Journal of Hand Surgery-American Volume最新文献

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.

Purpose: Routine practices without a clear impact on patient care merit continuous reassessment. This retrospective study evaluated the value of routine histopathologic and culture analysis in patients who underwent flexor or extensor tendon tenosynovectomy.

Methods: Current Procedural Terminology codes for isolated tenosynovectomy procedures were queried from an institutional database from 2018 to 2023, including all patients aged ≥18 treated by one of seven fellowship-trained hand surgeons. Demographics, past medical and surgical history, clinic notes, operative notes, imaging, pathology, and culture data were reviewed. We assessed for changes to the treatment course of each patient based on the pathology and culture data.

Results: A total of 57 patients were assessed histologically including 20 patients with known inflammatory conditions; histopathology did not alter the care of any of those 20 patients. One of the remaining 37 patients was referred to rheumatology and ultimately diagnosed with rheumatoid arthritis. A total of 50 patients were assessed by microbiology; when infection was suspected before surgery or intraoperatively, cultures were positive in 74% of cases. One of the 27 patients without a suspicion for infection tested positive for Mycobacterium marinum complex infection, altering the patient's care.

Conclusions: In patients with a known inflammatory condition, routine histopathologic analysis of tenosynovium did not alter patient care; based on these findings, we no longer routinely assess this tissue in these patients. Histopathology assessment in patients without an underlying diagnosis of inflammatory conditions and culture in patients without suspicion for infection altered care only rarely. In these groups, we recognize the likely negative evaluation but continue to assess biopsied tissues as positive tests will alter patient care.

Type of study/level of evidence: Diagnostic IV.

Purpose: In patients with mallet fractures, surgical fixation is traditionally recommended when over one-third of the distal phalanx articular surface is involved. Mallet finger patients with small-sized avulsion fractures, involving around 20% of the distal phalanx articular surface, can have instability at the distal interphalangeal (DIP) joint. This biomechanical study was conducted to determine whether damage to DIP joint collateral ligaments in mallet finger patients with small-sized avulsion fractures contributes to DIP joint instability causing subluxation in these patients.

Methods: Nineteen cadaveric fingers were given a mallet finger-style avulsion fracture, ranging from 9% to 35% involvement of the distal phalanx articular surface. DIP joint stability was tested with the DIP collateral ligaments intact, with collateral ligaments partially damaged, and finally with full collateral ligament resection. Mixed models were used to study the relationship between stability and collateral damage. A receiver operating curve analysis along with Youden's J statistic was used to determine the avulsion fracture size at which the DIP joint becomes unstable for different degrees of collateral damage.

Results: The likelihood of subluxation differs by degree of collateral ligament damage, with subluxation probability increasing as collateral damage moves from intact to 50% cut to 100% cut. In fingers with 50% collateral resection, avulsion fractures involving >28% of the distal phalanx articular surface are more likely to experience subluxation. In fingers with 100% collateral resection, avulsion fractures >15% are more likely to subluxate.

Conclusions: Collateral ligament injury contributes to instability at the DIP joint in a mallet fracture, increasing the likelihood of palmar subluxation.

Clinical relevance: Collateral ligament injury contributes to DIP joint instability in mallet fractures involving <40% of the articular surface, supporting the need for assessing finger stability with a physical examination.

Purpose: Percutaneous needle aponeurotomy (PNA) offers an effective, minimally invasive option for Dupuytren disease, but local anesthetic infiltration into the richly innervated palm can cause substantial procedural pain. Vapocoolant sprays induce rapid cutaneous cooling, potentially suppressing nociceptor activity and modulating pain transmission. Evidence for their role in hand surgery is sparse. This randomized controlled trial evaluated whether vapocoolant application before infiltration reduces injection pain during PNA.

Methods: In a single-center, single-blind, randomized controlled design, adults undergoing PNA were assigned 1:1 to receive either vapocoolant spray (5 seconds, 10 cm distance) immediately before infiltration with 1% plain lignocaine or lignocaine alone. Only the first injection was assessed. The primary end point was injection pain, rated on a 10-point visual analog scale (VAS). Secondary end points included immediate adverse events. Exploratory analyses examined correlations between VAS and demographic or disease variables.

Results: Ninety-four patients (47 per arm) were analyzed. The vapocoolant group was younger (65.8 ± 9.2 years) than controls (70.8 ± 8.5 years); sex distribution and comorbidities were comparable. Fifth ray involvement predominated (43%). Vapocoolant spray produced a significant reduction in mean injection pain (-2.70 VAS units), exceeding the reported minimal clinically important difference for acute procedural pain. No adverse events or complications occurred. Age demonstrated a moderate positive correlation with pain.

Conclusions: Preinfiltration vapocoolant spray significantly diminished injection pain during PNA without compromising safety. Given its immediacy, negligible cost, and ease of integration into clinical workflow, vapocoolant use represents a pragmatic analgesic adjunct in hand surgery. Broader adoption may enhance patient comfort, procedural tolerability, and overall satisfaction.

Type of study/level of evidence: Individual RCT/Ib.

Purpose: The purpose of this study was to compare the clinical outcomes, radiographs, and complications of radial head arthroplasty in patients with concomitant Monteggia or transolecranon fracture dislocations to patients with isolated radial head fractures.

Methods: A retrospective cohort comparison was performed, identifying unreconstructible radial head fractures that were treated with radial head arthroplasty. Patients >18 years of age with at least 1 year of follow-up were included. Patients with Monteggia or transolecranon fracture dislocations were matched by age (within 5 years), sex, and smoking status to patients with isolated radial head fractures for comparison. Outcome measures included range of motion, patient-reported outcome scores, complications, and reoperation rates.

Results: A total of 58 patients with a Monteggia (n = 38) or transolecranon fracture dislocation (n = 20) met the inclusion criteria and were matched to 58 patients with isolated radial head fractures. Clinical outcomes were similar across all three groups in range of motion and patient-reported outcome scores. There were significantly more complications and reoperations in the Monteggia and transolecranon fracture dislocation groups compared with the isolated radial head fracture group. Functional stiffness (flexion less than 30°-130°) and hardware irritation were more common in the Monteggia and transolecranon groups. Additionally, a higher incidence of ulnohumeral arthritis was identified in patients with transolecranon fractures (grades 3-4, 25%).

Conclusions: There were similar functional outcomes achieved in patients who underwent radial head arthroplasty in Monteggia and transolecranon fracture dislocations compared with isolated radial head fractures. The Monteggia and transolecranon groups had a higher incidence of complications and higher rates of reoperation, specifically hardware irritation and elbow stiffness requiring removal of hardware (proximal ulna plate) and contracture release, respectively.

Type of study/level of evidence: Prognostic IV.

Purpose: This study aimed to assess the long-term clinical and radiologic results after hemi-hamate arthroplasty in patients with acute or chronic irreparable fractures of the base of the middle phalanx.

Methods: Between 2010 and 2014, hemi-hamate arthroplasties were performed on 12 patients with a mean age of 29.5 (SD 4.9) years. The patients included acute cases (treated within 6 weeks of the fracture) and chronic cases (treated after 6 weeks). We assessed the cases at a mean follow-up of 10.7 years. We recorded visual analog scale (VAS) scores, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, Patient-Rated Wrist Evaluation (PRWE) scores, grip and pinch strengths, proximal interphalangeal (PIP) joint range of motion (ROM), and radiologic findings. The results were compared with those from the opposite hand.

Results: The mean active ROM of the PIP joint was 76.6ᵒ (SD 34.2). Patients lost an average of 6.7ᵒ of extension and 17.5ᵒ of flexion compared to the comparable joint in the healthy hand. The mean scores for VAS, QuickDASH, and PRWE were 1, 12.7, and 7.6, respectively. The presence of osteoarthritis, which was observed in 7 of 12 patients had a greater impact on PRWE scores and increased the amount of extension loss. The union rate was 91.6%. Graft resorption was observed in 3 patients and was associated with decreased extension and flexion. The average pinch and grip strengths of the injured hands were 23.2 (SD 6) and 100.4 (SD 15.3) pounds, respectively, which were comparable with those of uninjured hands. One patient incurred implant failure, and another had spontaneous fusion of the PIP joint.

Conclusions: The long-term results of hamate osteochondral grafts for PIP fracture-dislocation have generally acceptable clinical and radiologic outcomes. Despite reduced ROM and autograft changes, grip and pinch strengths and subjective outcomes are satisfactory.

Type of study/level of evidence: Therapeutic IV.