Journal of Hand Surgery Global Online最新文献

Purpose

Dupuytren contracture is characterized by the formation of cords and nodules in the palm. Surgical release has historically been the definitive treatment. Collagenase clostridium histolyticum (CCH) has been used successfully as an alternative to surgery. The treatment of proximal interphalangeal (PIP) contractures is the most challenging. The purpose of this study was to evaluate CCH treatment for Dupuytren contracture of the PIP joint.

Methods

A retrospective chart review was performed for CCH treatment of Dupuytren contracture at a single institution from January 2010 to April 2023. Data collected included pretreatment/posttreatment total flexion contracture and adverse events. Contractures were analyzed both by severity (high >40° and low <40°) and type (isolated PIP; combined metacarpophalangeal and PIP).

Results

A total of 304 patients with 470 PIP joints treated were included. Digits with isolated and combined contractures each had an average pre-CCH treatment contracture of 51 (±23) degrees. Postmanipulations the contractures were 6 (±13) and 7 (±16) degrees, respectively. Clinical success (<5° residual contracture) and improvement (>50% correction of contracture) were associated with low severity contractures at postmanipulation. There were 256 adverse events recorded (54.5%), including 187 skin tears (39.8%), 68 cases of lymphadenopathy (14.5%), and one injection site infection (0.2%). High severity and combined contractures were independently associated with an increased incidence of skin tears upon manipulation.

Conclusions

Collagenase clostridium histolyticum treatment is effective for isolated or combined PIP joint contractures. Adverse events were associated with more severe contractures. Given the degree of improvement based on contracture severity, earlier intervention may provide better correction of contracture.

Type of study/level of evidence

Therapeutic III.

The coadministration of xylazine, a veterinary tranquilizer, with illicit fentanyl has led to severe soft tissue injuries, ranging from superficial irritation to deep tissue necrosis and even bone involvement, because of multifactorial tissue toxicity. Despite its non-opioid nature, xylazine enhances and prolongs the euphoric effects of fentanyl, exacerbating the potential for abuse. The pathogenesis of the tissue damage from xylazine is multifactorial but most akin to a burn from local tissue injury. With illicit opioids increasingly adulterated with xylazine, particularly in urban areas like Philadelphia, the prevalence of associated wounds, especially in the upper extremities, is anticipated to rise. Managing these wounds demands a multidisciplinary approach, with hand surgeons and reconstructive surgeons playing a central role. This review summarizes the historical context, pharmacodynamics, initial evaluation, wound categorization, algorithmic treatment, and expected outcomes of xylazine-associated wounds.

Purpose

There is growing evidence for the safety of wide-awake, office-based, low-risk hand surgery. However, there is limited insight into patient receptiveness to these procedures. Here, we evaluate the public perceptions and degree of tolerance of low-risk, office-based hand surgery.

Methods

A prospective study was performed using a 26-question, paid survey via a clinically validated, public, online marketplace. Participants were divided based on (pre-education) perceptions of in-office hand surgery into three cohorts as follows: in-office surgery (IOS), no in-office surgery, or no preference (NP). Educational material was then presented comparing three surgical settings and anesthetic types. Then, participants selected their setting/anesthetic preferences for the following four procedures: trigger finger release, cyst excision, carpal tunnel release, and distal radius fracture. Statistical analyses with unpaired t tests and chi-square tests were performed. P < .05 was significant.

Results

There were 509 respondents—266 in the IOS group, 104 in the no in-office surgery group, and 139 in the NP group. Previous outpatient surgery was most frequent in the IOS cohort. In-office surgery and NP cohorts were more likely to believe that surgical procedures could be performed in the clinic setting. The remaining demographics were similar across cohorts. After reviewing the education graphic, 50 of the 139 in the NP group switched to prefer IOS. For procedure-specific questioning, 40.6% (207/509) were amenable to in-office trigger finger release and 58.3% (297/509) for cyst excision, unlike more invasive procedures (carpal tunnel release: 25.6% (130/509); distal radius fracture: 9.8% (50/509). The most influential factors determining surgical location were comfort during the procedure and total encounter time. The IOS group favored location to be at the surgeon’s discretion more than the no in-office surgery group.

Conclusions

In-office, low-risk, hand surgery appears desirable to select patients. If presented with the option for in-office trigger finger release or cyst excision, approximately 40.6% (207/509) and 58.3% (297/509), respectively, may be amenable to IOS.

Type of study/level of evidence

Prospective IB.

Peripheral nerve injuries that are not acutely repaired may lead to a nerve gap because of the surrounding zone of injury and elastic recoil of nerve tissue after laceration. This can result in tension across the repair site during primary neurorrhaphy. Decades of basic science literature using in vivo models consistently demonstrate a relationship between increasing strain at a neurorrhaphy site and compromised microvascular blood flow. Clinical and laboratory data suggest tension-free repairs are associated with optimal outcomes; in the setting of a short segmental nerve gap, data suggest primary repair may continue to yield good functional results. In the case of high strain, nerve grafting or other methods should be considered given poor results of primary repairs performed under high tension because of local ischemia and fibrosis on a cellular level.

The purpose of this systematic review was to assess the currently available evidence for the use of external stimulation to modulate neural activity and promote peripheral nerve regeneration. The most common external stimulations are electrical stimulation (ES), optogenetic stimulation (OS), and magnetic stimulation (MS). Understanding the comparative effectiveness of these stimulation methods is pivotal in advancing therapeutic interventions for peripheral nerve injuries. This systematic review focused on these three external stimulation modalities as potential strategies to enhance peripheral nerve repair (PNR). We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework to systematically evaluate and compare the efficiency of ES, OS, and MS in PNR. The review included studies published between 2018 and 2023 using ES, OS, or MS for PNR focused on enhancing recovery of peripheral nerve injuries in rodent models identified through PubMed and Google Scholar. The search strategies and inclusion criteria identified 19 studies (13 ES, 4 OS, and 2 MS) for detailed analysis, focusing on critical parameters such as functional recovery, histological outcomes, and electrophysiological data. Although ES demonstrated a consistent improvement in all the analyses, high-frequency repetitive MS (HFr-MS) emerged as a promising modality. HFr-MS demonstrated accelerated PNR, as histological and electrophysiological evidence indicated. In contrast, OS exhibited superior functional recovery outcomes. Notable limitations include constrained MS and OS data sets and the challenge of comparing relative improvements because of methodological diversity in evaluation techniques. Our findings underscore the potential of HFr-MS and OS in PNR while emphasizing the critical need for standardized testing protocols to facilitate meaningful cross-study comparisons. External stimulations have the potential to improve functional recovery in patients with nerve injury.

Purpose

Dermal matrices can be used in management of upper-extremity wounds to create vascularized wound beds in the setting of exposed bone or tendon. Early outcomes of Novosorb biodegradable temporizing matrix (BTM) demonstrated success when used in the treatment of complex wounds. We hypothesize that BTM is effective for reconstruction of upper-extremity wounds.

Methods

A retrospective review was performed for patients who underwent reconstruction of upper-extremity wounds with BTM between January 2017 and May 2022.

Results

In total, 51 patients (39 males and 12 females) were included. Wound etiology included trauma (n = 30), burn (n = 12), infection (n = 8), and vasopressor-related injury (n = 1). The average size of BTM was 162.5 cm², and the average time from BTM application to wound closure was 90.1 days. Twenty-seven (52.9%) patients required skin grafting, whereas 20 (39.2%) did not and re-epithelialized spontaneously. Those who did not require skin grafting had significantly smaller wound sizes compared to those who required skin grafting (58.5 cm² vs 248.6 cm²; P = .002). Complications occurred in 14 patients, including infection (n = 5), fluid collection (n = 5), and template dehiscence (n = 4). Wound closure was successful in 92% of patients.

Conclusions

Novosorb BTM is effective for the management of upper-extremity wounds with exposed bone and tendon.

Clinical relevance

In the management of complex upper-extremity wounds with exposed bone and tendon, even when devoid of paratenon or periosteum, Novosorb BTM provides a safe and effective alternative to more complex reconstructive options.

Anterior shoulder instability is a complex spectrum of pathology characterized by excessive translation of the humeral head across the glenoid, leading to apprehension, subluxation, and dislocation. Diagnosis and classification require a thorough clinical history, physical examination, and imaging to appropriately determine the severity of instability. Depending on the individual patient anatomy and severity of instability, there exist many management options that are well-positioned to successfully treat this pathology and allow patients to return to prior functional levels. Treatment options available are conservative management, arthroscopic or open Bankart repair, remplissage, open or arthroscopic Latarjet, and glenoid bone grafting. Each of these options provides unique advantages for the surgeon in treating a subset of patients along the spectrum of disease. Selection of treatment modality depends upon the number of instability events, appropriate quantification, classification bone loss, presence of associated soft tissue injuries, and patient-specific goals regarding return of function. The purpose of this review was to present an evidence-based approach to the investigation, treatment selection, and follow-up of anterior shoulder instability. Individualized patient care is required to optimally address intra-articular pathology, restore stability and function, and preserve joint health for all.

Effective nerve coaptation entails tensionless repair of healthy fascicles with intact fascicular architecture and a well-vascularized environment, supportive of the regenerative cellular behaviors of neurons, immune cells, and Schwann cells. Suture coaptations have historically been used to ensure that these criteria are met for end-to-end repair, nerve transfers, and allograft or autograft reconstructions; however, unfortunately, overall restoration of function remains poor. As optimal coaptation is required for return of sensorimotor function, adjunct biomaterials are increasingly being enlisted attempting to optimize these suture-based coaptations. The purpose of this review was to discuss the biological, preclinical, and clinical data for the use of fibrin glue and nerve wraps made of type 1 collagen, porcine small intestine submucosa, chitosan, and human amniotic membrane. This study provides available data on each material’s ability to optimize the regenerative potential of nerve repair as well as available outcomes data. Although each biomaterial discussed has benefits to nerve regeneration, at large, data remain heterogeneous, and continued investigation is required to fully understand the specific mechanisms involved and the long-term potential clinical impacts each can provide for improvement of sensorimotor outcomes.

Peripheral nerve injuries can be devastating. Although neuropraxic and some axonotmesis injuries will recover spontaneously, nerve repair or reconstruction is required to restore function in high-grade axonotmesis or neurotmesis injuries. The first step of nerve repair or reconstruction is adequate nerve debridement with removal of necrotic and fibrous tissues. Debridement decreases neuroma formation at the repair site and produces an optimal surface for axonal regeneration. This article discusses nerve debridement, including the goals of debridement, debridement techniques, and signs of adequate nerve debridement before repair.

Purpose

Patients who fracture their distal radius are at risk of developing carpal tunnel syndrome (CTS). Carpal tunnel syndrome occurs acutely; other patients may present with signs and symptoms of CTS weeks or months after the distal radius fracture. Because CTS may present in a delayed fashion after a distal radius fracture, some surgeons will perform carpal tunnel release (CTR) in patients who undergo open reduction and internal fixation even in those patients who do not have clinical evidence of CTS—a prophylactic CTR. In the current systematic review, we evaluated the literature regarding prophylactic CTR in the setting of surgical treatment of distal radius fractures.

Methods

We conducted our literature review based on the preferred reporting items for systematic reviews and meta-analyses guidelines. The search strategy reflected “prophylactic CTR during treatment of distal radius fractures” and was conducted in February 2024. Included studies are summarized in the Table.

Results

Six studies met the inclusion criteria. Publication dates ranged from 2001 to 2018. Five studies investigated clinical symptoms and/or electromyography: three of five studies found worsening or persistent median neuropathy, and two of five studies found improvement or no further development of symptoms in their respective patient cohorts. The sixth study found no difference in patient-reported outcomes between either approach.

Conclusions

There were no differences in wrist range of motion, postoperative grip strength, or patient-reported outcomes within each of the study cohorts. Based on the findings from the studies included in this review, we do not believe that there is sufficient evidence supporting prophylactic CTR in the setting of surgical treatment of distal radius fractures.

Type of study/level of evidence

Therapeutic 2a.