Journal of Hand Surgery-American Volume最新文献

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.

Purpose: To the best of our knowledge, no prior biomechanical study has determined how much fracture obliquity can be tolerated with intramedullary screw fixation. The purpose of this study was to compare the stiffness, load to failure, and fracture gapping of intramedullary fixation for oblique metacarpal fractures.

Methods: Forty-five metacarpal sawbones were divided into three fracture pattern treatment groups: transverse, short oblique, and long oblique. Fourth-generation sawbones models were used, which have been validated to simulate cortical bone strength and modulus. Osteotomies (0°, 30°, and 60°) were made through the shaft of each metacarpal to simulate fracture patterns, corresponding to each treatment group. Each metacarpal was reduced and fixed with a retrograde 3.5 × 52 mm intramedullary screw. Each construct was cycled under a cantilever bending force at a 45° angle to simulate physiologic loading and then loaded to failure. Stiffness, load to failure, and fracture gapping were measured and compared.

Results: There was no difference in the load to failure or stiffness among the three groups. The mean load to failure for the transverse, short oblique, and long oblique fractures was 222.0, 260.3, and 249.7 N, respectively, while the mean stiffness was 78.2, 78.3, and 72.2 MPa, respectively. Long oblique fractures had less gapping than short oblique and transverse fracture constructs following load removal. There was no difference in gapping between the short oblique and transverse fracture constructs. The mean fracture gapping for the transverse, short oblique, and long oblique fractures was 5.0, 3.3, and 0.6 mm, respectively.

Conclusions: Intramedullary fixation for simulated short oblique and long oblique metacarpal fracture patterns provides similar stability when compared to transverse fracture fixation.

Clinical relevance: Intramedullary fixation of oblique metacarpal fractures may be able to achieve adequate fixation, regardless of fracture obliquity.

Purpose: To investigate if volar locking plates (VLPs) are superior to external fixation (EF) with adjuvant pins in unstable distal radius fractures after 10 years of follow-up.

Methods: From 2007 to 2009, 111 unstable distal radius fractures were randomized to either EF or VLP. The patients' mean age was 54 years (20-84). At 10 years, 86 patients (77%) were assessed (VLP 43, EF 43). Eighty-one patients (VLP 42, EF 39) had a clinical and radiological examination. Five patients (EF 4, VLP 1) refused to attend the examination, but returned the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. There were 70 women and 16 men with 2 A2, 21 A3, 35 C1, 25 C2, and 3 C3 fractures (AO/ASIF). The patients were assessed clinically by using the visual analog scale pain score at rest/activity, Mayo wrist score, QuickDASH questionnaire, and range of motion. Complications were registered during the study period. The QuickDASH score at 10 years was the primary outcome measure.

Results: The QuickDASH score was not significantly different between the groups, with a mean score of 9 in the VLP and 10 in the EF. The final QuickDASH scores were lower than the normative values in this age group. There were no clinically relevant differences in the visual analog scale pain score, Mayo wrist score, and range of motion. There was less radial shortening in the VLP group. The C-type fractures demonstrated no significant clinical differences, but there were more cases of radiological osteoarthritis in the EF group. Nineteen patients had their VLPs removed because of hardware problems.

Conclusion: There were good clinical results in both groups at 10 years, but there is a concern that 19 patients had to have the VLPs removed.

Type of study/level of evidence: Therapeutic I.

Purpose: Internal fixation with a headless compression screw has become the gold standard for the surgical treatment of scaphoid fractures. Some authors reported on the theoretical benefit of dual screw fixation. Our aim was to investigate the optimal dual screw configuration for fixing scaphoid fractures with regard to biomechanical stability.

Methods: In a previously established finite element model of the scaphoid, a fracture plane at the scaphoid waist was modeled. Two 1.7 mm cannulated, partially threaded compression screws were positioned in parallel. The distance between the screws and their angulation relative to each other were systematically varied, using multiples of the screw diameter for the interscrew distance (3.4 mm, 5.1 mm, and 6.8 mm) and 5° increments for angle variation (5°, 10°, 15°, 15°, and 20°). For each scenario, maximum interfragmentary displacement (IFD in mm) and maximum von Mises stress (MPa) within the fracture planes of the distal and proximal fragments were compared.

Results: IFD values were 0.057, 0.031, and 0.0227 mm for screw distances of 3.4, 5.1, and 6.8 mm, respectively. Von Mises stress was 105.6 MPa, 105.36 MPa, and 84.84 MPa in the proximal fragment and 86.3 MPa, 73.68 MPa, and 56.6 MPa in the distal fragment, for the same distance variants. For angles of 5°, 10°, 15°, and 20° between the screws, the IFD was 0.0217 mm, 0.0219 mm, 0.0221 mm, and 0.0224 mm, respectively. The corresponding von Mises stress was 84.84 MPa, 83.95 MPa, 82.85 MPa, 82.78 MPa, and 82.09 MPa for the proximal fragment and 56.6 MPa, 56.14 MPa, 60.04 MPa, 58.84 MPa, and 58.56 MPa for the distal fragment for screw angulations of 5°, 10°, 15°, and 20°.

Conclusions: Despite morphologic limitations of the scaphoid to place two screws maximally apart, a larger distance is biomechanically advantageous and provides more rigid fracture fixation. Angulation, however, has no relevant biomechanical influence, although it may facilitate easier placement of the two screws.

Clinical relevance: The study provides a basis for before surgery planning to optimize biomechanical stability in dual screw fixation of scaphoid fractures.

Purpose: As the Google Artificial Intelligence (AI) Overview function becomes engrained in the search engine, it is important to understand the accuracy of these search results as they pertain to Current Procedural Terminology (CPT) codes. We hypothesized that the identified codes will not be 100% accurate and that there will be subgroups of procedures with relatively lower accuracy than others.

Methods: One hundred common CPT codes used in hand and upper-extremity surgery were selected and searched in Google using 150 different simplified phrases describing the procedure. The additional 50 phrases were intended to provide more detail on the importance of phrasing variation, for example, "arthrodesis" versus "fusion". The accuracy of the codes was assessed using American Academy of Orthopaedic Surgeons CodeX and the American Society for Surgery of the Hand Coding App. The accuracy was calculated as a percentage.

Results: Google AI Overview's response provided an accurate CPT Code 90% of the time. Tendon procedures (78%) and nerve procedures (71%) had lower accuracy than the remainder of the groups. Bony procedures had an 88% accuracy rate, and the remainder of the categories had over 90% accuracy. Ten percent of queries resulted in multiple codes; 14 of these 15 queries contained the correct code. Fifty-nine acronyms were used, and searches with acronyms resulted in accurate codes at a similar rate to those without acronyms.

Conclusions: This study demonstrates that providers and billers can use Google AI Overview as a tool but should not rely on it as being 100% accurate.

Clinical relevance: As AI becomes more involved in everyday clinical practice, hand surgeons should be aware of the potential strengths and weaknesses as it pertains to coding.

Purpose: Numerous studies have compared locking and grasping loop tendon repair configurations, with varying results. This study aimed to synthesize biomechanical evidence from experimental laboratory studies comparing these two configurations under linear static loading.

Methods: MEDLINE and Cochrane CENTRAL databases were searched for studies comparing locking and grasping configurations in flexor tendon repairs using linear static loading. Meta-regressions and subgroup analyses were performed to identify properties in repair configurations that could explain heterogeneity between studies.

Results: The search yielded 14 studies for the review. Locking repairs provided greater ultimate and 2-mm gap loads than grasping repairs, with the advantage being most pronounced when high tensile strength suture materials were used: the mean ultimate load was 40 N in grasping repairs and 7.9 N higher (95% CI, 5.6-10 N, I² = 87%) in locking repairs. A similar trend was observed for the 2-mm gap load, with a mean of 31 N in grasping and 5.8 N higher in locking repairs (95% CI, 3.6-8.1 N, I² = 83%).

Conclusions: In experimental laboratory settings, locking loop configurations provide superior ultimate and 2-mm gap loads compared to grasping loop configurations, particularly with high-strength suture materials. Given the high between-study heterogeneity and that the included studies were conducted in laboratory settings, additional similar biomechanical comparisons may have limited incremental value; clinical studies are needed to determine whether these biomechanical differences translate into improved clinical outcomes.

Clinical relevance: Locking loop tendon repairs appear to withstand greater loads than grasping loop repairs, suggesting a potential biomechanical advantage that may be clinically relevant.