Journal of Hand Surgery-American Volume最新文献

Purpose: The branching pattern of the deep motor branch of the ulnar nerve (DBUN) in the hand is complex. The anatomy of the motor branch innervating the fourth lumbrical (4L), where paralysis results in a claw hand deformity after ulnar nerve injury, is not well defined. This cadaver study focused on mapping and defining anatomical landmarks in relation to the motor branch to the 4L.

Methods: Ten fresh-frozen cadaver hands were dissected. The DBUN was exposed and followed distally, identifying all motor branches, until the branch to the 4L was seen. The small finger flexor tendons were reflected distally to enable visualization of the entire 4L motor branch and its distal entry point. The origin of the 4L motor branch was mapped in relation to fixed anatomical landmarks in the hand.

Results: A consistent motor branch to the 4L and third palmar interosseous (3PI) muscles was seen originating from the DBUN in all specimens. The mean number of motor branches innervating the hypothenar muscles proximal to the 4L/3PI motor branch was 2.1 (range 1 to 5). The mean distance from the origin of the DBUN to the 4L/3PI motor branch was 2.9 cm (range 2.5 to 4.2 cm). The mean length of the 4L/3PI branch was 3.1 cm (range 2.3 to 4.5 cm). In seven specimens, the 4L/3PI branch demonstrated an intramuscular course through the 3PI before terminating in the 4L. In three specimens the 4L/ 3PI branch ran on the volar surface of the 3PI before terminating in the 4L.

Conclusions: A consistent 4L/3PI motor branch was mapped and characterized in all specimens.

Clinical relevance: These findings provide a guide for intraoperative localization of the 4L/3PI motor branch and also may provide further evidence to explain findings seen after distal nerve transfers to treat ulnar nerve injury.

Purpose: Current technologies to define the zone of acute peripheral nerve injury intraoperatively are limited by surgical experience, time, cumbersome electrodiagnostic equipment, and interpreter reliability. In this pilot study, we evaluated a real-time, label-free optical technique for intraoperative nerve injury imaging. We hypothesize that fluorescence lifetime imaging (FLIm) will detect a difference between the time-resolved fluorescence signatures for acute crush injuries versus uninjured segments of peripheral nerves in sheep.

Methods: Label-free FLIm uses ultraviolet laser pulses to excite endogenous tissue fluorophores and detect their fluorescent decay over time, generating real-time tissue-specific signatures. A crush injury was produced in eight peripheral nerves of two sheep. A hand-held FLIm instrument captured the time-resolved fluorescence signatures of injured and uninjured nerve segments across three spectral emission channels (390/40 nm, 470/28 nm, and 540/50 nm). The average FLIm parameters (ie, lifetime and intensity ratios) for injured and uninjured nerve segments were compared. We used linear discriminant analysis to differentiate between crushed and uninjured nerve segments.

Results: A total of 23,692 point measurements were collected from eight crushed peripheral nerves of two sheep. Histology confirmed the zone of injury. Average lifetime at 470 nm and 540 nm were significantly different between crushed and uninjured sheep nerve segments. The linear discriminant analysis differentiated between crushed and uninjured areas of eight nerve segments with 92% sensitivity, 85% specificity, and 88% accuracy.

Conclusions: In this pilot study, FLIm detected differing average lifetime values for crushed versus uninjured sheep peripheral nerves with high sensitivity, specificity, and accuracy.

Clinical relevance: With further investigation, FLIm may guide the peripheral nerve surgeon to the precise zone of injury for reconstruction.

Purpose: The benefits of upper-extremity reconstructive surgery for patients with spastic deformities are well documented, but a small portion of eligible patients undergo surgery. We sought to determine perceptions of upper-extremity reconstructive surgery among brain injury patients and nonsurgical providers to identify potential barriers to surgical evaluation.

Methods: Electronic medical records at a referral center were reviewed for patients diagnosed with upper limb spasticity following brain injury. A patient-specific survey was distributed by email to all eligible patients. An anonymous provider-specific electronic survey was distributed to the members of United States-based professional societies that routinely provide nonsurgical medical care to patients with spasticity.

Results: Forty-three of 143 patients (30%) responded to the survey. All subjects underwent initial nonsurgical management for their spastic upper limbs, but only 19% (n = 8) underwent subsequent reconstructive upper-extremity surgery. Hesitancy to undergo surgery was primarily related to "uncertainty regarding its benefits" and "fear of worsened postoperative function." Thirty-seven medical providers responded to the survey. Seventy-six percent (n = 28) saw more than 10 patients afflicted with spasticity annually, but 83% referred fewer than 10 patients for surgical evaluation. Barriers to referral included "uncertainty regarding procedure effectiveness" (58%), "concerns regarding insurance approval" (56%), "uncertainty whether a patient is a surgical candidate" (53%), and "no relationship with an upper extremity surgeon" (39%) for referral.

Conclusions: Surgery is infrequently performed among brain injury patients with spastic upper limb deformities. Patients report unfamiliarity with surgical options and concerns regarding surgical risks and benefits. Nonsurgical providers describe uncertainty regarding surgical efficacy and candidacy and underdeveloped referral networks.

Clinical relevance: Surgical treatment of upper-extremity spasticity following brain injury is infrequently provided to eligible patients. Patient and provider perceptions of upper-extremity reconstructive surgery may help identify the factors that underlie the relative infrequency of surgical treatment and suggest opportunities to optimize the delivery of surgical care.

Purpose: This study aimed to quantify and assess perioperative costs in an integrated healthcare system for patients undergoing distal biceps tendon (DBT) repair with and without the use of postoperative bracing and formal physical (PT) or occupational (OT) therapy services. In addition, we aimed to define clinical outcomes after DBT repair using a brace-free, therapy-free protocol.

Methods: We retrospectively reviewed all cases of DBT repairs within our integrated system from 2015 to 2021. We performed a retrospective review of a series of DBT repairs utilizing the brace-free, therapy-free protocol. For patients with our integrated insurance plan, a cost analysis was conducted. Claims were subdivided to assess total charges, costs to the insurer, and patient costs. Three groups were created for comparisons of total costs: (1) patients who had both postoperative bracing and PT/OT, (2) patients who had either postoperative bracing or PT/OT, and (3) patients who had neither postoperative bracing nor PT/OT.

Results: A total of 36 patients had our institutional insurance plan and were included in the cost analysis. For patients using both bracing and PT/OT, these services contributed 12% and 8% of the total perioperative costs, respectively. Implant costs accounted for 28% of the overall cost. Forty-four patients were included in the retrospective review with a mean follow-up of 17 months. The overall QuickDASH was 12; two cases resulted in unresolved neuropraxia, and there were no cases of re-rupture, infection, or reoperation.

Conclusions: Within an integrated healthcare system, postoperative bracing and PT/OT services increase the cost of care for DBT repair and account for 20% of the total perioperative charges in cases where bracing and therapy are used. Considering the results of prior investigations indicating that formal PT/OT and bracing offer no clinical advantages over immediate range of motion (ROM) and self-directed rehabilitation, upper-extremity surgeons should forego routine brace and PT/OT utilization after DBT repair.

Type of study/level of evidence: Therapeutic IV.

Purpose: This study evaluated the prevalence, characteristics, and reimbursement of advanced practice providers, including nurse practitioners and physician assistants, who provide care related to the diagnosis and treatment of diseases and conditions of the hand, wrist, and upper extremities in the United States from 2013 to 2021.

Methods: Our analysis was a retrospective cohort study evaluating the diagnostic, procedural, and therapeutic services provided by advanced practice providers from 2013 to 2021 using the Medicare Provider Utilization and Payment Data Public Use Files from the Centers for Medicare and Medicare Services. The reported provider type and billing codes were used to identify health care professionals providing upper-extremity care such as ordering radiographs, applying casts and splints, and performing procedures on the hand, wrist, or other anatomic regions of the upper extremity. Trends over the study period and available data about services provided were analyzed.

Results: From 2013 to 2021, providers of upper-extremity care included 19,525 (64.7%) doctor of medicine or doctor of osteopathic medicine upper-extremity surgeons, 7,612 (25.2%) physician assistants, and 3,042 (10.1%) nurse practitioners. The nonsurgeon providers were more likely to be women and provide care in micropolitan areas with less than 50,000 people compared with upper-extremity surgeons. Overall, the number of advanced practice providers who billed for upper-extremity care increased by 170.9% from 1,965 in 2013 to 5,324 in 2021. Based on these trends, the growth of APPs providing upper-extremity care is expected to continue.

Conclusions: There is a growing prevalence of advanced practice providers in upper-extremity care, and this trend is expected to continue.

Clinical relevance: With a growing need for upper-extremity care and predicted shortages in the surgeon workforce, the scope of practice and integration of advanced practice providers merits further discussion and evaluation.

Purpose: Flexor pollicis longus rupture is a major complication after volar locking plate fixation of distal radius fractures. Although the distance between the flexor pollicis longus tendon and the plate (plate-tendon distance) measured by ultrasonography is used to predict tendon rupture risk, the timing of the ultrasonography can affect the measurements. Therefore, this study aimed to analyze the chronological change of the plate-tendon distance between the tendon and plate.

Methods: A total of 166 wrists underwent the plate-tendon distance measurement twice or more times within 15 months after surgery. Longitudinal ultrasonography scans with the wrist in a neutral position and the thumb flexed were used to measure the plate-tendon distance. The plate-tendon distances at 0-5 months, 5-10 months, and 10-15 months after surgery were compared. A multiple linear regression analysis was performed to evaluate the influence of the interval between surgery and examination, Soong grade, and plate type on the plate-tendon distance.

Results: The plate-tendon distance decreased as the interval between surgery and examination increased. The plate-tendon distance was an average of 2.0 ± 1.1 mm, 1.4 ± 0.9 mm, and 1.2 ± 0.9 mm at 0-5 months, 5-10 months, and 10-15 months after surgery, respectively. Significant differences were observed between 0-5 months and 5-10 months and between 5-10 months and 10-15 months after surgery. A multiple linear regression showed that significant predictors of the plate-tendon distance were the intervals between surgery and examination and Soong grade.

Conclusions: The plate-tendon distance decreased as the time since surgery increased. When ultrasonography is used for the assessment of tendon rupture risk, it should be considered that the plate-tendon distance decreases as the interval between the surgery and examination increases.

Type of study/level of evidence: Prognosis IV.

Purpose: The diagnosis of amyloidosis is important for early intervention, disease monitoring, and prevention of complications and progression. Carpal tunnel syndrome (CTS) and trigger digit (TD) are two common conditions associated with early disease. The purpose of this study was to define disease prevalence among patients with bilateral CTS and multiple TDs and assess for an increased rate of diagnosis in the presence of both.

Methods: Men older than 50 years and women older than 60 years of age diagnosed with bilateral CTS, multiple TDs, or a combination of the 2 were prospectively enrolled in our study. Tenosynovial biopsy samples taken at the time of surgery were tested for the presence of amyloid using Congo red staining. Demographic and medical covariates were also collected and analyzed for differences between amyloid-positive and -negative patients.

Results: Fifty-six patients were enrolled in the study, and nine patients tested positive for amyloid deposition. The demographics and medical comorbidities were similar between amyloid-positive and -negative patients. Thirty patients with bilateral CTS were enrolled, and four tested positive for amyloid. For patients with multiple TDs, a total of 17 patients were enrolled, and 4 tested positive for amyloid. Among patients with multiple TDs, only men tested positive for amyloid and were, on average, younger than those who tested negative (61 and 73 years, respectively). Patients presenting with a combination of CTS and TD did not exhibit increased amyloid discovery.

Conclusions: Hand surgeons should consider tenosynovial biopsy in men older than 50 years and women older than 60 years presenting with either bilateral CTS or multiple TDs.

Type of study/level of evidence: Prognostic IV.

Purpose: Reliable collection of postoperative patient-reported outcome measures (PROMs) is critical to understanding surgical outcomes and the value of care. Automated PROMs collection, triggered by the electronic medical record at the 1-year postoperative anniversary, may provide a simple way to acquire outcomes for patients who have been discharged from clinic. The purposes of this study were to (1) evaluate the percentage of responses with an automated PROMs collection platform and (2) identify whether such a system may introduce selection bias by comparing responders with nonresponders.

Methods: Adult patients (aged ≥18 years) undergoing hand and upper-extremity surgeries between August 2017 and January 2019 were included. Preoperative Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores were collected using tablet computer. Postoperative QuickDASH scores were collected using a single electronic survey request 1 year after surgery via an email with a personalized REDCap link. Univariate and multivariable regression analyses were performed to identify factors that differed between responders and nonresponders.

Results: A response rate of 27% (269 of 1010) was observed for the eligible postoperative patients. On multivariable analysis, the following were associated with greater odds of response: older age, Caucasian race (vs unknown), longer surgery duration, attending the first postoperative visit, and responding to the preoperative QuickDASH.

Conclusions: The poor response rate that was observed highlights that an automated single email postoperative contact for PROMs collection is insufficient-active follow-up via reminder emails and/or telephone calls is needed. Outcome researchers and clinicians must be aware of potential selection biases, such as age and race, that may exist with automated PROMs collection.

Clinical relevance: Single email postoperative contact to obtain postoperative PROMs is insufficient.

Purpose: The purpose of this study was to evaluate implant survivorship and clinical outcomes following radial head arthroplasty for fracture at long-term follow-ups.

Methods: A retrospective analysis was conducted on adult patients who underwent primary uncemented radial head arthroplasty for radial head or neck fractures between 2012 and 2015. Medical records were reviewed to collect information regarding demographics, injury characteristics, reoperations, and revisions requiring implant removal. A bivariate analysis was conducted to identify potential risk factors for reoperation. A Kaplan-Meier curve was created to determine implant survival rates. Eligible patients were contacted to confirm any reoperations and obtain Quick Disability of the Arm, Shoulder, and Hand scores at long-term follow-ups.

Results: A total of 89 patients were eligible for analysis and assessed at a mean of 97 months after surgery (range, 81-128). Reoperation rate was 16% (14 of 89 patients), including 5% of patients requiring implant removal or revision. However, 93% of reoperations occurred within the first 12 months of the index surgery. Fracture dislocations of the elbow had a higher rate of reoperation. A Kaplan-Meier curve demonstrated an implant survival rate of 96% at 10-year follow-up. Of the patients who responded, the mean Quick Disability of the Arm, Shoulder, and Hand score was 8.7 ± 10.3, with none requiring additional reoperations or revisions. There were otherwise similar outcome scores among patients requiring reoperation versus those who did not.

Conclusions: Although radial head arthroplasty for fractures has a high potential for reoperation within the first year, survival rates with uncemented implants remain high at 10 years, and patients report excellent Quick Disability of the Arm, Shoulder, and Hand scores at long-term follow-ups, despite any need for reoperation. Fractures with associated elbow dislocation may be at a higher risk for reoperation, and it is important to provide this prognostic information to patients who are likely to require arthroplasty for more extensive injuries.

Type of study/level of evidence: Therapeutic IV.

Purpose: Fragility fractures associated with osteoporosis and osteopenia are a common cause of morbidity and mortality. Current methods of diagnosing low bone mineral density require specialized dual x-ray absorptiometry (DXA) scans. Plain hand radiographs may have utility as an alternative screening tool, although optimal diagnostic radiographic parameters are unknown, and measurement is prone to human error. The aim of the present study was to develop and validate an artificial intelligence algorithm to screen for osteoporosis and osteopenia using standard hand radiographs.

Methods: A cohort of patients with both a DXA scan and a plain hand radiograph within 12 months of one another was identified. Hand radiographs were labeled as normal, osteopenia, or osteoporosis based on corresponding DXA hip T-scores. A deep learning algorithm was developed using the ResNet-50 framework and trained to predict the presence of osteoporosis or osteopenia on hand radiographs using labeled images. The results from the algorithm were validated using a separate balanced validation set, with the calculation of sensitivity, specificity, accuracy, and receiver operating characteristic curve using definitions from corresponding DXA scans as the reference standard.

Results: There was a total of 687 images in the normal category, 607 images in the osteopenia category, and 130 images in the osteoporosis category for a total of 1,424 images. When predicting low bone density (osteopenia or osteoporosis) versus normal bone density, sensitivity was 88.5%, specificity was 65.4%, overall accuracy was 80.8%, and the area under the curve was 0.891, at the standard threshold of 0.5. If optimizing for both sensitivity and specificity, at a threshold of 0.655, the model achieved a sensitivity of 84.6% at a specificity of 84.6%.

Conclusions: The findings represent a possible step toward more accessible, cost-effective, automated diagnosis and therefore earlier treatment of osteoporosis/osteopenia.

Type of study/level of evidence: Diagnostic II.