Journal of Hand Surgery-American Volume最新文献

In this review, we aim to discuss the history and future of the peer-review process within hand and upper-extremity surgery. In addition, this review will serve as a practical "how to" guide for reviewers by providing strategies and insights aimed at improving the quality of manuscript reviews. Prereview considerations, such as content, statistical expertise, bias, and potential conflicts of interest, will be addressed. Topics relative to each manuscript section will be presented including common methodological errors.

Purpose: Foveal tears of the triangular fibrocartilage complex (TFCC) are a major cause of distal radioulnar joint instability and often require surgical repair to restore forearm function. Although foveal repair is increasingly performed, postoperative immobilization protocols remain variable and poorly standardized. This systematic review and meta-analysis evaluated the effects of different immobilization methods and durations on clinical outcomes after TFCC foveal repair.

Methods: Comparative clinical studies assessing postoperative immobilization after TFCC foveal repair were identified through a systematic review of MEDLINE, EMBASE, Web of Science, and the Cochrane Library. Outcomes included pain (visual analog scale), Disabilities of the Arm, Shoulder and Hand scores, wrist range of motion, grip strength, and complications. For quantitative analysis, studies were grouped according to immobilization method: elbow-restricted immobilization versus forearm-restricted immobilization permitting elbow motion. Studies evaluating immobilization duration or timing of motion initiation were analyzed descriptively.

Results: Five comparative studies (288 patients) met the inclusion criteria; four evaluated immobilization methods, and 2 assessed immobilization duration or initiation of forearm rotation. Three studies were included in the meta-analysis. No significant differences were found between elbow-restricted and forearm-restricted immobilization in final pain visual analog scale (mean difference [MD] -0.34; 95% CI, -0.91 to 0.24), Disabilities of the Arm, Shoulder and Hand scores (MD -1.67; 95% CI, -6.71 to 3.38), grip strength (MD +0.38%; 95% CI, -9.69 to 10.45), or wrist range of motion, and complication rates were similarly low across groups. Studies investigating immobilization duration demonstrated that restricting pronation and supination for approximately 4-6 weeks yielded better pain relief and functional recovery than immediate rotation, without causing persistent elbow stiffness.

Conclusions: Based on currently available comparative studies, postoperative immobilization after TFCC foveal repair may benefit more from restricting forearm rotation than from restricting elbow motion. Additional restriction of elbow flexion and extension has not shown a consistent advantage in reported outcomes, whereas delaying forearm pronation and supination for up to 6 weeks may help protect the repair while still permitting early functional recovery. Further studies are needed to establish standardized guidelines.

Type of study/level of evidence: Therapeutic III.

Purpose: Postoperative clinical follow-up is standard practice for wound monitoring, patient reassurance, and surgical outcome assessment. However, overburdened health care systems necessitate optimized resource allocation. This study evaluates the utility of routine postoperative follow-up after elective, noninfectious soft tissue upper limb procedures.

Methods: We retrospectively reviewed patients aged ≥18 years who underwent elective soft tissue procedures between January 2023 and December 2024, including carpal tunnel, trigger finger and de Quervain tenosynovitis release, foreign body removal, and excision of skin and subcutaneous finger and palm masses. Medical records were analyzed for interventions performed during routine postoperative visits and unplanned procedure-related encounters.

Results: Of 394 patients meeting inclusion criteria (mean age 57.7 ± 17.8 years; 42% male), the mean time to follow-up was 22.2 ± 6.1 days. Only 12 routine visits (3%) yielded clinically notable interventions: five for wound complications, four for specific therapy instructions, two for postoperative neurapraxia, and one for severe pain management. Twenty-two surgical site infections and wound complications were reported. Most (77.3%) were identified and managed before the scheduled visit through emergency department or primary care encounters. Ninety-nine patients (25.1%) declined follow-up. Of these, 83 required no additional surgical or medical care, and 16 were lost to follow-up. Twenty-nine patients used the visit to raise unrelated new complaints.

Conclusions: Routine postoperative follow-up after elective, clean, soft tissue procedures had high medical yield in only 3% of cases, with most complications presenting through alternative care pathways. Further research should examine patient safety and satisfaction outcomes with voluntary, on-demand postoperative follow-up models.

Type of study/level of evidence: Therapeutic IV.

Purpose: This study aimed to explore the risk factors for postoperative displacement of the dorsal ulnar fragment following volar locking plate fixation in distal radius fractures and to develop a clinical prediction model.

Methods: A total of 168 cases of AO type C distal radius fracture with a dorsal ulnar fragment treated with volar locking plate fixation were retrospectively included in this study. The patients were grouped into the displaced group (n = 33) and the control group (n = 135) based on the presence of postoperative dorsal ulnar fragment displacement (>2 mm). Univariate analysis was performed to identify potential risk factors for postoperative displacement of the dorsal ulnar fragment, which were then included in a binary multivariate logistic regression model. The predictive performance of the model was evaluated using the area under the receiver operating characteristic curve, calibration curve, and decision curve analysis. Finally, a nomogram was constructed based on the model to facilitate the prediction of outcomes.

Results: The univariate and binary logistic regression analysis indicated that preoperative displacement was an independent risk factor, while a greater proportion of radiocarpal articular surface area involvement acted as a protective factor for postoperative displacement of the dorsal ulnar fragment following volar locking plate fixation in distal radius fracture. The binary logistic regression-based dual-marker combined predictive model demonstrated an area under the receiver operating characteristic curve of 0.83. The calibration curve and the Hosmer-Lemeshow test results indicated a good model fit.

Conclusion: Preoperative displacement and the proportion of radiocarpal articular surface area involvement are key predictors of postoperative displacement of the dorsal ulnar fragment in distal radius fractures and therefore should be considered in surgical decision-making.

Clinical relevance: This study developed a practical predictive model for postoperative displacement of the dorsal ulnar fragment after volar locking plate fixation in distal radius fractures, offering surgeons a tool for preoperative assessment and surgical planning to help them optimize fixation outcomes.

Purpose: The main reasons for revision surgery after primary trapeziometacarpal (TM) joint prosthetic implantation are trapezium loosening and instability. Although secondary trapeziectomy is the gold standard, here we describe alternative surgical procedures that can be integrated in a revision strategy based on residual trapezial bone stock after implant removal.

Methods: This single-center retrospective study analyzed the clinical and radiologic results for 41 patients who underwent surgical TM joint prothesis revision from 2006 to 2021 at our institution. We applied a classification of trapezium bone loss after removal of the failed prosthetic cup for deciding on the surgical revision strategy. The minimum follow-up was 24 months.

Results: If no bone loss was observed, trapezium cup replacement was performed. With trapezium loosening and limited central bone loss, cancellous bone grafting was performed before cup implantation in patients <85 years old, whereas a cemented cup was implanted in patients >85 years. With an excavated trapezium, a corticocancellous bone graft was impacted into the residual trapezium before cup implantation. With trapezium destruction, trapeziectomy was considered the gold standard. Pyrocarbon and scaphometacarpal implants were part of the strategy. Follow-up after surgical revision was a mean of 73 months (range 35-202). The mean visual analog scale score for pain was 2.1 ± 1.7, mean Disabilities of the Arm, Shoulder, and Hand score was 24/100 ± 18, and mean Kapandji opposition scale was 8.6/10 ± 11. Mean pinch strength was 63% and mean grip strength 61% of the contralateral side. We report five cases (12%) of additional surgical procedures for failed primary surgical revision.

Conclusions: Although uncommon, complications of TM joint prosthesis are mainly trapezium failure. The choice of alternative surgical options to secondary trapeziectomy can be based on residual trapezium bone stock. Overall, these surgical options had good clinical results, but the rate of secondary revision was high.

Type of study/level of evidence: Therapeutic IV.

Purpose: This study aimed to identify the formal differences between the three published versions of the Eaton classification system for trapeziometacarpal joint osteoarthritis and to assess their intra- and interrater reliability using true lateral thumb radiographs.

Methods: 100 lateral thumb radiographs from consecutive patients (72% women; median age, 63 years; interquartile range, 20 years) were assessed independently. Eight observers (4 hand surgeons, three residents, and one medical student) classified each radiograph according to the original textual descriptions of the Eaton-Littler (1973), Eaton et al. (1984), and Eaton-Glickel (1987) classifications. All observers completed a second round of assessment after two weeks. Intrarater and interrater reliability was calculated using Cohen's and Fleiss' κ and a subgroup analysis of stage-specific reliability was performed. A linear mixed-effects model evaluated the effects of classification version and rater training level on intrarater reliability.

Results: The κ values (95% confidence intervals) for intrarater reliability ranged from 0.51 (0.41; 0.61) to 0.98 (0.95; 1.00). The mixed-effects analysis showed that intrarater reliability of the Eaton-Littler classification was significantly lower than that of Eaton et al. (P = .040). The Eaton et al. and Eaton-Glickel classifications yielded nearly identical intrarater results. Training level had no significant effect on intrarater reliability. The interrater reliability (95% confidence interval) for the Eaton-Littler classification demonstrated fair agreement (0.39 [0.37; 0.42]), whereas the Eaton et al. and Eaton-Glickel classifications showed moderate agreement (0.45 [0.43; 0.47]).

Conclusions: Although observers may achieve acceptable intrarater reproducibility according to their own interpretation of the classification system, all three Eaton classifications involve limited interrater reliability, especially due to low reliability for intermediate stages II and III. Therefore, reliance on these classifications to guide treatment decisions is not supported based on the findings of the present study.

Type of study/level of evidence: Diagnostic III.

If injured alone, a painful, stiff or insensate index finger can hinder hand function and preclude useful recovery. In multiple injured digits, particularly involving the thumb, an injured index finger also can be used to improve overall hand function. In this article, one of the key concepts in hand reconstruction, spare parts surgery, is reviewed with examples. A spare part transferred from an otherwise problematic digit is a form of reconstruction that challenges the mind and the knowledge of the hand surgeon. Ability to plan in the moment first requires pattern recognition.

Purpose: Assessment of the microstructure of the distal radius demonstrates that the ulnar and volar cortices are the load-bearing components of the radius. We hypothesize that the center of rotation (COR) for the wrist lies directly distal to these cortices. The aim of this study was to define the radiographic relationship between the distal radius and the COR.

Methods: In total, 200 consecutive normal wrist radiographs were identified. The COR of the wrist, defined by Youm as the center of the proximal pole of the capitate on the posteroanterior (PA) view and the lunocapitate articulation on the lateral view, was identified. We drew circles of best fit over the capitate (PA view) and the lunocapitate joint (lateral view). These circles were portioned into thirds. Lines were drawn through the ulnar and volar cortices of the radial shaft parallel to the long axis of the radius on PA and lateral radiographs. We defined the offset as the distance from this line to the COR. The offset and the third of the COR through which the line passed was recorded.

Results: In total, 200 (90 left/110 right) wrists were identified in 195 patients (74 males and 121 females) with a mean age 40 years. On the PA radiographs the mean COR offset was ulnar 0.07 mm (±1.1 mm). The ulnar cortical line passed through the central third of the COR in 94% of wrists. On lateral radiographs the mean COR offset was dorsal 0.09 mm (±1.4 mm). The volar cortical line passed through the central third of the COR in 97% of wrists. If both PA and lateral radiographs are considered, the ulnar cortical line and volar cortical line pass through the central third of the COR in 91% of wrists.

Conclusions: The COR lies directly above the ulnar-volar cortex of the radius in over 90% of normal wrists. We believe that this radiographic relationship may be of considerable clinical use when assessing normal and abnormal wrist radiographs.

Type of study/level of evidence: Diagnostic IV.

Purpose: Carpal tunnel syndrome is commonly treated with open (OCTR) or endoscopic carpal tunnel release (ECTR), both effective for long-term symptomatic relief. However, early recovery trajectories and the prognostic value of short-term postoperative improvements remain poorly understood. Although prior studies have emphasized minimum clinically important difference (MCID), fewer have assessed higher, patient-centered benchmarks such as patient-acceptable symptom state (PASS) and substantial clinical benefit (SCB). This study evaluated the timing and rates at which patients undergoing OCTR and ECTR achieve MCID, PASS, and SCB, and whether early postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) upper-extremity (UE) scores can predict outcomes through 4 months.

Methods: This retrospective cohort study included patients undergoing unilateral OCTR or ECTR who completed PROMIS UE questionnaires before surgery and at 2 weeks, 1 month, 2 months, and 3 months after surgery. Patients with bilateral, revision, or combined procedures were excluded. Time-to-event analyses using Kaplan-Meier methods estimated cumulative incidence and compared rates of MCID, PASS, and SCB achievement between cohorts. Receiver operating characteristic (ROC) analysis determined optimal 2-week PROMIS UE thresholds for predicting PASS achievement by 4 months among patients with complete follow-up.

Results: A total of 152 patients were included (OCTR n = 74; ECTR n = 78), with 76% completing all follow-up timepoints. Compared to OCTR patients, ECTR patients were more than twice as likely to achieve PASS at any time through 4 months postoperatively, resulting in a higher proportion of patients reaching PASS. Nonetheless, both groups reported similar proportions of patients achieving MCID and SCB. A 2-week PROMIS UE score ≥ 34 predicted achievement of PASS by 4 months with excellent discrimination (area under the curve = 0.86), 77% positive predictive value, and 82% negative predictive value.

Conclusions: Both OCTR and ECTR provide effective functional restoration within 4 months. However, ECTR confers an early advantage in recovery, with patients reaching PASS quicker and more often than OCTR patients. Regardless of the surgical technique utilized, early postoperative-PROMIS UE scores offer valuable prognostic information in identifying patients at risk for delayed functional recovery, potentially supporting targeted follow-up and proactive rehabilitation.

Type of study/level of evidence: Therapeutic IV.

Thumb carpometacarpal joint arthrosis is the second most common form of degenerative joint disease in the hand but the most frequent form of arthrosis treated surgically. Traditional surgical management involving trapeziectomy dates to the 1940s, with several modifications having evolved to improve stability, strength, appearance, and convalescence. However, although most outcomes of resection arthroplasty are good, they fail to completely restore the joint to its previous vitality, and strong clinical evidence of superiority of any technique is lacking. As total joint arthroplasty remains one of the crowning achievements in orthopaedic surgery overall, attempts to recreate the thumb carpometacarpal joint have continued to develop. The purpose of this article is to discuss the progress, design, technical aspects, and outcomes of total joint arthroplasty in the thumb carpometacarpal joint.