi (ADM) and flexor pollicis brevis (FPB) fascicles and the combined intrinsic fascicle identified by its terminal branch (first dorsal interosseus (FDI)). Using a standardized grid system, the branch point location of each terminal branch was measured relative to the hook of the hamate. Diameters of VSB, DCB, and motor fascicles were also measured.

Results: Mean branch point coordinates relative to the hook of the hamate for the FDI were 22.8 mm radial/32.1 mm distal, 13.6 mm radial/25.1 mm distal for FPB, 7.7 mm ulnar/5.2 mm proximal for ADM, and 15.7 mm ulnar/95.3 mm proximal for DCB. The diameters of the VSB, motor branch, and DCB had a mean of 2.3, 1.9, and 1.6 mm, respectively. Proximal to the hook of the hamate, the fascicular arrangement from radial-to-ulnar was VSB, FPB, FDI/intrinsics, ADM, and DCB.

Conclusions: This study provides a complete characterization and mapping of the distal ulnar nerve and its branches to assist surgeons with treatment of ulnar nerve injuries, including nerve transfer.

Background: Perilunate dislocations are severe upper extremity dislocations to the wrist involving ligamentous injury. Previous literature cites closed reduction of perilunate injuries at 25%. Herein, the technique and results of closed reductions for perilunate dislocations are described.

Methods: Chart reviews were conducted of perilunate injuries treated from 2017 to 2022. Imaging was evaluated to categorize by Herzberg stage. Reduction was performed in the emergency department (ED) and involved traction, relaxation, and manipulation. Reduction attempts and success rates were recorded as were presence and resolution of median nerve symptoms.

Results: Fifty-six perilunate injuries were included with an average age of 36 years. Forty-five (80%) underwent attempted closed reduction, of which 37 (82%) were successful. Twenty-seven (48%) were Herzberg I, 18 (32%) were Herzberg IIA, and 11 (20%) were Herzberg IIB. Two Herzberg IIB injuries were mal-reduced, with the lunate returned to the lunate fossa inverted. Scaphoid fractures were more likely in Herzberg I injuries and did not influence the success of reduction. Thirty (54%) patients presented with median nerve symptoms, of which 25 underwent attempted closed reduction in ED. Perilunate reduction resolved nerve symptoms in 92% of cases. Nerve symptoms were not more common in Herzberg II perilunate injuries. Successful closed reduction of perilunate injuries was not associated with a specific Herzberg stage.

Conclusion: Closed perilunate reductions in the ED can have a high success rate >80%. Herzberg II perilunate injuries have >70% (76%) success rate in closed reduction. Rates of median nerve symptoms were high and resolved in most cases (92%) after reduction. Closed reduction of perilunate injuries can safely be attempted in the ED and resolves nerve compression prior to surgery.