Journal of Hand Surgery-American Volume最新文献

Purpose: The aim of this research was to evaluate median nerve neuropathy after distal radius fracture (DRF) using nerve conduction studies (NCSs) before and after treatment.

Methods: This prospective follow-up study included 109 patients who were admitted to a level-1 trauma center with DRFs between July 2021 and January 2022, 52 of whom were treated nonsurgically and 57 of whom were treated surgically. Patients who were treated nonsurgically and were suitable for circumferential casting in the emergency department, patients with known median nerve pathology, and patients who underwent procedures other than volar locking plate surgery were excluded. Nerve conduction studies were performed three times: before treatment, at week 6, and at week 12. The relationships between NCS results and demographic (age and sex), therapeutic (treatment method, reduction time, and treatment time), functional (Disabilities of the Arm, Shoulder, and Hand score), and radiological data were evaluated.

Results: Nerve conduction study abnormalities after DRFs were more frequently observed in older patients. In patients undergoing surgical treatment after DRFs, NCS findings indicating median nerve neuropathy were observed more frequently in pretreatment NCSs than in patients treated nonsurgically. However, this difference was not found at the 6- and 12-week NCSs. Median nerve neuropathy findings in pretreatment NCSs were seen more frequently in patients with delayed reduction, but this difference was not observed at the 6- and 12-week NCSs. Disabilities of the Arm, Shoulder, and Hand scores were higher for patients with abnormalities at the pretreatment and 12-week NCSs. There was no difference in NCS findings between radiological parameters or sex.

Conclusions: Age was a risk factor for median nerve neuropathy after DRFs. Delayed reduction was associated with median nerve neuropathy but resolved spontaneously within 6-12 weeks. Early median nerve neuropathy is more common with severe fracture types that usually require surgical intervention.

Type of study/level of evidence: Prognosis IV.

Total wrist arthroplasty has undergone substantial evolution in indications, implant design, and expected functional outcomes over the past decade. Osteoarthritis has overtaken rheumatoid arthritis as the major underlying etiology for joint replacement. Patient expectations have also evolved with a trend toward motion-preserving procedures. Finally, implant design based on careful experimental research efforts has assisted in outcome optimization. This article reviews these points in greater depth and provides examples and some technical points for the interested hand surgeon to consider.

The traditional management of distal radius fractures involves the use of fluoroscopy or capsulotomy to guide articular reduction. Arthroscopy is a tool that can aid in achieving articular congruity as well as the management of concomitant injuries, where indicated. In this article, we present a practical arthroscopic step-by-step guide in the treatment of distal radius fractures.

Purpose: The study aimed to evaluate the accuracy of augmented reality-assisted total wrist arthroplasty (AR-TWA) in a cadaveric model using a three-point registration method. The hypothesis is that AR-assisted surgery can enable surgeons to achieve accurate implant placement comparable with surgeries performed under specialist guidance.

Methods: Fourteen fresh-frozen upper extremities from seven cadavers were used for TWA. Computed tomography data were imported into three-dimensional image analysis software for surgical planning. On one side, AR-TWA was performed by a board-certified orthpaedic surgeon with no clinical experience in TWA, and on the contralateral side, non-AR-TWA was performed by the same surgeon under the guidance of an experienced hand surgeon. The accuracy of implant placement was assessed by comparing preoperative and postoperative computed tomography scans and measuring deviations and angular errors between the planned and actual component positions.

Results: For both the radial and carpal components, four of six parameters demonstrated smaller errors in the AR-TWA. Although certain parameters favored the non-AR-TWA, overall variability was lower with AR. When classified as acceptable or outlier, all seven radial cases in the AR-TWA were acceptable for deviation, and six were acceptable for angular error, indicating better consistency than the non-AR-TWA. On the carpal side, AR-TWA demonstrated higher accuracy than non-AR-TWA, but more outliers were observed, suggesting relatively greater variability in this region.

Conclusions: Augmented reality-assisted TWA using a three-point registration method improved the accuracy of implant placement, even when performed by a less experienced surgeon.

Clinical relevance: Augmented reality technology may assist less experienced surgeons in performing technically demanding procedures, such as TWA, with improved accuracy.

Purpose: Scaphotrapeziotrapezoid osteoarthritis (STT-OA) may be related to the progression of carpal instability. This study analyzed the radiographic carpal indices in wrists with varying grades of STT-OA to investigate an association between the severity of STT-OA and the occurrence of dorsal intercalated segment instability (DISI), and to identify radiographic characteristics of carpal instability associated with STT-OA.

Methods: We retrospectively measured carpal indices in 135 wrists with STT-OA (Crosby's classification grade 2, 62; grade 3, 73). Carpal indices measured included radiolunate (RL), radioscaphoid (RS), scapholunate (SL), and lunocapitate (LC) angles and SL distance. We compared the values of these carpal indices and the occurrence of DISI between the STT-OA grade 2 and grade 3 groups. We evaluated the presence of radiographic OA in other joints. In the wrists with DISI, we further investigated the relationship between the RL angle and other carpal angles.

Results: The RL and RS angles of grade 3 patients with STT-OA were smaller than those of grade 2 patients. The LC angle of grade 3 was greater than that of grade 2. DISI was identified in 3 grade 2 wrists (5%), and 44 grade 3 wrists (60%). None of the wrists had an SL angle >70°, a widened SL distance (>3mm), or radiographic OA in the RS joint. In the 47 wrists with DISI, there was a negative correlation between RL and LC angles, and positive correlation between RL and RS angles.

Conclusions: We found an association between the severity of STT-OA and occurrence of DISI, and identified unique characteristics of this carpal instability, which include an extended position of the scaphoid, a normal SL angle, and no development of RS-OA.

Type of study/level of evidence: Differential diagnosis/symptom prevalence study IV.

Purpose: First dorsal compartment tendonitis is a common cause of radial wrist pain. Initial treatments include corticosteroid injections, bracing, and anti-inflammatory medications, with surgical release reserved for persistent symptoms. This study investigated the efficacy of injections and intervention-free survival time.

Methods: Patients at a single academic institution with first dorsal compartment tendonitis treated with at least one corticosteroid injection between 2014 and 2024 were included. Primary events were defined as a repeat injection or operative release. Time between injection and primary event was recorded and analyzed using the Kaplan-Meier product limit method.

Results: Overall, 2,122 hands received a corticosteroid injection for first dorsal compartment tendonitis. With one injection, 66.5% of cases had no further intervention, which increased to 81.0% with two injections. Following an initial injection, 6.7% of cases progressed to surgery at a median of 111 days, and 26.8% had repeat injections. Intervention-free rates were 97% at 6 weeks, 87% at 3 months, and 75% at 6 months. After a second injection, 18.8% had a third injection at a median of 122 days, and 33.6% underwent surgical release. In the group with more than one injection, intervention-free rates were 97% at 6 weeks, 85% at 3 months, and 64% at 6 months.

Conclusions: A high proportion of patients with first dorsal compartment tendonitis appear to have symptom relief in response to corticosteroid injections. A second corticosteroid injection is less effective in reducing the need for operative release or repeat injection. Patients with first dorsal compartment tendonitis should be advised that corticosteroid injections generally provide relief and mitigate the need for repeat interventions.

Type of study/level of evidence: Prognostic IV.

Purpose: Radioscapholunate (RSL) fusion is a motion-preserving limited wrist fusion treatment option for symptomatic radiocarpal arthritis; however, there is no consensus regarding the need for excision of the distal scaphoid or triquetrum. This study aimed to determine the impact of distal scaphoid excision (DSE) and triquetrum excision (TE) in RSL fusion and compare the outcomes and complications.

Methods: A systematic review of the literature was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and relevant clinical studies on RSL fusion were retrieved from Scopus, MEDLINE, and Embase. Meta-analysis with a random-effects model was used to assess the functional and clinical outcomes, including range of motion; grip strength; Disabilities of Arm, Shoulder, and Hand scores; visual analog scale pain scores; and Patient-Rated Wrist Evaluation scores. The rates of complications were analyzed.

Results: The analysis included a total of 24 studies involving 477 wrists, of which, 49% had RSL fusion alone, 41% had RSL fusion with DSE, and 10% had RSL fusion with DSE and TE. Meta-analysis demonstrated improved postoperative flexion and radial deviation in wrists with DSE compared to those without, by 8° and 3°, respectively. The incidence of nonunion was significantly lower in wrists with DSE and wrists with DSE and TE. The incidence of secondary midcarpal osteoarthritis was the lowest in wrists with DSE, but highest in wrists with DSE and TE.

Conclusions: Excision of the distal scaphoid resulted in slightly increased ranges of wrist flexion and radial deviation and reduced the rates of nonunion and secondary midcarpal osteoarthritis in RSL fusion. Patients who have had combined DSE and TE, demonstrated an increased incidence of secondary midcarpal degeneration.

Type of study/level of evidence: Therapeutic IV.

Purpose: To evaluate the impact of preoperative osteoporosis on rates of revision and reoperation for patients with rheumatoid arthritis (RA) who underwent primary metacarpophalangeal (MCP) arthroplasty with silicone or pyrocarbon implants.

Methods: We retrospectively identified all primary silicone and pyrocarbon MCP arthroplasties performed in patients with RA at our institution over an 18-year period. Patient osteoporosis status was determined according to the National Bone Health Alliance criteria. We report survival free from revision (implant removal or replacement) and all-cause reoperation (including revisions) in these groups. We used cluster-robust, multivariable Cox proportional hazards models to analyze osteoporosis as a risk factor for revision and all-cause reoperation and report subgroup analysis for pyrocarbon and silicone implants.

Results: The osteoporosis group included 200 joints (168 silicone, 32 pyrocarbon) in 56 patients with a mean follow-up of 7.9 years. The nonosteoporosis group included 129 joints (93 silicone, 36 pyrocarbon) in 42 patients with a mean follow-up of 10 years. With pyrocarbon implants, the osteoporosis group had lower 10-year survival free from revision (58% vs 100%) and all-cause reoperation (40% vs. 81%) than the nonosteoporosis group. In multivariable analysis of pyrocarbon implants, osteoporosis was associated with increased hazard for revision (HR, 11.0; 95% CI, 1.27-95.8) and all-cause reoperation (HR, 3.4; 95% CI, 1.2-10.3). With silicone implants, there was no difference in 10-year survival free from revision (88% in osteoporosis, 89% in nonosteoporosis) or all-cause reoperation (85% osteoporosis, 85% nonosteoporosis). Osteoporosis did not affect risk for silicone implant revision or reoperation.

Conclusions: Osteoporosis is associated with increased risk for pyrocarbon implant revision and all-cause reoperation in RA patients, though the precise effect size is unknown. Silicone MCP arthroplasty remains a durable option for patients with RA regardless of osteoporosis status.

Type of study/level of evidence: Therapeutic IV.

Purpose: The effect of digital edema on tensile forces in zone II flexor tendon injuries has not been extensively investigated. The purpose of this study was to examine the effect of digital edema on flexor tensile forces following six-strand repair of a zone II flexor tendon laceration and to assess how these forces change throughout the total arc of motion.

Methods: Eight cadaveric upper extremities were used in the study. All specimens were placed in a dorsal blocking splint with the wrist in neutral and metacarpophalangeal joints at 45° of flexion. Continuous force-displacement curves were generated for the following experimental conditions: at baseline; following zone II flexor digitorum profundus six-strand repair, with mild, moderate, and severe edema; and with self-adherent wrap in place. The force required to produce 3 millimeters of tendon gap was measured as the load to failure in this model. A linear mixed effect model was used to evaluate differences in average flexion force among experimental groups.

Results: The average peak force to achieve 270° of flexion for each experimental condition was 10.3 N, 16.1 N, 21.4 N, 28.1 N, 34.3 N, and 47.5 N. The average load to failure was 44.6 N. Digital flexion forces increased nonlinearly throughout the arc of motion. At 180°, moderate edema, severe edema, and self-adherent wrap resulted in significantly increased tensile forces compared to the control and postrepair measurements.

Conclusions: Flexion forces increase exponentially throughout the arc of motion and increase significantly with moderate and severe edema beyond 180° in this model. In the setting of moderate to severe edema, active flexion should be limited to the first half of the arc of motion.

Clinical relevance: This is a biomechanical study that quantifies the effect of edema and self-adherent wrap on flexor tendon tensile forces throughout the arc of motion. The patient and therapist should be aware of this kinetic pattern to avoid complications after surgery.