Journal of Hand Surgery-American Volume最新文献

Purpose: Office-based surgery, is a safe, well-tolerated option associated with high patient satisfaction. However, some patients remain hesitant due to concerns of being awake during surgery. Preoperative anxiety may be linked to poorer postoperative outcomes. The purpose of this study was to examine patients' distress prior to, during, and following office-based hand surgery under local anesthesia and to identify patient variables associated with distress.

Methods: This study included 57 patients, 19 of whom had a history of anxiety and/or depression. Each patient completed the Amsterdam Preoperative Anxiety and Information Scale (APAIS) before surgery; patients completed the Subjective Units of Disturbance Scale (SUDS) before surgery, immediately after surgery, and at their first postoperative visit. They rated their SUDS with respect to the following distress domains: Being Awake During Surgery, Needlestick, Surgical Pain, and Discomfort.

Results: The average distress experienced was less than the patients' preoperative expectations across all domains, and most patients rated their experiences to be equivalent to or better than expected (81 to 96% of patients, depending on the domain). Patients with elevated APAIS scores were more likely to have less distress (a better experience) than expected compared to those who were not.

Conclusions: Average distress levels experienced were better than expected. Patients with higher APAIS had less distress (better experiences) than they expected.

Type of study/level of evidence: Prognosis II.

Nerve transfers have re-emerged in the past several decades as a powerful tool for restoration of neurological function and are an essential part of peripheral nerve surgical practice. There is extensive literature describing outcomes from nerve transfers for the restoration of motor nerve function and describing the complication profile. Recently, interest and use of nerve transfers for restoration of sensation has increased. In this review, we highlight the limitations of the current literature on outcomes from sensory nerve transfers and showcase potential complications from their use, particularly related to use of the superficial branch of the radial nerve as a donor sensory nerve.

Purpose: Pain, allodynia, and stiffness in complex regional pain syndrome (CRPS) greatly affects social, vocational, and community engagement. The aim of this study was to evaluate the effect of isolated median nerve releases on the outcome of CRPS 1 of the hand.

Methods: In this prospective case series, people of any age diagnosed with and treated for CRPS 1 of the upper limb attending the author's practice were consecutively recruited. All were self-referrals dissatisfied with the treatment provided previously. Only patients who had been treated with nerve release to control their symptoms were included. Primary outcome measures were pain and Disabilities of the Arm, Shoulder, and Hand score. A secondary outcome was withdrawal from pain medication. Full resolution was defined as 0 pain, on a scale of 0-10, and total withdrawal from pain medication at the latest follow-up.

Results: Between January 2018 and December 2022, 82 participants with CRPS 1 of the hand for an average of 20 months were evaluated. Eighty-five nerve releases were performed. As per protocol, carpal tunnel release was performed in all, and three patients also received an endoscopic pronator release. Minor procedures unrelated to the pain were carried out concomitantly in 17 patients. Significant improvements were observed in pain score (mean 8.9 ± 1.2 at baseline vs 0.6 ± 1.8 at 35 months) and in Disabilities of the Arm, Shoulder, and Hand score (82 ± 13 vs 13 ± 20) for the same period. Five patients (6%) were considered failures. In contrast, 65 patients (79%) had full resolution of their symptoms.

Conclusions: This study demonstrates that a large percentage of patients diagnosed with and treated for CRPS type 1 can have full resolution of their symptoms with carpal tunnel release. Future research is needed to understand the pathophysiology and the failures.

Type of study/level of evidence: Therapeutic II.

The widespread availability of administrative claims data has unlocked opportunities to answer challenging clinical questions in hand surgery, overcoming the limitations of traditional data sets. Researchers are taking advantage of claims data sets to obtain samples from broader segments of the population and achieve statistical power that was previously unattainable. Therefore, a basic understanding of claims database research is quickly becoming an invaluable tool in the surgeon's toolkit, enabling the performance of ground-breaking research and the critical evaluation of data-driven results to inform clinical practice. We provide an overview of methodological approaches to claims data analysis for hand surgery and a roadmap for analyzing and interpreting these studies in clinical practice.

Purpose: The role of corticosteroid injection for radial tunnel syndrome (RTS) has not been studied in a placebo-controlled clinical trial. The present clinical trial aimed to evaluate the effect of local triamcinolone injection on pain intensity, upper-extremity disability, and elbow function of patients with RTS.

Methods: Forty-nine patients clinically diagnosed with RTS were randomized into the intervention and placebo groups. The diagnosis of RTS was made based on the following criteria: activity-related pain, maximal tenderness 3 to 5 cm distal to the lateral epicondyle, pain that worsens with forearm supination, pain radiating to the dorsoradial aspect of the forearm, and a positive Lister test. To confirm RTS, patients needed to exhibit at least four of these five criteria, with the requirement that one of the criteria be the tenderness located 3-5 cm distal to the lateral epicondyle. Patients in the intervention group received local injection of a single dose of corticosteroid (0.25 mL lidocaine 1% and 1 mL triamcinolone 40 mg/mL), and the placebo group received injection of single dose of normal saline (0.25 mL lidocaine 1% and 1 mL normal saline). The clinical outcomes, including QuickDASH (Disabilities of the Arm, Shoulder, and Hand), visual analog scale for pain, and Oxford Elbow Score, were evaluated before treatment, as well as 2 weeks and 3 months after the injection.

Results: Visual analog scale pain score, QuickDASH score, and Oxford Elbow Scores were similar between the intervention and placebo groups at 2 weeks and 3 months of follow-up. However, reduction in visual analog scale pain, QuickDASH score, and Oxford Elbow Scores were statistically significant over time among both groups.

Conclusions: Triamcinolone injection does not have any superior effect on the clinical outcomes of patients with RTS, compared with placebo.

Type of study/level of evidence: Therapeutic II.

Purpose: The purpose of this study was to conduct a systematic review evaluating the reported complications and outcomes of bone-anchored prostheses in digit and partial hand amputees.

Methods: A literature review of primary research articles on osseointegration and bone-anchored prostheses for digit and partial amputees was performed. The Medline, Embase, Scopus, and Cochrane Library databases were queried. Inclusion criteria were journal articles that evaluated osseointegration and bone-anchored prostheses in digit and partial hand amputees. The main outcome measures were reported complications and the need for revision surgery. Secondary outcomes included all reported outcome assessments.

Results: Fifteen articles were included with publication dates ranging from 1996 to 2022. The sample sizes ranged from single-patient case reports to a 13-patient retrospective study. Overall, 33 men and 16 women were reported with a mean age of 33.6 years (range: 12-68) and a total of 71 amputated digits. The median follow-up was 2.1 years (IQR: 1.1-6.8 years). A total of 24 complications were reported in 14 digits (19.7%). Complications included superficial infection in 6 digits (8.5%), abutment loosening or failure in 5 (7%), fixture aseptic loosening in 4 (5.6%), deep infection in 1 (1.4%), and soft tissue instability in 1 (1.4%). Sixteen revision surgeries or component changes were reported.

Conclusions: Bone-anchored prostheses using osseointegrated implants in the hand are associated with favorable outcomes in the limited number of low-quality studies available for review. Superficial infections and implant-related failures were the most frequently reported complications.

Type of study/level of evidence: Systematic review IV.

Purpose: The objective of this study was to describe potential working portals positioned directly over the extensor carpi ulnaris (ECU) tendon and assess their safety in relation to the dorsal branch of the ulnar nerve (DBUN).

Methods: A descriptive anatomical study was conducted on 15 fresh human cadaver upper limbs. Five distinct portals over the ECU were examined, and the shortest distances from these portals to the DBUN were measured. Additionally, three distances from two portals and the ulnar styloid to the point where the DBUN crosses the ECU tendon were assessed.

Results: The measurements of the distance to the DBUN from the portal at the level of the ulnocarpal joint (UCJ) from the proximal ECU (PECU) portal and from the portals located two and three centimeters proximal to the PECU indicate that no distances fell within the high-risk category (less than 3.5 mm). Measuring from the portal at the level of the UCJ to the DBUN, only one specimen fell within the medium-risk range (3.5-4.5 mm). However, in the rest of the previously described portals, all measurements corresponded to a low-risk range (more than 4.5 mm). The measurements from the distal ECU (DECU) portal to the DBUN revealed that 4 of 15 specimens had a distance less than 3.5 mm (high-risk range), whereas 2 of 15 fell within the medium-risk range.

Conclusions: Proximal portals are safer and present a lower risk of nerve injury. Three distinct zones have been defined along the ECU based on their safety characteristics. The "green zone" is the safest area, situated 1 cm proximal to the 6R portal. The "yellow zone" encompasses the area extending from 1 cm proximal to 0.5 cm distal to the 6R portal. Finally, the "red zone" is located 0.5 cm distal to the 6R portal.

Clinical relevance: For arthroscopic procedures involving the ECU, additional portals may be necessary. This anatomical study may be valuable in developing and implementing surgical techniques tailored for ECU pathology.

Purpose: The surgical management of adult traumatic brachial plexus injuries (BPI) is challenging, with no consensus on optimal strategies. This study aimed to gather preferred reconstructive strategies from BPI surgeons for actual cases from a multicenter cohort to identify areas of agreement.

Methods: Four case files (history, physical examination, and imaging and electrodiagnostic testing results) were distributed to eight self-designated Level IV expert BPI surgeons in the United States. Each surgeon independently reviewed the cases and provided a preferred reconstructive plan via free text response.

Results: For a pan-plexus case after blunt trauma (67 years old; 3 months from injury): three surgeons recommended nerve grafting upper trunk roots to distal targets. There was disagreement in shoulder reconstruction: one suggested early shoulder fusion, two preferred cranial nerve XI to suprascapular nerve (SSN) transfer, and two anticipated future salvage shoulder fusion. For elbow reconstruction, six surgeons preferred intercostal nerve to musculocutaneous nerve transfer. For an upper trunk injury from a motorcycle accident (33 years old; 6 months from injury), only one surgeon recommended nerve grafting, six preferred XI to SSN transfer, all recommended triceps-to-axillary transfer, and all but one favored a double fascicular transfer.

Conclusions: There is inconsistency in the use of nerve grafting for BPI patients, especially in pan-plexus injuries where options are limited. Variability exists in shoulder reconstruction and stability management, with some advocating early glenohumeral arthrodesis. Although single fascicular and triceps-to-axillary transfers are consistently favored, there is no consensus for restoring shoulder and elbow function when intraplexal transfers are unavailable.

Clinical relevance: This study highlights substantial variability in surgical approaches to BPI among experts, underscoring the need for standardized treatment protocols. Understanding these diverse strategies can inform clinical decision making and help develop more uniform guidelines to improve patient outcomes.

Purpose: Peripheral neuropathies are commonly occurring conditions that are chronic and debilitating for patients. Established nonsurgical treatments have yielded mixed and patient-dependent results. Although cannabinoids have demonstrated efficacy as a treatment for central neuropathic pain, the therapeutic potential of cannabis-based medications for the management of peripheral neuropathic pain caused by nerve injury, trauma, and other noncompressive etiologies has yet to be definitively established. This study aims to determine whether cannabinoids are a potentially effective treatment for pain and symptoms associated with peripheral neuropathy.

Methods: A systematic search was conducted by two independent reviewers across PubMed, Cochrane, Ovid Medline, and CINAHL to identify studies in accordance with the predetermined inclusion/exclusion criteria. Information regarding study design, medication, dosage, effect on neuropathic pain, and other related outcomes was extracted. Meta-analysis of pain scores was performed for seven studies, and descriptive statistics were used to summarize other study findings as appropriate.

Results: Of the 927 studies identified, 14 randomized controlled trials were included. Thirteen of 14 studies (79%) observed a statistically significant decrease in neuropathic pain score following treatment with a cannabinoid. Meta-analysis yielded a mean difference of -0.67 [-0.89, -0.45]) on a 0-10 scale compared with placebo. Improvements in secondary outcomes such as sleep, sensory symptoms, and quality of life were observed.

Conclusions: Our analysis of the literature shows that cannabis-based medicines may be effective in treating the pain and symptoms of peripheral neuropathy. These findings suggest the applicability of cannabis-based medicines for peripheral neuropathy.

Type of study/level of evidence: Therapeutic IV.

Radiation induced brachial plexopathy represents a constellation of symptoms that present in a delayed manner because of peri-plexus progressive fibrosis or direct neural injury with demyelination. Symptom onset is typically delayed months to years after radiotherapy. Patients may report neuropathic pain, weakness, or extremity dysfunction associated with morbidity and diminished quality of life. Reported surgical interventions include plexus neurolysis, nerve transfers, and vascularized free tissue transfer. In this review, we aim to present the practicing hand surgeon with an update and analysis on the current state of the radiation induced brachial plexopathy literature.