Journal of Hand Surgery-American Volume最新文献

Purpose: Hand trauma is a challenge to triage and manage, especially in rural states, because of the relative paucity of fellowship-trained hand surgeons and equipped treatment centers. Since the establishment of the Arkansas Hand Trauma Telemedicine Program (AHTTP) in 2014, early data suggest a successful reduction in hospital transfers for hand trauma. The purpose of this economic and decision analysis study was to perform a comprehensive, longer-term analysis describing trends in emergency medical service (EMS) transfer rate for hand trauma in Arkansas in relation to the establishment of AHTTP. Secondary end points included estimated health care cost savings and geographic distribution of consults.

Methods: Data from all AHTTP encounters were used to conduct trend analyses in program utilization and interfacility transfers from 2013 to 2023. Cost savings were estimated based on Arkansas Medicare fee schedules. Consult origins were mapped to observe geographic distribution.

Results: The AHTTP facilitated 7,260 remote hand trauma consults in its first decade. The rate of EMS ground transfer for consults placed via the AHTTP considerably decreased from 44.9% to 33.2% during the study period and as low as 28.8% in 2022. Transfer rates were markedly lower compared with prior to the system's inception when the EMS transfer rate for hand trauma was 72.6%. The incidence of air ambulance fell from a maximum of 31 in 2016 to three in 2021. An estimated 2,519 EMS ground and 156 EMS air transfers were saved, roughly correlating to a cost savings of $12,200,000. A geographically diverse distribution of consults was observed.

Conclusions: The AHTTP has notably decreased the overall rate of transfer for management of hand trauma across Arkansas, including EMS ground and air transfer, saving patients and taxpayers an estimated $12.2M and increasing availability of local emergency medical resources.

Type of study/level of evidence: Economic and decision analysis, IV.

Purpose: The purpose of this study was to investigate the psychometric properties of a 2-dimensional artificial intelligence (AI) camera software application (app) for range of motion measurements in the upper extremity. We hypothesized that the 2-dimensional AI-camera app would have excellent inter-rater reliability and high concurrent validity with manual goniometry.

Methods: Fifty patients were prospectively recruited. Patients aged 18-75 years with upper-extremity pathology and no immobilization were eligible for inclusion. For each patient, 27 range of motion measurements were performed, beginning with manual goniometer measurement by a fellowship-trained hand surgeon (MD) and then the 2-dimensional AI-camera app. The primary outcomes were the inter-rater reliability of the measurements (intraclass correlation coefficient [ICC]) and concurrent validity (proportion of measurements falling within the clinical agreement parameters) between raters. The measurement time was recorded.

Results: The mean patient age was 49.2 years. The overall inter-rater reliability was excellent (ICC 0.99; 95% CI 0.98 to 0.99). Forearm pronation, forearm supination, and wrist extension were the only range of motion measurements without excellent inter-rater reliability (ICC < 0.9). Bland-Altman analysis showed that 81% (22/27) of motions had high concurrent validity, with low concurrent validity seen with forearm supination, wrist extension, long finger total active motion (TAM), ring finger TAM, and small finger TAM. The mean time to completion of all measurements using the 2-dimensional AI-camera app was 60 seconds, compared to 273 seconds by the MD.

Conclusions: The 2-dimensional AI-camera app demonstrated excellent inter-rater reliability and high concurrent validity for the majority of motions; however, the reliability and validity were both lower for forearm supination and wrist extension.

Clinical relevance: In upper extremities with pathologic conditions, the overall reliability and validity of the 2-dimensional AI-camera app render it potentially useful to providers in the clinic or as a remote monitoring tool, with limitations in the consistency and accuracy of certain motions.

Purpose: To investigate patient-reported symptom relief day-by-day and the use of postoperative analgesics after open trigger finger release. The primary outcome of this study was the number of days to resolution of pain. Secondary outcomes were the use of analgesics and the number of days to complete resolution of stiffness and triggering.

Methods: In this prospective, multicenter cohort study, a total of 107 adult patients with clinically diagnosed trigger finger were included. Patients recorded daily visual analog scale scores for pain and any presence of residual stiffness and/or triggering for 6 weeks after surgery. Daily use of analgesics was also documented.

Results: Ninety-nine patients (92.5%) sent in follow-up forms. Three patients (2.8%) sent in incomplete forms, leaving 96 with complete data (90%). At the 6-week follow-up, 61 patients (64%) reported complete relief of all symptoms. The median number of days to total symptom relief was 11 days for pain (range 1-39, n = 74), 12 days for stiffness (range 11-39, n = 64), and instant relief of triggering after surgery (range 1-36, n = 77). Median number of days for analgesics usage was 1 for paracetamol and 0 for ibuprofen; 19 patients (20%) did not take any analgesics.

Conclusions: Open release is an effective treatment for trigger finger with limited need for nonprescription drugs, since almost all patients reported full resolution of triggering within 6 weeks, and analgesic use was minimal. However, 23% of the patients reported persisting pain and 33% residual stiffness at 6 weeks, indicating that the recovery process is longer than expected.

Level of evidence: Therapeutic 2b.

Purpose: A robust suture technique is essential to permit early mobilization after flexor tendon repair. It requires sufficient contact between two lacerated tendon ends. However, the core suture knot, which is embedded commonly between these two ends in many repair techniques, impedes the contact of tendon ends and possibly hinders tendon healing. This study aimed to identify the biomechanically optimal location for the core suture knot embedded outside the junction of lacerated tendon ends in a modified Kessler repair.

Methods: Two canine flexor digitorum profundus tendons were used to exhibit the proportion of cross-sectional area occupied by the suture knot. Forty canine flexor digitorum profundus tendons were repaired using a modified Kessler technique with the core suture knot embedded in various locations. The gliding properties and repair strength of the repaired tendons were investigated.

Results: A knot of 4-0 core suture occupied approximately 24% of the tendon's cross-section. The repaired tendons with the core suture knot embedded in the volar side demonstrated larger gliding resistance and greater work expenditure than those with the core suture knot placed between the lacerated tendon ends or embedded in the radial or dorsal side of the tendon during the identical cycles of repeated gliding. Moreover, the dorsal embedding of the core suture knot resulted in an increase of load for 2-mm gap formation and ultimate load relative to the other locations.

Conclusions: The biomechanically optimal location of the core suture knot in a modified Kessler repair was under the dorsal surface of flexor tendon.

Clinical relevance: The embedding of the core suture knot in the dorsal side could facilitate the early postoperative mobilization and the healing of repaired flexor tendon.

Scapholunate (SL) ligament injuries are a common cause of wrist pain and instability but can be diagnostically challenging. Standard radiographs, ultrasound, computed tomography, and magnetic resonance imaging have been used for many years to assist in the diagnosis of these injuries, and all of them have benefits and limitations. Advanced dynamic modalities, such as real-time magnetic resonance imaging and four-dimensional computed tomography, can distinguish functional from static injuries but are not widely available. The emergence of artificial intelligence applications is promising to improve diagnostic accuracy in automated SL gap detection and kinematic analysis. As each imaging modality presents strengths and trade-offs in terms of invasiveness, resolution, and dynamic assessment, combining imaging with thorough clinical examination remains essential. This current concepts review summarizes modern imaging techniques for SL ligament injuries and highlights emerging innovations.

Purpose: Pantrapezial osteoarthritis affects the trapeziometacarpal (TMC) and scaphotrapezial-trapezoid (STT) joints, causing pain, functional loss, and sometimes necessitating surgery. Among the various reconstructive options available for pantrapezial osteoarthritis, trapeziectomy and ligament reconstruction with tendon interposition have consistently yielded favorable long-term outcomes in many series. However, implant arthroplasty remains a valuable alternative for selected patients. This study evaluated a dual-prosthesis approach designed to preserve carpal stability and optimize thumb function.

Methods: This retrospective study included 41 patients with advanced pantrapezial osteoarthritis who underwent simultaneous TMC and STT prosthesis implantation. Functional outcomes were assessed using grip strength, pinch (tip and key), strength, range of motion, and the Kapandji score. Patient-reported outcomes were measured using the QuickDASH and Patient-Rated Wrist Evaluation scores. Complications and revision rates were documented.

Results: The mean follow-up period was 48 months. Grip strength reached 95% of the contralateral side; tip and key pinch strengths reached 100%, with no decline over time. Range of motion and Kapandji scores improved significantly from preoperative values. High patient-reported outcome scores were recorded (QuickDASH 9; Patient-Rated Wrist Evaluation 9), indicating satisfactory recovery in terms of hand use and pain. No instability was observed, and the complication rate was low.

Conclusions: Simultaneous TMC and STT prosthesis implantation offers a possibly promising solution for pantrapezial osteoarthritis, overcoming biomechanical limitations of prior techniques. By preserving carpal stability and thumb function, this approach achieves favorable functional outcomes and a low complication rate, making it a potentially superior alternative for patients with high functional demands or those requiring durable long-term results.

Type of study/level of evidence: Therapeutic IV.

Purpose: The purpose of this study was to evaluate whether total wrist arthroplasty (TWA) component alignment affects wrist range of motion (ROM), component impingement, and tendon forces.

Methods: Six fresh frozen cadaver wrists were moved through five wrist motions before and after implantation of the KinematX TWA using a "refined alignment" strategy: the radial component was aligned parallel to the longitudinal axis of the forearm in the coronal plane, and the carpal component colinear with the ulnar cortex of the long finger metacarpal shaft. Comparisons were made to a prior study that tested six specimens with "classic alignment": the radial component was aligned parallel to the distal radial shaft axis, and the carpal component colinear with the long finger metacarpal shaft. Maximum wrist ROM and tendon forces were compared before and after implantation.

Results: When comparing wrist ROM between classic and refined alignments after TWA implantation, there were no significant differences in wrist flexion with either neutral or free radioulnar deviation. With the refined alignment, there was a significant increase in wrist extension at both neutral and free radioulnar deviation. There was also greater radial and ulnar deviation with the refined alignment. Only one of the six refined alignment specimens impinged in maximum radial deviation, compared with four of the six classic alignment specimens. There was no significant increase in the tendon forces during any of the five wrist motions after TWA using the refined alignment.

Conclusion: Aligning the TWA radial component in line with the forearm axis and the carpal component in line with the ulnar cortex of the long finger metacarpal shaft increased wrist extension and radial and ulnar deviation, resulting in less component impingement.

Clinical relevance: This study demonstrates the importance of implant alignment on wrist ROM and component impingement, informing both surgeons and implant designers on the refinement of surgical technique.