Journal of Hand Surgery-American Volume最新文献

Purpose: Cable grafting is a well-established technique for repairing major peripheral nerve defects but requires extensive microsurgical suturing, increasing operative time and foreign body burden at the coaptation. A novel microhook nerve connector (MNC), originally developed to improve surgical efficiency and repair alignment in direct coaptations, could offer a potential alternative to microsuture cable grafting. This study evaluated the biomechanical integrity of MNC cable grafting compared to traditional microsutures in a cadaver model. Our hypothesis is that cable-graft repairs using MNC will demonstrate greater holding strength than those repaired with microsutures.

Methods: After transection, 16 cadaveric nerves (5-6 mm diameter) were reconstructed through cable grafting with either an MNC or microsutures. Sixty-four smaller nerves (1.5-2 mm diameter) were cut to 3 cm length and assembled into 4-strand cable grafts. In the microsuture group, each strand was inset on both ends with two 9-0 nylon sutures. In the MNC group, each strand was positioned onto a single microhook column, secured, and wrapped in the small intestinal submucosa backing. Biomechanical integrity was assessed via tensile testing to determine load to failure.

Results: MNC-assisted repairs exhibited significantly higher maximum load to failure than microsuture repairs (3.05 ± 0.57 N vs 1.55 ± 0.53 N). Both groups demonstrated sequential failure patterns, with MNC repairs sustaining significantly higher loads at each failure peak. Observationally, nerve strands from MNC repairs remained entubulated during sequential failure, temporarily maintaining the proximity of nerve ends.

Conclusions: MNC cable grafts demonstrated higher biomechanical holding strength overall and of each individual strand.

Clinical relevance: The MNC is a sutureless alternative to traditional microsuture cable grafting. These findings support further investigation of MNC-assisted cable grafting for clinical use in major peripheral nerve repairs.

Purpose: New symptoms from established idiopathic or senescent pathophysiology are often misinterpreted as an injury (damage to tissues by an external force). Misinterpretation of age-related imaging abnormalities as damage from an external force introduces potential for overdiagnosis, overtreatment, overprotection, and misplacement of a condition under work insurance. Evidence from the shoulder and knee suggests that awareness of the bilateral nature of many idiopathic and senescent pathophysiologies can limit erroneous diagnosis of traumatic pathophysiology.

Methods: Sixty-four scrutinized work injury claims with unilateral wrist symptoms underwent bilateral wrist magnetic resonance imaging (MRI) as part of routine care. The radiologist's interpretation of the MRIs was reviewed. Abnormalities were documented for each side and rated as either corresponding with or incidental to the location of the symptoms. We analyzed factors associated with MRI abnormalities present in the symptomatic wrist alone.

Results: MRI signal abnormalities were detected in 97% (n = 62) of symptomatic wrists and 91% (n = 58) of asymptomatic wrists, with an average of three abnormal findings per wrist. Signal abnormalities of the articular disc and extensor carpi ulnaris tendon were present in 64% and 45% percent of wrists and they were bilateral in 85% and 72% of patients, respectively. MRI findings were considered incidental to the symptoms in 95% (n = 61) of patients. In 55% (n = 35) of the cohort, symptoms were attributed to idiopathic or senescent pathophysiology and in 41% (n = 26) symptoms were considered nonspecific (no pathophysiological explanation). A trip and fall injury mechanism was the only variable associated with the presence of an abnormal MRI signal in the symptomatic wrist alone.

Conclusions: Occupational injury claimants with unilateral wrist symptoms tend to have symmetric MRI signal changes that do not correspond with symptoms, suggesting that new symptoms from idiopathic or degenerative conditions are far more common than traumatic pathophysiology.

Type of study/level of evidence: Diagnostic IV.

Purpose: The digital pulley system enables efficient finger flexion. The A2 and A4 pulleys are biomechanically critical, with injury causing tendon bowstringing and impaired grip. Tendon-bone distance (TBD) is widely used as a surrogate for pulley injury, with a threshold of 2 mm often cited as diagnostic. However, this assumes a limited capacity for physiologic adaptation. Emerging evidence suggests that increased TBD and pulley thickness may reflect adaptive remodeling, similar to other ligamentous structures. The purpose of this study was to quantify pulley morphology in a broad sample of individuals and explore the potential for structural adaptation. We hypothesized that pulley morphology would correlate with climbing experience and force production.

Methods: A cohort of 56 uninjured recreational climbers and 18 controls was assembled. Each underwent ultrasound of eight digits to assess TBD at the A2 and A4 pulleys, pulley thickness, flexor tendon thickness, and volar plate thickness at the proximal interphalangeal and distal interphalangeal joints. Maximal voluntary contraction (MVC) was measured. Linear mixed-effects models assessed correlations among morphology, MVC, and climbing status while controlling for other factors.

Results: Tendon-bone distance exceeded 2.0 mm in 39/542 fingers (7.2%; 22/74 participants) at A2 and 83/541 fingers (15.3%; 34/74 participants) at A4. Increased MVC was associated with increased A2 TBD (0.10 mm per 10 kg MVC) and A2 (0.02 mm per 10 kg MVC) and A4 pulley thickness (0.03 mm per 10 kg MVC), but not flexor tendon thickness. Climber status was associated with increased distal interphalangeal volar plate thickness (+0.20 mm).

Conclusion: This study demonstrates that fingertip force production is associated with annular pulley morphology. The structural changes observed are consistent with the mechanical loading demands, supporting the hypothesis of use-dependent adaptation.

Clinical relevance: The use of patient-specific cutoff values for injury diagnosis warrants further investigation to minimize the risk of overdiagnosis.

Purpose: This study assessed the efficacy of combining the "two-extension block Kirschner wire (K-wire) technique" and "dorsal counterforce technique" for treating delayed bony mallet fractures (≥4 weeks), previously introduced to prevent fracture fragment rotation in axial and sagittal planes in acute cases.

Methods: Twenty-nine patients with delayed bony mallet fractures were treated using percutaneous curettage, which was performed with a K-wire to debride fibrous tissue from the dorsal fracture gap to the articular side, followed by the two-extension block K-wire technique, incorporating the dorsal counterforce technique for cases of inadequate reduction. If a satisfactory reduction could not be achieved, an open procedure was performed. Outcomes were evaluated over a 6-month postoperative period, focusing on healing time, range of motion, complications, and Crawford functional outcomes.

Results: Of the 29 patients with delayed bony mallet fractures, 13 were treated using percutaneous curettage combined with the two-extension block K-wire technique, and 15 required additional dorsal counterforce technique. One patient required conversion to an open procedure due to failure to restore a congruent joint surface and was excluded from the outcome assessment. All 28 fractures treated using our suggested method healed within 8 weeks, with 24 patients (85.7%) achieving healing within 6 weeks. According to Crawford's evaluation system, the outcomes were excellent, good, fair, and poor in 19, 6, 1, and 2 patients, respectively.

Conclusion: Two-extension block K-wire technique combined with the dorsal counterforce technique appears to be a feasible option for delayed bony mallet fractures, achieving a congruent joint surface and satisfactory outcomes in most cases.

Type of study/level of evidence: Therapeutic IV.

Purpose: The Personal Meaningful Gain (PMG) is a construct identifying a patient's self-defined improvement goal, capturing the individual's threshold to be satisfied with treatment results. Previous research shows that patients who achieve their expressed PMG should be satisfied with their treatment results, but this is not always the case. This study explored the lived experiences of patients who were dissatisfied with their treatment results despite having achieved their expressed PMG.

Methods: We conducted a qualitative study comprising semistructured interviews using Interpretative Phenomenological Analysis. Data were collected in a specialized hand surgery and therapy clinic in the Netherlands. The validated PMG was identified before the initial surgeon consultation and treatment. We interviewed patients who had met their expressed PMG (ie, their goal to become satisfied) but responded as being "very" or "extremely" dissatisfied with their treatment results on a validated questionnaire.

Results: We included six patients and identified four main themes. Three themes were directly related to satisfaction with treatment results: (1) the expressed goal was a means to an end (eg, elimination of pain) instead of the true goal (eg, feeling capable to perform activities); (2) disappointment resulting from unexpected, undesirable events; and (3) positive care experiences ameliorate, but do not resolve, dissatisfaction. The fourth theme reflected patients' attempts to cope with dissatisfaction.

Conclusions: Our study shows that, although the PMG is valid and predicts satisfaction, some dissatisfied patients may have expressed a PMG that was only a means to an end. Positive care experiences could ameliorate dissatisfaction, but they rarely resolve it completely. Unexpected and undesirable events, as well as the patient's coping style, influenced satisfaction with treatment results.

Clinical relevance: Clinicians should prioritize understanding the patients' actual goals and target factors such as coping and care experiences to improve satisfaction in patients who remain dissatisfied despite achieving their expressed PMG.

Purpose: The aim of our study was to perform a cost-utility analysis comparing trapeziometacarpal joint (TMJ) implant arthroplasty with resection-suspension-interposition arthroplasty (RSIA) during 1 year after surgery.

Methods: We compared 80 working patients undergoing TMJ implant arthroplasty with 39 working patients receiving RSIA. Over 1 year, we assessed return to work, costs because of loss of productivity, quality-adjusted life-years (QALYs), and direct medical costs. Sensitivity analyses were conducted to extrapolate data over 5 years as well as to account for the data of nonworking patients.

Results: Implant arthroplasty patients returned to work significantly faster (mean 52 vs 84 days), leading to reduced costs due to productivity loss. Patients with TMJ implant arthroplasty had significantly higher QALYs (0.89 vs 0.85) and lower total costs (USD 26,809 vs USD 33,953), resulting in a negative incremental cost-effectiveness ratio. At a threshold of USD 110,000 per QALY, implant arthroplasty was found to be cost effective with 99% probability. Sensitivity analyses showed that implant arthroplasty was cost effective over 5 years, despite higher revision risks and also if nonworking patients were included in the population.

Conclusions: The study indicates that TMJ implant arthroplasty is less expensive and improves quality of life more effectively than RSIA.

Level of evidence: Economic 1c.