Journal of Hand and Microsurgery最新文献

Background  Distal radius fractures (DRF) are the second most common fragility fracture experienced by the elderly, and surgical management constitutes an appreciable sum of Medicare expenditure for upper extremity surgery. Using Medicare data from 2012 to 2017, our primary aim was to describe temporal changes in surgical treatment, physician payment, and patient charges for DRF fixation. Methods  We examined surgical volumes and retrospective patient charge (services billed by surgeon) and surgeon payment (professional fee) data from 2012 to 2017 for four DRF surgeries: closed reduction percutaneous pinning (CRPP), open reduction internal fixation (ORIF) of extra-articular fractures, ORIF of intra-articular (IA) (2-fragment) fractures, and ORIF of IA (> 3 fragments) fractures. The reimbursement ratio was defined and calculated as the ratio of charges to payment. Rates were adjusted for inflation using the annual consumer-price index. Results  For these four surgeries from 2012 to 2017, total patient charges grew by 64% from $117 to 193 million, while surgeon payment grew by 42% from $30 to 42 million. CRPP cases fell by 47%, while ORIF increased by 17, 14, and 45% for extra-articular, IA (2-fragment), and IA (> 3 fragments) surgeries, respectively. After adjusting for inflation, payment to physicians increased by more than or equal to 16% for all procedures except for CRPP, which fell by 2%. Charges during this same period increased from 13 to 38%. Reimbursement ratios declined from -9.2% to -13% for each procedure. Conclusion  From 2012 to 2017, while charges have outpaced surgeon payment, payment has outpaced inflation for all forms of distal radius ORIF, aside from CRPP. There has been a continued sharp decline of CRPP. Level of Evidence is III, economic.

Coverage of posttraumatic and chronic wounds at the distal leg is a difficult problem due to limited soft tissue available for local flaps. The sural flap is a versatile and effective method for reconstruction in this area since it does not need a significant amount of time or assistance to complete. Improving the survival of these flaps is critically dependent on understanding the basics of flap circulation and why recent modifications were introduced. This review will serve as a much-needed comprehensive analysis of these topics for surgeons looking to increase the reliability of their sural flaps.

We report a case of chronic scapholunate ligament insufficiency in a patient with scaphocapitate coalition. After more than 4 years of mild symptoms, there was no radiological evidence of progression to scapholunate advanced collapse in spite of minimal load-bearing repetitive physical activities undertaken by the patient as a professional guitarist. We believe that scaphocapitate coalition could contribute to mitigate the progression to scapholunate advanced collapse by preventing abnormal flexion of the scaphoid once the ligament is not competent anymore. The biomechanical and surgical implications of this type of carpal coalition are also discussed.

Objectives  Flap surgery using a wide awake local anesthesia no tourniquet (WALANT) technique has historically been avoided because of technical challenges and concerns regarding the vasoconstriction caused by the necessary injection of epinephrine alongside the local anesthetic. The objective of our work was to evaluate the viability of the hand flaps performed using a WALANT technique compared with those performed under regional with a tourniquet. Materials and Methods  Seventy-four patients were enrolled in a prospective comparative single-center study and subsequently divided into two groups: 36 patients in the locoregional anesthesia group and 38 patients in the WALANT group. Flap viability was evaluated on day 2 and day 10 using predetermined criteria. Results  We did not find any significant difference in outcomes assessed for flap viability between the two groups postoperatively. Conclusion  There was no evidence to suggest that vascularization of the flaps was compromised by the injection of epinephrine. The WALANT technique may, therefore, potentially be able to be safely deployed within this population.

Objective  Since 1958, more than 50 postresidency fellowship programs in hand surgery have been introduced within the United States. Ongoing changes in health care and medical education necessitate the evaluation of these fellowships. The purpose of this study is to identify trends in operative experience over time regarding procedure volume, surgery type, and anatomic region. Materials and Methods  National Accreditation Council for Graduate Medical Education (ACGME) case logs of graduating orthopaedic hand surgery fellows were evaluated for years 2011 to 2019. Procedures were grouped according to ACGME-defined categories for hand surgery. The mean number of procedures per fellow in each category was trended over time using a Mann-Kendall test. Results  All 1,257 fellows were included. The mean number of procedures completed annually by each fellow increased from 797.6 in 2011 to 945.6 in 2019 ( p  < 0.01). Over the course of the study period, there were increases in the number of "soft tissue," "fracture," and "nerve" procedures ( p  < 0.001), while the number of "congenital" procedures decreased ( p  < 0.05). Additionally, small but statistically significant increases were found in "amputation," "Dupuytren's," and "decompression of tendon sheath/synovectomy/ganglions" procedures ( p <  0.01). Conclusion  There has been an increase in the number of procedures performed by orthopaedic hand surgery fellows over the past decade. This appears to be due to the increase in nerve, fracture, and soft tissue categories, and there has been a decrease in the number of congenital cases completed. These data confirm that the operative experiences for most hand surgery fellows are robust and growing over time.

Background  Spastic joint contractures remain a complex and challenging condition. For patients with upper extremity spastic dysfunction, improving the muscle balance is essential to maximize their hand function. Multiple procedures, including proximal row carpectomy (PRC) and wrist arthrodesis (WA), are considered among the different surgical alternatives. However, the biomechanical consequences of these two procedures have not been well described in current literature. Hence, the objective of our study is to assess the change in the extrinsic digit flexor tendon resting length after proximal row carpectomy and wrist arthrodesis. Methods  Six fresh-frozen cadaver upper extremities (four females and two males) with no obvious deformity underwent dissection, PRC, and WA. All the flexor digitorum profundus (FDP), flexor digitorum superficialis (FDS), and flexor pollicis longus (FPL) tendons were marked proximally 1-cm distal to their respective myotendinous junction and cut distally at the marked point. The overlapping segment of each distal flexor tendon from its proximal mark was considered the amount of flexor tendon resting length change after PRC and WA. A descriptive evaluation was performed to assess the increment in tendon resting length. Additionally, a regression analysis was performed to evaluate the relation between the tendon resting length and the proximal carpal row height. Results  Following PRC and WA, the mean digit flexor tendon resting length increment achieved across all tendons was 1.88 cm (standard deviation [SD] = 0.45; range: 1.00-3.00 cm). A weak direct relationship ( R  = 0.0334) between the increment in tendon resting length and proximal carpal row height was initially suggested, although no statistical significance was demonstrated ( p  = 0.811). Conclusion  This study provides an anatomic description of the increased extrinsic digit flexor tendon resting length after PRC and WA in cadaveric specimens. Findings provide a useful framework to estimate the amount of extrinsic digit flexor resting length increment achieved after wrist fusion and the proximal carpal row removal.

Background  The clinical results of replantation for an amputated distal finger are functionally acceptable. However, few reports exist regarding sequential clinical postoperative recovery. The purpose of this study was to examine the clinical recovery at every 3 months up to 1 year postoperatively. Methods  Nineteen patients (16 patients were men), representing 19 fingers with complete amputation at Tamai's zone 1 and replanted successfully, were included in this study. Total active motion (TAM), grip strength (GS), Semmes-Weinstein monofilament (SW) test result, static two-point discrimination (s2PD), and Disability of the Arm, Shoulder, and Hand (DASH) score questionnaire results were obtained postoperatively at 3, 6, 9, and 12 months. Pulp atrophy and nail deformity were assessed at 12 months postoperatively. Results  The postoperative %TAM (compared to the uninjured side, 81.8 ± 18.1 at 3 months vs. 91.5 ± 11.9 at 6 months, p  < 0.01), %GS (compared with the uninjured side, 61.3 ± 25.9 at 3 months vs. 78.3 ± 20.4 at 6 months, p  = 0.02), s2PD (excellent and good/poor; 7/12 at 3 months vs. 18/1 at 6 months, p  < 0.01), and DASH scores (26.1 ± 23.1 at 3 months vs. 12.0 ± 12.9 at 6 months, p  < 0.01) recovered significantly from 3 to 6 months but did not change significantly from 6 months onward. The SW test results showed a significant recovery between 3 and 12 months postoperatively (2.83 and 3.61/4.31, 6.65, and undetectable, 1/18 at 3 months vs. 7/12 at 12 months, p  = 0.04). The DASH score at 12 months postoperatively was significantly associated with %TAM ( r  = -0.64, p  < 0.01) and %GS ( r  = -0.58, p  < 0.01) at 12 months postoperatively and age ( r  = 0.52, p  = 0.02). Five fingers had pulp atrophy and four fingers had nail deformity. Conclusion  This 1-year follow-up study showed the sequential clinical recovery after replantation for complete amputation in Tamai zone 1. Postoperative %TAM, %GS, and the DASH score recovered significantly between 3 and 6 months but significant recovery up to 1 year was not observed.

The advent of hand surgery in India reads like a fortuitous saga, a continuum of the hand deformity correction on leprosy patients pioneered by Dr. Paul Wilson Brand at the Christian Medical College (CMC) Vellore, Madras State (Tamil Nadu [TN]), in 1948. The "Hand Research Unit," established in 1951, became the largest repository for hand reconstructive surgeries and with its head-start drew in most hand dysfunctions in the country. Early industrialization and disorderly road traffic generated hand injuries that threatened workforce in India. Propitiously, a hand injury service was opened in 1971 at the Government Stanley Medical College Hospital, Chennai. The inexorable growth of hand surgery continued and incorporated the gamut of conditions that required hand care and rehabilitation, including brachial plexus injuries. Continuing Medical Education programs, Hand Surgery workshops, Indian Society for Surgery of the Hand meetings, Hand Fellowships, etc., increased the number of "hand surgery" practitioners, which drew the attention of the Medical Council of India to commence a postgraduate Hand Surgery program that it eventually gazetted. The sagacity of the members of the Board of Studies of TN Medical University honored the historical role of CMC Vellore in hand surgery and allowed it to commence the first Master of Chirurgiae Hand Surgery course in India in 2015. An intuitive understanding of 70 years of hand surgery accomplishments that redesigned and restored deformed and injured hands and protected livelihoods have made young surgeons increasingly take hand surgery as a career.

Background  Free vascularized ulnar nerve flaps (VUNF) are effective method for long nerve defects reconstruction. However, the monitorization of its microvascular circulation and the nerve regrowth can be challenging since it is usually designed as a buried flap. We designed a skin paddle based on a septocutaneous perforator from the ulnar artery that can be dissected and raised in conjunction with the vascularized ulnar nerve flap, which aims to improve postoperative monitorization to optimizing the clinical results. Methods  We retrospectively reviewed 10 cases with long nerve defects who underwent reconstruction using VUNF between June 2018 and June 2019, including eight acute brachial plexus injuries, 1 multiple nerve injury due to a rolling machine accident, and 1 sequalae of nerve injury after arm replantation. All the demographic data, surgical details, outcomes, and perioperative complications were recorded. Results  We evaluated 10 male patients, with a mean age of 34 ± 16 years. Cases included 5 antegrade, 4 retrograde, and 1 U-shaped VUNF. All chimeric skin paddles survived, and all of the underlying nerves presented with adequate circulation and functional improvement. There were no intraoperative or microvascular complications. One skin paddle had a transitory postoperative circulation compromise due to external compression (bandage) which resolved spontaneously after pressure release. Conclusion  VUNF chimerization of a septocutaneous perforator skin flap is a relatively easy and efficient method for postoperative monitorization of the nerve's microvascular circulation as well as beneficial for postoperative Tinel's sign checkup to confirm the success of the nerve coaptation. The outcome is potentially improved.