Journal of Hand and Microsurgery最新文献

Background: Suture selection in elective hand surgery closures has traditionally been non-absorbable sutures (NAS) rather than absorbable sutures (AS). The goal of this study was to evaluate absorbable versus non-absorbable closures of various primary elective hand procedures. Our group hypothesized that no differences in major short-term outcomes would exist.

Methods: A retrospective review of 867 patients was conducted. Patients were identified using Current Procedural Terminology (CPT) codes specific to surgical cases from forearm to fingertip. Patients undergoing emergent trauma operations or debridement for infection were excluded. Two experimental groups were evaluated: one in which surgical wound closures were performed with non-absorbable suture (nylon) vs one in which closures were performed with absorbable suture (monocryl). Outcomes measured were wound dehiscence, need for postoperative antibiotics, 30-day general complications, and reoperations within 60 days.

Results: A total of 867 patients were investigated in this study. The AS cohort consisted of 455 patients whereas the NAS group contained 412. No significant differences were noted between the AS and NAS groups with regards to age, gender, or diabetes. Postoperatively, there was no significant difference in rates of dehiscence, infections, or antibiotic prescription. Furthermore, rates of 30-day complications (1.36 % vs 1.47 %; p = 1.000), 60-day complications (0.68 % vs 2.19 %; p = 0.113) and reoperation (1.13 % versus 1.46 %; p = 0.903) were similar between the AS and NAS cohorts.

Conclusion: Wound closure in hand surgery using absorbable suture appears to have comparable outcomes with non-absorbable suture.

Level of evidence: 3.

The triangular fibrocartilage complex (TFCC) is crucial for stability and acts as a shock absorber and load transmitter at the distal radioulnar joint (DRUJ). It is often injured in wrist trauma, particularly in young athletes. Clinical assessment involves patient history, physical examination, and imaging modalities like MRI, with wrist arthroscopy as the gold standard for diagnosing TFCC tears. Multiple classification systems categorize TFCC tears based on location and arthroscopic appearance, guiding treatment decisions. Surgical options are recommended for tears refractory to conservative management or severe tears. Despite numerous arthroscopic treatments available in the literature, this article aims to simplify the approach. It presents the authors' surgical algorithm for managing acute traumatic TFCC tears arthroscopically. The choice of technique depends on the lesion's location, with various options for peripheral and foveal tears. Post-operative rehabilitation is crucial for optimal recovery. This article provides a comprehensive review of acute traumatic TFCC injuries, covering anatomy, classification, assessment, and treatment options. Emphasis is placed on accurate diagnosis and appropriate arthroscopic management through a structured approach.

Microvascular anastomotic couplers are a safe alternative to traditional vein suture techniques. They are versatile and widely used for flap vein anastomoses; however, the technique has limitations. Most problems which can arise, have reasonable solutions that we have learned using this device. We describe advanced tips to avoid pitfalls and aid successful venous anastomoses with couplers in challenging situations.

Broader adoption of ultrasound (US) imaging in carpal tunnel syndrome management enhances patient care and outcome. This case underscores the importance in diagnosing carpal tunnel syndrome, highlighting its capability to uncover hidden anomalies and assist in surgical planning.

Introduction: Transition to outpatient surgery has grown with an emphasis on delivery of safe, high-quality medical care. The purpose of this study is to compare 90-day emergency department (ED) visits, readmissions, and complications between patients undergoing outpatient versus inpatient pollicization surgery.

Methods: A single institution database was queried for primary thumb pollicization from 2010 to 2022 in patients under 18 years of age. Standard demographic data, comorbidities, surgical information, and discharge disposition were collected. Primary outcome measures were complications including ED visits, unplanned reoperations and hospital readmissions within 90-days of index procedure.

Results: Twenty-seven patients underwent pollicization surgery. Twenty patients were outpatient surgery while 7 had postoperative hospital admission, defined as an overnight hospital stay. The outpatient cohort had no major postoperative complications including no ED visits, reoperations or readmissions within 90 days of index procedure. One outpatient experienced swelling around bilateral thumb pin sites without infection or vascular compromise. One inpatient represented to the ED within 90 days of surgery for bilateral hand cellulitis.All patients with ASA I classification were performed outpatient. Three of 7 inpatients (43 %) had congenital heart disease versus 5 of the 20 (25 %) outpatients. There was a trend that inpatients were younger than the outpatient cohort (19 vs. 33 months). The average length of procedure in the inpatient cohort was significantly longer than the outpatient cohort (237 vs. 173 min). Pollicizations performed between 2017 and 2022 were more likely to be outpatient than those performed between 2010 and 2016.

Conclusion: On properly selected patients, outpatient pollicization appears to be a safe option. Patients with longer operative times were more likely to require postoperative hospital admission. Over the study years evaluated at our institution, pollicization procedures were more likely to be performed outpatient, reflecting an evolution of our practice.

Level of evidence: Level III, retrospective cohort study.

Background: We sought to determine the diagnostic utility of the flexion-compression (F-C) test for carpal tunnel syndrome (CTS). Using electrodiagnostic testing as the gold standard, we hypothesized that the F-C test would be a better diagnostic test for CTS as compared to the wrist flexion (Phalen's) or palmar compression (Durkan's) tests alone.

Methods: We studied patients who presented with and without CTS symptoms, designated as study and control group patients, respectively. At the first clinic visit, all patients were evaluated using the CTS-6 score, and then the Phalen's, Durkan's, and F-C tests in a random order. Patients in the study group were then sent for electrodiagnostic testing.

Results: 162 patients were included after power analysis, 81 each in the study and control groups. Among study group patients with electrodiagnostic evidence of CTS, the positive likelihood ratio (LR+) of the Phalen's test (1.29) was higher than the Durkan's (1.06) and F-C (0.95) tests, though less than the CTS-6 score (1.64). Performing any physical exam test in conjunction with the CTS-6 score was not more useful than the CTS-6 alone. As expected, all three physical exam maneuvers were more likely to be positive among study patients compared to control patients.

Conclusions: None of the physical exam maneuvers were highly predictive of electrophysiologically-positive CTS. The CTS-6 score alone better predicts electrodiagnostic evidence of CTS than physical exam, though it only very slightly increases the post-test probability of disease. Formal electrodiagnostic testing remains important in diagnosing CTS when compared to physical exam maneuvers and CTS-6.

Background: Trigger finger is a common disorder of the hand characterized by pain and locking of the digits during flexion or extension. In cases refractory to nonoperative management, surgical release of the A1 pulley can be performed. This study evaluates the ability of machine learning (ML) techniques to predict short-term complications following trigger digit release surgery.

Methods: A retrospective study was conducted using data for trigger digit release from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) years 2005-2020. Outcomes of interest were 30-day complications and 30-day return to the operating room. Three ML algorithms were evaluated - a Random Forest (RF), Elastic-Net Regression (ENet), and Extreme Gradient Boosted Tree (XGBoost), along with a deep learning Neural Network (NN). Feature importance analysis was performed in the highest performing model for each outcome to identify predictors with the greatest contributions.

Results: We included a total of 1209 cases of trigger digit release. The best algorithm for predicting wound complications was the RF, with an AUC of 0.64 ± 0.04. The XGBoost algorithm was best performing for medical complications (AUC: 0.70 ± 0.06) and reoperations (AUC: 0.60 ± 0.07). All three models had performance significantly above the AUC benchmark of 0.50 ± 0.00. On our feature importance analysis, age was distinctively the highest contributing predictor of wound complications.

Conclusions: Machine learning can be successfully used for risk stratification in surgical patients. Moving forwards, it is imperative for hand surgeons to continue evaluating applications of ML in the field.

Flexor tendon pulley reconstruction in patients with multiple pulley ruptures and proximal interphalangeal joint contracture after closed injuries is relatively uncommon. The paucity of evidence in the literature supporting one technique can make these surgical decisions and surgeries challenging. This article presents the surgical technique we use for treatment of the proximal interphalangeal joint stiffness and pulley reconstruction at the same time, using wide-awake local anesthesia with no tourniquet (WALANT). The clear advantage of this anesthetic technique for this procedure is the ability to directly verify the contracture release and tendon's gliding through the reconstructed pulley system during the patient's active mobilization, allowing the surgeon to make adjustments during the surgery and educating the patient on the postoperative therapy.

Background: Aim of the present paper is to report the preliminary results of CAD-CAM (Computer-Aided Design - Computer-Aided Manufacturing) technology application to distal femur nonunion treatment with free fibula flap, custom made medial plating and maintenance of a stable lateral locking plate.

Methods: Two cases of distal femur nonunion that occurred after lateral locking plating were treated and prospectively followed-up. Surgical planning followed the same preoperative protocol adopted for mandibular CAD-CAM reconstruction. Wide cutting sections were planned to obtain radical debridement. The tailored custom-made plate, a 3D rendering of bone defect and the cutting guides were produced and sterilized. Surgical intervention was conducted by steps (medial approach, bone resection, recipient vessels isolation, fibula harvesting and cutting, plate-fibula construct assembly, microvascular anastomosis, final fixation).

Results: The mean follow-up was 13 (12-15) months. Bone union was achieved in both cases at mean 3.1 months. Full weight bearing without referred pain or discomfort was reached in both cases at mean 8,5 months (range 7-10). No complications occurred.

Conclusions: CAD-CAM technology proved to be useful and reliable in custom made medial plating combined with free fibula transfer for the treatment of distal femur nonunion after lateral locking plating.

Trial registration: none.