Journal of Hand Surgery Global Online最新文献

Purpose

Methods

Results

Conclusions

Type of study/level of evidence

Purpose

Methods

Results

Conclusions

Type of study/level of evidence

Purpose

Methods

Results

Conclusions

Level of Evidence

Nerve injuries secondary to gunshot wounds (GSWs) have been traditionally thought of as neurapraxic injuries with high likelihood of complete recovery. A review of the literature, however, highlights the misconceptions surrounding ballistic nerve injuries and their treatments. Contrary to this accepted dogma, approximately 30% to 60% of GSWs to the upper extremity may result in nerve injury requiring repair or reconstruction. Surgical exploration following ballistic injury reveals that 20% to 55% of nerves were lacerated requiring repair or grafting. Despite these numbers, outcomes after nerve repair or grafting are limited, and the limited data show evidence of poor functional recovery. In our experience, delayed exploration of GSW-related nerve injuries in patients without signs of functional recovery demonstrate large neuromas in continuity often requiring meticulous dissection and excision with resulting large gaps that require reconstruction. This has led us to explore options to identify patients with nerve deficits after GSWs who may benefit from earlier exploration. Others advocate for the exploration of all ballistic nerve injuries, which would represent a logistical challenge in high volume centers and may lead to unnecessary explorations of in continuity nerves. To facilitate identification of nerve injury following GSWs, we have explored the utilization of early ultrasound to identify patients with nerve lacerations that may benefit from early exploration (1–2 weeks after injury). Earlier exploration can lead to less technically challenging surgery, shorter nerve gaps, and more time for the nerve to recover. Herein, we present a series of cases to help illustrate this approach to the patient. Although early exploration and repair versus grafting of nerves may have benefits as outlined above, there are little to no data on outcomes of nerve repair or grafting in ballistic injuries in the more acute setting, 1 to 2 weeks after injury. Further research is needed both with regards to diagnosis and utilization of ultrasound, as well as postoperative outcomes in patients with ballistic nerve injuries to help guide our ever-evolving treatment protocols.

Peripheral nerve injuries affect a significant number of patients who experience trauma affecting the hand and upper extremity. Improving unsatisfactory outcomes from repair of these injuries remains a clinical challenge despite advancements in microsurgical repair. Imperfections of the nerve regeneration process, including imprecise reinnervation, distal axon degradation, and muscular atrophy, complicate the repair process. However, the capacity for peripheral nerves to regenerate offers an avenue for therapeutic advancement. Regeneration is a temporally and spatially dynamic process coordinated by Schwann cells and neurons among other cell types. Neurotrophic factors are a primary means of controlling cell growth and differentiation in the repair setting. Sustained axon survival and regrowth and consequently functional outcomes of nerve repair in animal models are improved by the administration of neurotrophic factors, including glial cell-derived neurotrophic factor, nerve growth factor, sterile alpha and TIR motif containing 1, and erythropoietin. Targeted and sustained delivery of neurotrophic factors through gelatin-based nerve conduits, multiluminal conduits, and hydrogels have been shown to enhance the innate roles of these factors to promote expedient and accurate peripheral nerve regeneration in animal models. These delivery methods may help address the practical limitations to clinical use of neurotrophic factors, including systemic side effects and the need for carefully timed, precisely localized release schedules. In addition, tacrolimus has also improved peripheral nerve regrowth in animal models and has recently shown promise in addressing human disease. Ultimately, this realm of adjunct pharmacotherapies provides ample promise to improve patient outcomes and advance the field of peripheral nerve repair.

Purpose

The objective of this study was to perform a cost-utility analysis comparing open carpal tunnel release (OCTR), endoscopic carpal tunnel release (ECTR), and carpal tunnel release with ultrasound (CTR-US) guidance. The aim of this study was to determine whether one of the three approaches was dominant from a societal perspective in terms of cost-utility, in order to help inform policy and treatment decision making going forward.

Methods

This study was performed using a decision tree model, with three potential treatment decisions (OCTR, ECTR, and CTR-US). A cost-utility analysis was performed, using the incremental cost-effectiveness ratio. The willingness-to-pay threshold was set at $50,000/quality-adjusted life year (QALY) as per previous literature.

Results

The total payer episode costs for OCTR, ECTR, and CTR-US were $4,324, $4,978, and $3,249, respectively. The cost of time off work for each procedure was $4,376.14, $3,650.24, and $622.20, respectively. The overall QALYs gained from each procedure were 0.42, 0.42, and 0.43, respectively (the maximum possible being 0.5 for a 6-month period). Compared with OCTR, ECTR and CTR-US were both less costly from a societal perspective (−$71.90 and −$4,828.94, respectively) and associated with greater QALYs gained (+0.0004 and +0.0143, respectively).

Conclusions

Overall, the key finding of this study is that, from a societal perspective, CTR-US is less costly and provides greater QALY improvement when compared with OCTR and ECTR, and thus, CTR-US is considered a dominant intervention over both OCTR and ECTR.

Type of study/level of evidence

Economic and decision analysis; IIb.

Tendon entrapment is a rare complication of closed forearm fractures. A 16-year-old boy sustained a type 1 open both bone forearm fracture after falling from a skateboard. The injury was initially managed with irrigation, debridement, and flexible intramedullary nailing. Seven weeks after surgery, a flexion contracture of the ipsilateral thumb interphalangeal joint was noted. Subsequent hardware removal and hand therapy failed to improve thumb extension. The patient was taken to the operating room for planned tenolysis and possible tendon reconstruction. Intraoperatively, the flexor pollicis longus tendon was found to be wrapped around the radial shaft as an apparent complication of the initial procedure, which necessitated division and reconstruction of the tendon. To our knowledge, this is the first pediatric reported case of dorsal flexor pollicis longus tendon entrapment through the fracture site in a both bone forearm fracture requiring tendon reconstruction. This case highlights a unique surgical approach to a novel complication of pediatric both bone forearm fracture.

Peripheral nerve injuries are potentially devastating injuries leading to pain and impairment in motor and sensory functions. Since the first published use of microsurgical epineural repair of peripheral nerves in 1964, a wide variety of adjuncts have been studied. Polyethylene glycol is a fusogen that has been shown to restore axolemmal membranes. The use of polyethylene glycol in nerve injuries was first described in 1986, and animal studies have shown fusion of transected sensory and motor nerves following early application at the time of surgical repair with improved motor and sensory outcomes. Early human clinical trials have shown promising results, although more data are needed to provide specific indications and protocols. This article summarizes the background, current evidence, and future directions as well as potential applications of polyethylene glycol–mediated nerve fusion.

Purpose

Magnetic resonance imaging (MRI) is the most widely used imaging to diagnose lateral epicondylitis (LE). However, the importance of MRI findings in LE remains unclear. This study aimed to classify the signal intensity changes of the extensor carpi radialis brevis origin and the shape and length of the synovial fold using MRI and compare them with clinical symptoms. We hypothesized that MRI findings in LE are not associated with clinical symptoms.

Methods

Two hundred and forty-three patients (261 elbows, mean age: 51.2 ± 8.5 years, mean duration of LE: 18.2 ± 11.3 months) who were evaluated using pretreatment MRI were included. The signal change of the extensor carpi radialis brevis origin was classified using coronal T2-weighted (T2) imaging and coronal fat-suppressed proton density T2 imaging, and the shape and length of the synovial folds were evaluated using coronal and sagittal T2 imaging. Furthermore, MRI findings were compared with clinical symptoms at the first visit.

Results

The number of elbows with high signal intensity on fat-suppressed proton density T2 was 252 of 261 (96.5%), and those on T2 were 207 of 261 (79.3%). Synovial folds were observed in 231 of 261 (88.5%) of the elbows, and synovial folds having a dull shape were observed in 95 of 261 (36.4%) elbows. The length of the synovial fold was >1/3 of the radial head in 87 of 261 (33.3%) of the elbows. There was no statistically significant correlation between the MRI findings and clinical symptoms.

Conclusions

A high rate of high signal intensity changes of the extensor carpi radialis brevis origin was observed, and fat-suppressed proton density T2 could detect finer signal changes than T2. Furthermore, synovial folds were found in many cases of LE. However, there was no association between MRI findings and clinical symptoms at first visit.

Type of study/level of evidence

Prognostic IV.

Tissue-engineered nerve guidance conduits (NGCs) are an area of research interest and investment. Currently, two separate three-dimensional, filled NGCs have Food and Drug Administration approval in the management of nerve gaps up to 3 cm in length, with more on the horizon. Future NGC options will leverage increasingly intricate designs to mimic the natural biology and architecture of native nerve tissue. To enhance the development of next-generation NGCs, experimental protocols and models should be standardized. For the NGCs currently on the market, more clinical data and randomized comparative studies are needed.