Journal of Hand Surgery-American Volume最新文献

Purpose: The purpose of this study was to assess the evolving landscape of surgical interventions for basilar thumb arthritis.

Methods: Using a national insurance claims database spanning from 2016 to 2022, patients undergoing surgical treatment for thumb carpometacarpal (CMC) arthritis were identified through International Classification of Disease 10 and Current Procedural Terminology codes. The incidence of each type of surgical procedure was collected and normalized to the 2016 level. The total percentage change in incidence and linear regression trendline was calculated over the 7-year period. Multiple variable logistic regression assessed factors associated with thumb CMC denervation.

Results: Among 64,281 surgically treated patients, trapeziectomy with interposition arthroplasty was the most common (83.8%). Although thumb CMC denervation was the least common surgery and accounted for only 1.0% of all surgery, the incidence of denervation increased over the study period from 0.47 to 1.30 per 1,000,000, alongside a 41% rise in trapeziectomy alone. Regression analysis revealed male sex, Western US region, and concomitant carpal tunnel syndrome as associated factors for thumb CMC denervation.

Conclusions: The study indicates a notable shift in surgical approaches for basilar thumb arthritis. Although CMC denervation was the least commonly performed basal joint surgery, there was an increase in denervation procedures from 2016 to 2022. Denervation was not associated with patient age and was most strongly associated with male sex.

Type of study/level of evidence: Therapeutic IV.

Purpose: Carpal tunnel release (CTR) remains the most common hand and wrist surgery in the United States, with an estimated 500,000 procedures per year. The introduction of wide-awake local anesthetic, no tourniquet (WALANT) technique and use of a minor sterile field has allowed CTR procedures to be performed in a clinic setting. Our study aimed to quantify the solid waste and related emissions associated with WALANT CTR procedures performed in a hospital operating room, ambulatory surgical center, and clinic.

Methods: All WALANT unilateral CTRs performed by three fellowship-trained hand surgeons from the same hospital system were prospectively studied over a 6-month period. Data gathered were surgical venue (hospital operating room, ambulatory surgical center (ASC), or clinic) and weight of solid waste produced by material type. The carbon emissions associated with the production and disposal of this waste were calculated using emissions factors from the UK Government's Department for Energy Security and Net Zero.

Results: Over 43 cases, there were significant differences in solid waste production. The average waste generated was 4.6 kg in the hospital operating room, 2.6 kg in the ASC, and 0.7 kg in the clinic. Similarly, greenhouse gas emissions, denoted in equivalent amount of CO₂ (kgCO₂-eq) varied by site, with the operating room emitting 41.6 kg of CO2eq, the ASC 26.0 kg, and the clinic 8.3 kg on average.

Conclusions: Our research considers the environmental impact of the same procedure performed in different settings. Under our institution's current policies, the clinic setting is the most sustainable venue to perform CTR. This supports and replicates previous studies at other institutions.

Clinical relevance: Limiting the environmental impact of surgery is possible. Moving common hand surgeries such as CTR to the clinic may be a more efficient way to achieve improvements in environmental impact than changing hospital or ASC policies.

Purpose: The use of prophylactic antibiotics in patients with existing total hip or knee arthroplasty undergoing elective hand surgery has not been studied. We tested the null hypothesis that perioperative antibiotic administration is not associated with the incidence of prosthetic joint infection (PJI) in patients undergoing elective, soft tissue hand surgery.

Methods: We used a large, national administrative claims database to identify patients with existing total hip or knee arthroplasty undergoing soft tissue hand surgery (carpal tunnel release, de Quervain release, trigger finger release, limited palmar fasciectomy, ganglion or mucoid cyst removal, or soft tissue mass removal). Antibiotic prophylaxis was defined as the same day administration of intravenous cefazolin, vancomycin, or clindamycin. Patients receiving antibiotics were propensity score-matched in a 1:1 ratio to those who did not, accounting for age, sex, geographic region, insurance plan, subsequent surgeries, and the presence of comorbid diabetes mellitus, rheumatoid arthritis, myocardial infarction, congestive heart failure, chronic kidney disease, human immunodeficiency virus infection, chronic kidney disease, malignancy, obesity, or tobacco use. Residual differences between matched cohorts were adjusted for using multivariable logistic regression. The primary outcome was the incidence of PJI within 6, 9, and 12 months after hand surgery.

Results: The overall incidence of PJI was 0.8% (166/21,582) within 12 months after hand surgery. There was no difference in the incidence of PJI between patients who received antibiotic prophylaxis and those who did not at 6 (0.3% vs 0.5%), 9 (0.6% vs 0.7%), or 12 months (0.7% vs 0.8%) after hand surgery. These findings were unchanged after adjusting for residual confounding. Surgical site infection within 3 months after hand surgery was also not associated with PJI at 6, 9, or 12 months.

Conclusions: We found no association between prophylactic antibiotic administration in patients with prior total hip or knee arthroplasty undergoing soft tissue hand surgery and the incidence of PJI at 6, 9, and 12 months after surgery.

Type of study/level of evidence: Prognostic II.

Purpose: Baek's modified Bilhaut-Cloquet procedure is indicated for patients with symmetric bifid thumbs in Wassel type II or III polydactyly. The radially deviated type of thumb polydactyly with asymmetric bifid thumbs was previously contraindicated for this procedure. The objective of the study was to describe the results of our modified Bilhaut-Cloquet procedure using a neurovascular island flap of the radial duplicate for radially deviated type of thumb polydactyly with hypoplasia.

Methods: Twelve thumbs of 12 patients with a radially deviated type of thumb polydactyly underwent our modified Bilhaut-Cloquet procedure using a neurovascular island flap of the radial duplicate and were followed up for an average of 38.4 months. Functional and cosmetic assessments were made using the Japanese Society for Surgery of the Hand scoring system.

Results: All neurovascular island flaps survived, and the thumb size was restored close to that of the unaffected contralateral side in all cases. According to the Japanese Society for Surgery of the Hand scoring system, 8 cases achieved good results, and 4 achieved fair results. In terms of functional and aesthetic results, all cases were considered acceptable by the patient's parents.

Conclusions: Our technique using a neurovascular island flap of the radial duplicate in conjunction with the modified Bilhaut-Cloquet procedure was effective for the treatment of radially deviated type of thumb polydactyly with hypoplasia. This technique is an option for the treatment of radially deviated type of thumb polydactyly with hypoplasia.

Type of study/level of evidence: Therapeutic IV.

Purpose: The epitendinous suture is a critical part of flexor tendon repair. In addition to smoothing the repair site, it augments repair strength and increases gap resistance. This study aimed to determine whether increasing the number of passes or increasing suture caliber would improve the strength (primary outcome), 2 mm gap resistance, or stiffness of a simple running epitendinous suture.

Methods: A total of 30 flexor pollicis longus (FPL), flexor digitorum profundus (FDP), and flexor digitorum superficialis (FDS) tendons were harvested from three cadavers, and transverse tendon lacerations were produced. Tendons were repaired with only an epitendinous suture (no core suture) in three groups: 6-0 Prolene with six passes, 5-0 Prolene with six passes, or 5-0 Prolene with six passes. Epitendinous repair strength was tested using a materials testing machine.

Results: The use of eight passes had significantly greater ultimate tensile strength than six passes (21 +/- 7 N vs 14 +/- 5 N). Although 5-0 suture had a higher average ultimate tensile strength than 6-0 suture, this difference was not statistically significant (14 N +/- 5 vs 10 N +/- 3). Failure mode for all groups was most often suture tear-through.

Conclusions: A simple epitendinous suture using eight passes provides almost 50% more epitendinous repair strength and greater 2 mm gap resistance than six passes when using 5-0 Prolene.

Clinical relevance: When performing a simple running epitendinous repair to augment a core flexor tendon repair, the surgeon should consider the additional strength and gap resistance provided by eight passes compared to six.

Purpose: The ten test (TT) is a sensory assessment used to quantify the sensation of each digit. Because it does not require additional equipment, it may have utility in telemedicine. Our purpose was to evaluate the validity and reliability of the TT.

Methods: Adult patients with nontrauma upper-extremity complaints were evaluated within an academic outpatient clinic. Two examiner groups (hand surgeons [group 1] and residents/physician assistants [group 2]) administered the TT and static two-point discrimination (2PD). Hand surgeons were blinded to the results obtained by the initial examiners. The TT is administered by having the patient define an area of normal sensation with their uninvolved index finger and then rate digital sensation against the involved hand on a 1-10 scale, with 10 defined as perfectly normal sensation. A cut-point analysis was employed, and both sensory assessments were categorized as either normal (2PD ≤5 mm, TT ≥9) or abnormal sensation for the entire median-nerve distribution and individual digit level. Agreement statistics including sensitivity (Sn) and specificity (Sp) were calculated for the TT, using static 2PD as the reference standard. Interrater reliability was compared between the groups of examiners.

Results: A total of 201 patients (1,005 digits) were examined. The Sn/Sp for the TT was 53%/84% and 54%/85% at the digit-level and median-nerve distribution level, respectively. Interrater reliability for the TT between the groups of examiners was substantial at the digit level (κ = 0.68, SE = 0.02).

Conclusions: The Sn/Sp for the TT was 53%/84% when using static 2PD as the reference standard. Interrater reliability for TT was substantial (κ = 0.68). The TT can serve as an alternative to other sensory assessments that require instrumentation. As telemedicine programs continue to evolve within upper-extremity surgery, the TT may be a useful tool with virtual applications.

Type of study/level of evidence: Diagnostic I.