Journal of Hand Surgery-American Volume最新文献

Purpose: There is a paucity of research on the demographic trends of orthopedic and plastic hand surgery fellows. The purpose of this study was to ascertain the current state of racial and gender demographic trends in hand surgery fellowship from 2007 to 2021.

Methods: We analyzed fellowship demographic data from the Accreditation Council for Graduate Medical Education public database from 2007-2008 through 2020-2021. The gender of hand surgery fellows was categorized as male, female, or not reported and their race/ethnicity as White, Non-Hispanic; Asian or Pacific Islander, Hispanic; Black, Non-Hispanic; American Indian or Alaskan Native; other; or unknown. We extracted the number of fellows per year for each category and calculated the percentage equivalents and average percentages. We performed the chi-square test for trend (Cochran-Armitage test) to identify any significant changes in the percentages of gender and race/ethnicity between 2007 and 2021.

Results: There was a significant increase in the percentage of hand surgery fellows who are women (20.7% to 30.7%) and Asian or Pacific Islander (13.3% to 25.3%). There was no significant change in the percentage of Hispanic or Black, Non-Hispanic fellows.

Conclusions: Although there have been some increases, hand surgery fellows continue to be underrepresented by women and minorities, consistent with the demographic of orthopedic and plastic surgery residents. There have been increasing trends in the number of women and minorities in medical schools, which leaves room for improvement from the downstream prospective applicant pool.

Clinical relevance: The physician-patient relationship can potentially be strengthened by race and gender concordance; however, many minority and female hand surgery patients do not have physicians who are women or of the same ethnic background. Patient satisfaction, trust, and potential health outcomes may be improved with a physician workforce that reflects the diversity of their patients.

Purpose: Several limited midcarpal arthrodeses have been used in the treatment of midcarpal osteoarthritis as part of scapholunate advanced collapse and scaphoid nonunion advanced collapse. There is no consensus on whether two-carpal arthrodesis (2CA), three-carpal arthrodesis (3CA), bicolumnar arthrodesis, or four-carpal arthrodesis (FCA) results in the best outcomes. The objective of this study was to determine whether there is a difference in outcomes in patients undergoing FCA, 3CA, 2CA, or bicolumnar arthrodesis for midcarpal osteoarthritis.

Methods: A systematic review and meta-analysis were performed in multiple databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting the four surgical techniques were included. The primary outcomes were postoperative visual analog scale pain score, the Disabilities of the Arm, Shoulder, and Hand score, and the Mayo Wrist Score. The secondary outcomes were active range of motion, grip strength, and reported complications.

Results: Of 2,270 eligible studies, 80 articles were selected, including a total of 2,166 wrists. The visual analog scale pain scores for both the 2CA and FCA groups reached an adequate pain reduction based on the Patient Acceptable Symptom Scale. The Disabilities of the Arm, Shoulder, and Hand score was also comparable between these two groups. The 2CA group also showed a significantly better active range of motion than the FCA group for both flexion-extension and radioulnar deviation arc. The incidence of nonunion was 6.9% in the FCA group compared with 10.0% in the 2CA group.

Conclusions: Although the 2CA procedure has a theoretical advantage over the FCA method, the analysis of data showed that generally, these techniques have similar outcomes and complications. Therefore, both (2CA and FCA) are good options for midcarpal osteoarthritis in scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists.

Type of study/level of evidence: Therapeutic IV.

Purpose: The purpose of this study was to biomechanically evaluate the stability of the 6.5 mm intramedullary (IM) olecranon screw compared to locking compression plate fixation for Orthopedic Trauma Association/AO Foundation (OTA/AO) 2U1B1 olecranon fractures under cyclic range of motion of the elbow.

Methods: Twenty paired elbows were randomized to either IM olecranon screw or locking compression plate fixation of a simulated OTA/AO 2U1B1 fracture. Pullout strength was tested by increasing force applied to the triceps and proximal fragment. Fracture gap displacement was measured using differential variable reluctance transducers as the elbow was cycled through a 135° arc of motion using a servohydraulic testing system.

Results: Analysis of variance revealed significant interaction between group and load on fracture distraction after the 500th cycle in three settings: between the plate at 5-pound load and screw at 35-pound load, the screw at 5-pound load and screw at 35-pound load, and between the plate at 15-pound load and screw at 35-pound load. The difference in the rate of failure between plate (2 of 80 samples) and screw (4 of 80 samples) was not statistically significant.

Conclusions: For OTA/AO 2U1B1 olecranon fractures, a single 6.5 mm IM olecranon screw demonstrated similar stability when compared to the locking compression plates throughout range of motion testing.

Clinical relevance: From a biomechanical perspective, 6.5 mm IM screws and locking compression plates have similar ability to maintain fracture reduction following simulated elbow range of motion exercises in OTA/AO 2U1B1 fractures, giving surgeons another option in the management of these fractures.

Purpose: The patient-acceptable symptom state (PASS) is a threshold score on a patient-reported outcome measurement beyond which patients consider themselves "well." Our purpose was to establish the PASS for the numeric rating scale (NRS) for pain in a 1-year postoperative hand surgery population.

Methods: This retrospective study included adult patients undergoing non-shoulder upper-extremity surgery at a single, tertiary medical center identified over a 9-month period. At 1 year after surgery, NRS pain and responses to a pain-specific anchor question were collected. Patients were dichotomized based on achieving "PASS(+)" or failing to achieve "PASS(-)" an acceptable symptom state based upon their response to a pain-specific anchor question. Threshold values of a PASS(+) state were calculated for the NRS pain score using the following three methods: (1) mean score of PASS(+) patients, (2) Tubach method (75th percentile threshold for PASS(+) patients), and (3) the Youden index (receiver operating curve analysis to maximize sensitivity and specificity).

Results: Of 233 included patients, mean age was 54 years (±17), and 58% (n = 136) were women. Mean NRS pain scores differed between PASS(+) and PASS(-) patients (0.7 ± 1.2 vs 3.8 ± 2.7, respectively). PASS(-) patients were more likely to be non-White and have a diagnosed psychiatric comorbidity. Patient-acceptable symptom state estimates ranged from 0.73 to 2.1 for NRS pain, depending on the calculation method (0.73 for the mean score method, 1.0 for the Tubach method, and 2.1 for the Youden index). The area under the curve for the Youden index method was 0.86 consistent with excellent discrimination.

Conclusions: We propose the value of 2.1 to represent the PASS threshold for the NRS pain score in this population.

Clinical relevance: This PASS value should be used when interpreting NRS pain score outcomes at a population level. This threshold is expected to yield excellent discrimination for patient satisfaction when applied to a postoperative hand surgery population.

Purpose: Ulnar shortening osteotomy (USO) is commonly performed to alleviate pathologies causing ulnar-sided wrist pain. Surgical complications include nonunion and hardware removal, with rates up to 18% and 45%, respectively. The primary objective of the study was to report the overall complication rate of USO. The secondary objective was to identify risk factors for complications.

Methods: A retrospective multicenter cohort review was undertaken, including six Canadian cities over a 6-year period (January 2013-December 2018). Chart review was used to collect demographic data, surgical technique, implant used, and postoperative complications. Descriptive statistics of demographics and operative characteristics, including plate positioning, type of osteotomy, plate type, and ulnar variance (mm), were analyzed. Univariate analyses were used to select predictor variables for nonunion and hardware removal. These predictor variables were then entered into an adjusted multivariable logistic regression model.

Results: A total of 361 USOs were performed. Mean age was 46 ± 16 years (60.7% men). The overall complication rate was 37.1%, hardware removal rate was 29.6%, and nonunion rate was 9.4%. There was a workers' compensation claim associated with 21.6% of all complications, and it was a risk factor for both hardware removal (odds ratio [OR] = 3.81) and nonunion (OR = 2.88). Neither smoking nor diabetes was associated with complication rates. Seventy percent of plates were placed volarly, 25.5% dorsally, and 3.9% directly ulnar. Osteotomies were oblique in 83.7% of cases and transverse in 15.5%. Adjusted multivariate regression analysis revealed that younger age (OR = 0.98) was a risk factor for hardware removal and male sex (OR = 2.49) was a risk factor for nonunion. A surgical factor associated with hardware removal was direct ulnar plate placement (OR = 9.93). No surgical factors were associated with nonunions.

Conclusions: There are substantial rates of complications with USOs. Direct ulnar plate placement should be avoided. Patients should be thoroughly counseled on the risks of complications prior to proceeding with USO.

Type of study/level of evidence: Therapeutic IV.

Purpose: The incidence and etiology of primary osteoarthritis (OA) of the scaphotrapeziotrapezoid joint (STTJ), radiocarpal joint (RCJ), and distal radioulnar joint (DRUJ) remains unknown. The purpose of this study was to evaluate the prevalence and factors associated with primary wrist OA in a cross-sectional study of a basic resident registry.

Methods: A total of 1,297 residents between the ages of 50 and 89 years were randomly sampled from the registry of a Japanese town. A questionnaire was administered to all subjects, and each of them underwent radiographs of the bilateral hands, wrists, and elbows. STTJ, RCJ, and DRUJ radiographic osteoarthritis (ROA) were evaluated according to a previously described method. Associated factors for STTJ and DRUJ ROA were recorded. Associations between the incidence of ROA of the DRUJ, ulnar variance, and severity of elbow ROA were investigated.

Results: A total of 676 wrists (162 men and 176 women; mean age of 69.0 years) were investigated. The prevalence of STTJ, RCJ, and DRUJ ROA was 5.3%, 1.5%, and 21.2%, respectively. Factors associated with STTJ ROA were thumb carpometacarpal joint ROA, female sex, and increasing age. Factors associated with DRUJ ROA were elbow ROA, use of vibrating tools, increasing age, and positive ulnar variance. Prevalence of DRUJ ROA was 54.4% in wrists with severe-grade elbow ROA. Ulnar variance of the wrist in severe-grade elbow ROA was significantly larger than that in mild-grade or nonelbow ROA.

Conclusions: The prevalence of ROA was highest in the DRUJ, followed by the STTJ, and lowest in the RCJ. The occurrence of ROA of the STTJ and DRUJ was affected by the presence of ROA of the adjacent joint.

Clinical relevance: Primary DRUJ ROA occurs at a moderate frequency, similar to primary ROA of other extremity joints; however, primary STTJ and RCJ ROA is rare.

Purpose: The optimal timing for surgical treatment of open distal radius fractures remains an area of debate. The purpose of this study was to examine the outcomes of open distal radius fractures treated surgically before or after 24 hours.

Methods: A multicenter retrospective review was performed on all open distal radius fractures treated over 11 years. Patient demographics, injury mechanism, and initial treatment were recorded. Fracture severity was graded by the Gustilo-Anderson classification. Comparisons were made between those treated surgically within and after 24 hours. Outcomes examined included infection, revision surgery, osteomyelitis, and nonunion.

Results: A total of 230 cases met the inclusion criteria. The cohorts of early and delayed surgical intervention were similar with regard to preoperative demographics. The most common mechanism of injury was motor vehicle accident. Approximately 40% of cases were graded as type I, 40% as type II, and 20% as type III. Mean time to debridement in the group treated after 24 hours was 5 days. A mean postoperative follow-up of greater than 6 months was obtained in both cohorts. Similar outcomes were found between cohorts with respect to postoperative infection, revision surgery, osteomyelitis, and nonunion.

Conclusions: Similar outcomes with regards to infection, revision, osteomyelitis, and nonunion were found between open distal radius fractures treated emergently versus those managed in a delayed fashion. Patient- and injury-specific factors are important in dictating care.

Type of study/level of evidence: Prognostic IIB.

Partial capitate shortening osteotomy represents a feasible surgical approach to reduce load distribution to the lunate in Kienböck disease, with preservation of the scaphoid-capitate articular surface. A surgical procedure, presented here, entails arthroscopic partial resection of the proximal capitate articular surface to alleviate pressure on the lunate.

Purpose: Triangular fibrocartilage complex (TFCC) peripheral tears with persistent wrist pain can be treated with arthroscopic surgical repair owing to vascularization of the peripheral region. The safety and efficacy of all-inside repair has been shown in prior case series. The purpose of this study was to compare two methods of arthroscopic peripheral TFCC repair: all-inside vertical mattress and outside-in horizontal mattress.

Methods: A 5-year retrospective review was performed on patients treated from 2016 to 2021 with wrist arthroscopy and TFCC repair for Palmer 1B tears. Patients with ulnar extrinsic ligament repair, distal radioulnar joint instability, concomitant ulnar shortening osteotomy, and extensor carpi ulnaris instability were excluded. Patient therapy and office visit records were reviewed. Outcomes including Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH); range of motion; grip strength; immobilization time; complications; and need for revision procedures were compared.

Results: Fifty-two patients were included in the study, 32 in the outside-in group and 20 in the all-inside group. The average follow-up length was 24.8 weeks, with similar range of motion and strength in both groups. The average postoperative QuickDASH score was 13 in the outside-in group and 9 in the all-inside group at 43.5 months, compared with the preoperative QuickDASH scores of 47 and 50, respectively. Mean immobilization time was longer for outside-in than for all-inside (5.25 vs 2.0 weeks, respectively).

Conclusions: All-inside arthroscopic peripheral TFCC repair showed range of motion, grip strength, complications, revisions, and postoperative improvement in QuickDASH scores similar to those with the outside-in technique.

Type of study/level of evidence: Therapeutic IV; retrospective comparative study.