Journal of Hand Surgery-American Volume最新文献

Purpose: Surgical performance that improves with experience is often depicted as representing a "learning curve." Although numerous studies examine the tensile properties of various flexor tendon repairs, few compare the associated learning curves. This study aims to address this gap by comparing the learning curves of Adelaide- and Gan-modified Lim-Tsai repairs. Emphasizing the difference in learning curves is crucial because it highlights the tension between achieving biomechanically superior repairs, which may be challenging to many surgeons, and opting for possibly incrementally less strong but more feasible techniques.

Methods: We organized a workshop attended by 20 medical students whose experience in surgery was limited to a few suturing exercises. Each participant repaired five porcine tendons in situ either with Adelaide- or Gan-modified Lim-Tsai, followed by a peripheral suture. We tested all tendons with linear static testing to measure ultimate and yield loads. In addition, repair times were recorded for each repair. We used a linear mixed model to compare learning between the techniques.

Results: Ultimate loads increased with experience and were higher in Adelaide technique during the first two repairs, compared with Gan-modified Lim-Tsai (80 N vs 63 N and 79 N vs 66 N, respectively). Yield loads also increased with experience but did not differ between the repair techniques at any time point. Mean repair times decreased from 44 to 28 minutes and from 46 to 25 minutes with Adelaide- and Gan-modified Lim-Tsai repairs, respectively.

Conclusions: The Adelaide core suture had a higher initial ultimate load capacity despite fewer suture strands, possibly indicating better tension consistency. The ultimate load of the Gan-modified Lim-Tsai repair increased between the first and fifth repair, and repeats were needed to achieve comparable results with the Adelaide repair.

Clinical relevance: The results of this study suggest that both repair methods are suitable for novice surgeons, but Adelaide tends to result in higher strength from the first repair. Generalizability to other repairs should be made with caution.

Purpose: To compare rates of revision surgery between primary endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR). In addition, we aimed to assess the influence of fellowship training on revision rates. We hypothesized that ECTR would not be associated with higher rates of revision surgery.

Methods: We conducted a retrospective, single-center replication study of a recently published comparative assessment of ECTR and OCTR. All patients between 18 and 75 years old undergoing primary ECTR or OCTR over a 6-year period were included if they were seen within 1 year after surgery. To control for confounding, adjusted binary logistic regression models were inverse-weighted by propensity scores. Early (12 months) and overall revision rates were compared between ECTR and OCTR, as were revision rates relative to surgeon training.

Results: A total of 4,160 patients and 63 surgeons were included. Eighty-one percent underwent OCTR. Nine patients (0.21%) underwent revision within 12 months of index CTR at a mean of 231 days postoperatively. The early revision rate for OCTR and ECTR were 0.24% and 0.13%, respectively. After adjusting for patent characteristics and confounding, ECTR cases were 0.28 times (95% confidence interval, 0.09-0.90) less likely to undergo revision. Early OCTR revision rates for hand surgeons were similar to nonhand surgeons (0.23% vs 0.24%); however, statistically significant higher revision rates were noted for nonhand surgeons (1.04%) compared to hand surgeons (0.42%) for revisions beyond 12 months.

Conclusions: Within a single health care system, the early revision rate after primary CTR was 0.21%. When adjusting for patient characteristics and controlling for confounding, ECTR was 0.28 times less likely to undergo revision compared to OCTR. Hand fellowship training was associated with lower OCTR revision rates beyond 1 year. These data highlight the need for future investigations to clearly define indications for, and outcomes following, revision CTR.

Type of study/level of evidence: Prognostic II.

Health disparities related to race, ethnicity, gender, level of education, and other social determinants of health remain prevalent in medicine and surgery. Understanding the impact of health disparities on treatment decisions and outcomes among common hand surgery conditions has been a major focus of the American Society for Surgery of the Hand. Creative strategies are necessary to go beyond the description of disparities and move toward the proposal of actionable solutions. Community engagement research is one feasible approach that can help hand surgeons narrow these gaps and improve health care outcomes. With this approach, hand surgeons can improve patient-provider communication, increase knowledge of specific hand conditions among community members, and help guide subsequent initiatives to improve access and usage of hand surgery treatment. Community members can take on various roles ranging from participants to partnered investigators, enhancing the overall process to identify actionable solutions with the end user in mind. Additionally, the creation of community-academic partnerships through community engagement research is an excellent way to dismantle the historical mistrust among underrepresented groups through the deliberate inclusion of community members in the research design and execution.

A biologically safe, noninvasive method for visualizing bone and soft tissue relationships has been developed recently. Termed the ultrasonic transmission imaging system, its advantages include visualization of soft tissues in real time while motion is underway. The image can be correlated to standard x-ray films, but since no ionizing radiation is involved, repeated risk-free visualization of extremities for either diagnostic assessment or biomechanical studies is permitted. Resolution of 1 mm and a depth of field of 8 mm are adequate for visualization of neurovascular bundles, tendons, ligaments, bones, and joints. The image can be digitized and stored for later analysis on computer graphic systems. Pilot studies have correlated the ultrasonic anatomy of normal and abnormal living and cadaver hands with known anatomic structures. The benefits to biomechanical analysis include the ability to visualize and accurately measure in a noninvasive manner the in vivo changes of position of tendons and other structures during movement. These initial efforts indicate the growing diagnostic and analytic capabilities of this instrument.

Purpose: In contrast to younger adult populations, clinical practice guidelines state that there is no difference in long-term functional outcomes in surgically versus nonoperatively treated distal radius fractures in patients ≥65 years old. In this study, we asked the following questions: (1) has treatment for distal radius fractures in younger and older adult populations changed over time? (2) What patient and surgeon factors are associated with treatment trends?

Methods: Using a national administrative claims database, we identified patients aged ≥18 years with isolated, closed distal radius fractures, subdivided by age (18-64 years, ≥65 years old). We characterized the proportion of patients who underwent open reduction and internal fixation (ORIF) over time. We stratified our analysis by surgeon subspecialty, region, and mean area income. Changes in ORIF utilization over time were evaluated using linear regression models.

Results: The proportion of distal radius ORIF, including in patients aged ≥65 years, increased from 10.4% in 2012 to 15.1% in 2020. Of the ORIF procedures performed, hand surgeons accounted for an increasing proportion over time, with a corresponding decrease in those performed by general orthopedic surgeons. The proportion of ORIF increased over time in all US regions, with the largest rate of increase in the Midwest for patients aged ≥65 years and Northeast for patients aged 18-64 years. Patients living in areas with mean family income ≥$65,000 were more likely to undergo ORIF.

Conclusions: The proportion of distal radius ORIF including in older adult populations is increasing in all US regions, and an increasing proportion is performed by hand surgeons.

Clinical relevance: Further analysis of the drivers of these trends is warranted, given the rising incidence of surgical treatment in older patients, which could reflect evolving patient activity demands and suggest a need to further evaluate conventional treatment algorithms based on age.

Purpose: The purpose of this study was to determine if there were differences in the tendon forces needed to cause wrist motion and in the passive range of wrist motion following total wrist replacement (TWR) using a contemporary arthroplasty design.

Methods: Eight fresh frozen cadaver arms were moved through five different wrist motions using a wrist joint simulator before and after the insertion of a TWR. Changes in the peak tendon forces and wrist range of motion were compared.

Results: During each of the five wrist motions following TWR, there were significant increases in the extensor tendon forces. Most notably, the force in the extensor carpi radialis longus more than doubled in four motions. Also, the range of motion significantly decreased in flexion (average 18 degrees, range of 23 to -5 [one wrist had an increase in flexion]), extension (average 23 degrees, range of 4-32), and radial deviation (average 19 degrees, range of 29 to -2 [one wrist had an increase in radial deviation]) following TWR. The hand and carpus shifted distally following the insertion of a wrist implant (average of 8.5 mm; range of 3.6-18.0).

Conclusions: Wrist tendon forces increased with TWR insertion, even with a fourth-generation design. Positioning of the implant or differences in the biomechanical properties of the implant compared with the intact specimen may have been factors in the reduced range of motion and distal movement of the carpus. The difficulties of implanting a prosthesis that allows normal kinematics may also play a role in these results.

Clinical relevance: Despite the marked improvements in recent TWR designs, additional design and surgical technique modifications are needed to further reduce the tendon forces required to move a wrist following TWR and increase its range of motion.

Purpose: To study if patients who would be deemed high-risk individuals by traditional classifications of American Society of Anesthesiologists (ASA) or the updated guidelines of ASA Practice Advisory (ASAPA) can safely undergo surgery under wide-awake local anesthesia, no tourniquet in a procedure room setting without any increased risks of complications.

Methods: We analyzed 436 surgeries performed in our procedure room over a 4-year period. No medical comorbidities precluded a patient from surgery within the procedure room, and no preoperative clearance was required. All patients were risk-stratified based on two classifications systems: ASA and ASAPA recommendations. Complications were documented. Patients were categorized into a surgical site infection (SSI) cohort and a non-SSI cohort. Mann-Whitney Wilcoxon and chi-square analyses were used to detect differences between cohorts.

Results: The prevalence of SSI was six out of 437 (1.4%). Our total complication rate (mass recurrence, need for additional surgery, etc.) was 12 out of 425 (2.7%). The number of patients within each risk classification was similar. Patient characteristics were similar on the basis of age, body mass index, smoking status, or presence of diabetes. The ASA or ASAPA classification did not show a relationship to complications. Additionally, no patients were transferred to the emergency department or admitted overnight after their procedures.

Conclusions: Our study demonstrated a complication rate of 2.7% for hand surgery procedures performed in the procedure room setting. Using standardized measures of anesthetic risk related to comorbidities, this study showed that there was no increase in complications for high-risk patients who had surgeries performed in the procedure room.

Type of study/level of evidence: Prognosis IV.

Purpose: The standard treatment for recurrent carpal tunnel syndrome (CTS) has been open revision. We hypothesize that endoscopic carpal tunnel release can be used successfully in the revision setting.

Methods: We identified patients between 2018-2023 who underwent revision carpal tunnel release (CTR). All patients underwent prior open or mini-open CTR (OCTR). All had electrodiagnostically proven CTS and CTS-6 scores >12. Those with suspected or documented nerve injury after primary CTR were excluded. Patient-reported outcomes, including visual analog scale pain scores and 5-point Likert-style rating of symptom improvement, were collected.

Results: Thirty patients were identified: 22 with recurrent and 8 with persistent CTS. Average time from index surgery was 110 months in recurrent and 18 months in persistent CTS cases. Twenty-five patients had prior mini-open CTR, and five underwent traditional-open CTR. Intraoperative findings included incomplete release (n = 4), median nerve (MN) adhesions to skin (n = 1) or flexor retinaculum (n = 4), inadequate visualization of the MN (n = 5) and no documented findings (n = 17). Five of 30 patients (16%) were converted from endoscopic to open release procedures intraoperatively. All conversions occurred in patients with prior traditional-open CTR and incisions crossing the wrist flexion crease. At 6-month follow-up, average visual analog pain scores improved from 7 to 2 after revision endoscopic release and from 7 to 3 in cases in which conversion from endoscopic to open release was required. Of the patients, 92% in the revision endoscopic group and 60% in the conversion group had symptom improvement (5-point Likert score ≥3 at final follow-up).

Conclusions: Revision endoscopic carpal tunnel release can be performed successfully after primary mini-open CTR. A prior traditional OCTR with an incision crossing the wrist crease is more likely to require conversion to open release. A lower proportion of patients converted to OCTR have postoperative symptom improvement than those treated with revision endoscopic release.

Level of evidence: Therapeutic IV.

Purpose: Cubital tunnel syndrome (CuTS) is the second most common upper-extremity neuropathy and can cause debilitating symptoms. Patients presenting to care with severe CuTS can be left with permanent weakness and numbness despite treatment. The aim of this study was to examine the relationship between area-level deprivation and the severity of CuTS on presentation to a hand surgeon.

Methods: We retrospectively identified 369 patients who were diagnosed with CuTS at a new patient visit between January 2017 and December 2021. We queried the electronic health record to assess the severity of CuTS using the McGowan grade. We used patient addresses to determine the national percentile of area-level deprivation for each patient. Bivariate analyses were used to determine if sociodemographic factors were associated with CuTS severity on presentation or rates of surgical intervention.

Results: In bivariate analysis, patients with higher levels of area-level deprivation had more severe CuTS. Those who were older, were men, and had public insurance were also found to have more severe CuTS. Secondary analysis revealed that patients with higher levels of deprivation were more likely to receive nerve conduction testing. No sociodemographic factors were associated with whether patients received surgical intervention or in time from presentation to surgery.

Conclusions: Patients from marginalized backgrounds present to hand surgeons with more severe CuTS disease.

Clinical relevance: Delayed presentation can lead to worse outcomes in CuTS. Understanding barriers to earlier presentation in more deprived locations and certain patient populations can help develop solutions to address these disparities.