Journal of Hand Surgery-American Volume最新文献

Purpose: There is a lack of comprehensive data concerning the prevalence of surgically treated peripheral nerve injuries (PNIs) and associated financial burden within the United States. Our purpose was to determine incidence of operatively managed major mixed upper-extremity PNIs and to quantify direct payments for PNI surgical intervention.

Methods: We analyzed administrative data from the Merative MarketScan Commercial Database and the Multi-State Medicaid Database from 2016 to 2022, focusing on adults aged 18-64 with surgically managed PNIs. Incidence, demographics, and direct payments within the first year postsurgery were examined. We used descriptive statistics to summarize payment data and the Mann-Kendall test to assess trends in annual incidence rates from 2016 to 2022.

Results: There were 5,735 patients and 2,917 patients in the commercial and Medicaid databases, respectively, who met inclusion criteria. The incidence of surgically managed PNIs in the commercial insurance population remained relatively stable, averaging 3.73 per 100,000 individuals annually. In the Medicaid population, incidence increased from 2.8 to 4.4 per 100,000 insured individuals between 2016 and 2022. Among patients with 365 days of continuous enrollment, mean total payments over 1 year were $31,840.55 in the commercial data set and $27,517.00 in the Medicaid data set. At 30, 90, and 180 days, mean total payments were $16,759.69, $20,367.30, and $24,537.40 for commercially insured patients as well as $10,443.09, $13,892.63, and $17,536.23 for Medicaid patients, respectively; these payments represent interval-specific averages, not cumulative payments.

Conclusions: The incidence of surgically treated PNIs is stable in the commercially insured but is rising in the Medicaid-insured population. Of the patients who remained insured in the year after injury, there were ongoing direct payments, highlighting the persistent claims-based financial footprint associated with PNI. These estimates reflect only direct payments and do not assess cost-effectiveness or broader societal costs but serve as a foundation for future investigations.

Type of study/level of evidence: Economic/Decision Analysis IV.

Purpose: Bennett fractures are inherently unstable intra-articular fractures of the first metacarpal base and are subject to multiple deforming forces. Suboptimal treatment can lead to fracture displacement, malunion, and post-traumatic arthritis of the carpometacarpal joint. The purpose of this study was to evaluate three fixation techniques for the stabilization of Bennett fractures. Our hypothesis was that screw fixation would be stiffer than the other methods.

Methods: Thirty fresh frozen cadaver hands were obtained. Bennett fractures were created by a fellowship-trained hand surgeon. Specimens were then randomized to fixation with one of three techniques: two 1.2 mm (0.047 in) Kirschner wires (K-wires), two 1.2 mm cortical lag screws, or a single 1.7 mm (0.067 in) headless compression screw with a minisuspensory cortical button construct (suture-button/screw). The specimens were loaded in displacement-controlled axial compression until failure. Radiographs were taken before and after testing to compare the final displacement and method of failure. Interfragmentary motion and applied load were recorded. The maximum force and relative motions of the first metacarpal and Bennett fragment were filtered and calculated.

Results: The median force to failure for screw, K-wire, and suture-button/screw were 166.6 N (38.9-590.3), 98.4 N (41.9-444.0), and 97.5 N (24.5-242.6), respectively, with no significant differences between constructs. Similarly, there were no significant differences in median displacement measured in three-dimensional space (5.7 mm (1.6-8.4), 5.7 mm (1.9-11.5), and 6.1 mm (3.9-17.9), respectively, or stiffness (37.2 N/mm (5.6-345.0), 22.8 N/mm (2.0-113.8), and 14.3 N/mm (5.5-285.9), respectively, between the groups.

Conclusions: All three methods of Bennett fracture fixation performed similarly at time zero in this in vitro biomechanical study.

Clinical relevance: The results of the present study may be taken into consideration along with patient factors and fracture characteristics when treating Bennett fractures.

The regionalization of trauma care has resulted in improvement of patient outcomes by triaging complex injuries to tertiary and quaternary hospitals with more resources, greater availability of subspecialty care, and higher case volumes. Undertriage of complex patients is associated with poor patient outcomes and mortality. Conversely, overtriage, defined as the overestimation of injury severity and unnecessary transfer to a higher level of medical care, risks overburdening higher trauma tier hospitals, can create a bottleneck effect of scarce resources and personnel, and may impede access for other critically ill patients. The increasing burden is borne by these trauma centers, which is more concerning, given the current trend of fewer practicing hand surgeons taking hand call. The medical decision to transfer a patient from a local hospital to a higher-tier hospital is a complex, shared decision between providers, and this is generally subject to time constraints with limited information regarding the patient's injuries. Furthermore, previous research has demonstrated that nonmedical factors often considerably influence the decision to transfer, including insurance status, Black race, and presentation to a local emergency department during night or weekend hours. This article discusses a number of ethical concerns that arise in the consideration of interhospital transfers of hand surgery patients and implications for practicing hand surgeons on both the referring and receiving sides. The main focuses of the article include the following: (1) the regionalization of hand trauma care; (2) the harms of undertriage; (3) the practical problems with overtriage; (4) viewing through the lens of principalism; and (5) recommendations for the path forward.

Purpose: Kienböck disease (KD), osteonecrosis of the lunate, has an unclear etiology. While there is a strong and clear association between KD and negative ulnar variance (UV), it is likely not the only mechanical factor. The capitate, which has a large joint surface with the lunate, may play a role in KD pathogenesis. This study investigated the association between capitate morphology and KD. We classified the capitate into three types based on the angle and length ratio of the capitotrapezoid (CT) and scaphocapitate joint lines: type I (short, vertical CT facet), type II (pentagonal with a large, oblique CT facet), and an intermediate type. We hypothesized that type II capitate increases capitate-lunate loading, leading to a higher incidence of KD.

Methods: A case-control study was conducted, including 80 KD patients who underwent surgery between 2019 and 2024 and 467 controls with radiographs from suspected scaphoid fracture cases. Demographic data, UV, and capitate type were analyzed.

Results: The prevalence of type II capitate in the control group was 18%. Patients with KD had considerably higher rates of negative UV (35% vs 7%) and type II capitate (30% vs 18%) compared to the control group. Among 488 non-negative UV patients and 59 negative UV patients, type II capitate remained more common in the KD group (42% vs 17%). Multivariable analysis confirmed negative UV (OR = 9.2, 95% CI: 4.8-17.4) and type II capitate (OR = 2.7, 95% CI: 1.5-5.0) as independent risk factors for KD.

Conclusions: Our study introduces a radiographic classification of capitate morphology and establishes its association with KD. These findings suggest that, beyond negative UV, type II capitate is an associated factor, warranting further research into its mechanical and vascular role in KD pathogenesis.

Type of study/level of evidence: Diagnostic III.

Purpose: This study compared the clinical effectiveness and safety of single-stage fasciectomy versus a two-stage approach for the treatment of severe proximal interphalangeal joint contractures in Dupuytren disease. The two-stage approach involves first using an external extension torque device (EETD) to correct the deformity, followed by removal of the device and fasciectomy at the second stage. We sought to determine whether the staged approach would (1) improve intraoperative correction and reduce residual contracture, (2) decrease operative time for fasciectomy, and (3) reduce complications in the short to mid-term.

Methods: We performed a retrospective cohort study of patients with proximal interphalangeal joint contractures of 70° or greater treated at a single center. Fifty-two patients (54 digits) underwent single-stage fasciectomy, whereas 23 patients (23 digits) received a two-stage approach using the EETD for 6-10 weeks followed by fasciectomy. Primary outcomes included immediate postoperative correction and residual flexion contracture, operative time, and perioperative complications. Measurements were taken before surgery, immediately after surgery, and at final follow-up.

Results: The staged approach provided considerably greater intraoperative correction (86° vs 69°) and lower immediate residual contracture (2° vs 15°) compared with the single-stage procedure. At final follow-up (mean 31 weeks, median 13 weeks, range 10-192), residual contracture did not differ between groups (32° vs 31°). Operative time for fasciectomy was considerably shorter in the two-stage group (80 vs 120 minutes); however, total surgical time was similar. Major complications occurred more frequently in the single-stage group, at roughly twice the rate observed in the two-stage group.

Conclusions: Staging with the EETD led to improved immediate correction and shorter fasciectomy time. Major complications occurred at roughly half the rate in the staged group, suggesting a potential safety advantage, although the study was underpowered for complication analysis. Final residual contracture did not differ between groups, but this outcome was also underpowered, leaving the long-term effectiveness of the staged approach uncertain.

Type of study/level of evidence: Therapeutic IV.

Purpose: This study compared lunate morphology on wrist radiographs from patients with scaphoid fractures with those from a control group without scaphoid fractures.

Methods: Patients with scaphoid fractures diagnosed between 2015 and 2023 were reviewed retrospectively. Wrist radiographs were assessed to determine lunate morphology, capitate-triquetrum distance, and scaphoid fracture location. The lunate morphology was assessed according to both the midcarpal (Viegas classification) and radiocarpal (Antuña-Zapico classification) joints. The results were compared with 200 control wrist radiographs without scaphoid fractures.

Results: The distribution of lunate morphology according to the Viegas classification revealed type II lunates in 64% (212/331) of scaphoid fractures compared with 34% (68/200) in controls. In contrast, radiocarpal-based lunate morphology showed no between-group difference. The capitate-triquetrum distance was higher in the scaphoid fracture group than in controls. Within the scaphoid fracture group, no association was observed between lunate morphology, capitate-triquetrum distance, and fracture location.

Conclusions: Lunates with a medial hamatolunate facet (type II) were more frequent among patients with a scaphoid fracture than in controls, and the capitate-triquetrum distance was also higher in the fracture group. By contrast, radiocarpal-based lunate morphology was not associated with scaphoid fracture.

Type of study/level of evidence: Prevalence IV.

Purpose: Patient-reported outcome measures (PROMs) reported within the hand and upper extremity (UE) field are not standardized. The ability to compare or combine cohorts using different PROMs is limited by the use of a variety of outcome measures. This study aimed to develop a linkage for the PROMIS UE CAT v2.0 and the brief Michigan Hand Questionnaire (bMHQ) to allow interconversion between these PROMs in a hand surgery population.

Methods: A retrospective review identified patients at a single academic tertiary care center who had completed PROMIS UE CAT v2.0 and the bMHQ instruments at the same clinical encounter. Minors and patients with elbow pathology were excluded. Only one randomly selected visit was included in the analyses for patients with multiple visits. Strength of the relationship between scores was evaluated using Pearson and Spearman correlation coefficients. Score linkage was performed using common linking methods. Linkage quality was assessed using intraclass correlation coefficients and R squared comparing the linked scores with the observed. Subgroup analysis was performed based on age (<60 or ≥60 years) and the Area Deprivation Index.

Results: A total of 7,269 patients were included. Mean PROMIS UE CAT v2.0 and bMHQ scores were 37 (SD = 11) and 54 (SD = 21), respectively. There was a strong positive correlation between the UE CAT v2.0 and bMHQ (Spearman r = 0.70). The equipercentile equating linkage model demonstrated strong performance (intraclass correlation coefficient = 0.69, R² = 0.39), and crosswalk tables were developed from this model. Subgroup biases of the linkage model were small, indicating that linking relationships were similar for older age and low area deprivation index.

Conclusions: The PROMIS UE CAT v2.0 and bMHQ scores were successfully linked. Crosswalk tables allow for bidirectional score interconversion between these outcome measures.

Clinical relevance: This crosswalk study allows for conversion of scores between two commonly used PROMs.

Purpose: The effectiveness of ligament reconstruction for chronic traumatic thumb carpometacarpal (CMC) instability is debated because of concerns of trauma-induced cartilage damage affecting postoperative results. This study aimed to assess patient- and clinician-reported outcomes of ligament reconstruction in these patients.

Methods: This study included patients with chronic traumatic CMC instability undergoing various ligament reconstruction techniques. The visual analog scale (range 0-100) for pain and the Michigan Hand Outcome Questionnaire (MHQ, range 0-100) scores at intake were compared to those at 3 and 12 months and at long-term follow-up. Secondary outcomes included grip and pinch strength, range of motion, complications, and patient satisfaction. A linear mixed model was used to analyze which variables influence postoperative MHQ pain scores.

Results: Forty-three patients were included with a mean follow-up of 8 years (range, 3.2-12.5). The visual analog scale pain score significantly improved from 60 (95% CI, 53-67) at intake to 26 (95% CI, 18-33) at 12 months, remaining consistent over long-term follow-up. The MHQ total, pain, and function scores also improved considerably. All thumbs were stable after surgery with preserved range of motion. Grip and pinch strength notably improved. One patient progressed to osteoarthritis during follow-up. The dorsal ligament reconstruction technique was a predictor of worse postoperative MHQ pain scores.

Conclusions: Patient- and clinician-reported outcomes considerably improved postsurgery, affirming ligament reconstruction as a viable treatment for chronic traumatic CMC instability. The dorsal ligament reconstruction technique should be approached with caution.

Type of study/level of evidence: Therapeutic IV.