Journal of Hand Surgery-American Volume最新文献

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.

Purpose: The aim of this research was to evaluate median nerve neuropathy after distal radius fracture (DRF) using nerve conduction studies (NCSs) before and after treatment.

Methods: This prospective follow-up study included 109 patients who were admitted to a level-1 trauma center with DRFs between July 2021 and January 2022, 52 of whom were treated nonsurgically and 57 of whom were treated surgically. Patients who were treated nonsurgically and were suitable for circumferential casting in the emergency department, patients with known median nerve pathology, and patients who underwent procedures other than volar locking plate surgery were excluded. Nerve conduction studies were performed three times: before treatment, at week 6, and at week 12. The relationships between NCS results and demographic (age and sex), therapeutic (treatment method, reduction time, and treatment time), functional (Disabilities of the Arm, Shoulder, and Hand score), and radiological data were evaluated.

Results: Nerve conduction study abnormalities after DRFs were more frequently observed in older patients. In patients undergoing surgical treatment after DRFs, NCS findings indicating median nerve neuropathy were observed more frequently in pretreatment NCSs than in patients treated nonsurgically. However, this difference was not found at the 6- and 12-week NCSs. Median nerve neuropathy findings in pretreatment NCSs were seen more frequently in patients with delayed reduction, but this difference was not observed at the 6- and 12-week NCSs. Disabilities of the Arm, Shoulder, and Hand scores were higher for patients with abnormalities at the pretreatment and 12-week NCSs. There was no difference in NCS findings between radiological parameters or sex.

Conclusions: Age was a risk factor for median nerve neuropathy after DRFs. Delayed reduction was associated with median nerve neuropathy but resolved spontaneously within 6-12 weeks. Early median nerve neuropathy is more common with severe fracture types that usually require surgical intervention.

Type of study/level of evidence: Prognosis IV.

Total wrist arthroplasty has undergone substantial evolution in indications, implant design, and expected functional outcomes over the past decade. Osteoarthritis has overtaken rheumatoid arthritis as the major underlying etiology for joint replacement. Patient expectations have also evolved with a trend toward motion-preserving procedures. Finally, implant design based on careful experimental research efforts has assisted in outcome optimization. This article reviews these points in greater depth and provides examples and some technical points for the interested hand surgeon to consider.

Purpose: The study aimed to evaluate the accuracy of augmented reality-assisted total wrist arthroplasty (AR-TWA) in a cadaveric model using a three-point registration method. The hypothesis is that AR-assisted surgery can enable surgeons to achieve accurate implant placement comparable with surgeries performed under specialist guidance.

Methods: Fourteen fresh-frozen upper extremities from seven cadavers were used for TWA. Computed tomography data were imported into three-dimensional image analysis software for surgical planning. On one side, AR-TWA was performed by a board-certified orthpaedic surgeon with no clinical experience in TWA, and on the contralateral side, non-AR-TWA was performed by the same surgeon under the guidance of an experienced hand surgeon. The accuracy of implant placement was assessed by comparing preoperative and postoperative computed tomography scans and measuring deviations and angular errors between the planned and actual component positions.

Results: For both the radial and carpal components, four of six parameters demonstrated smaller errors in the AR-TWA. Although certain parameters favored the non-AR-TWA, overall variability was lower with AR. When classified as acceptable or outlier, all seven radial cases in the AR-TWA were acceptable for deviation, and six were acceptable for angular error, indicating better consistency than the non-AR-TWA. On the carpal side, AR-TWA demonstrated higher accuracy than non-AR-TWA, but more outliers were observed, suggesting relatively greater variability in this region.

Conclusions: Augmented reality-assisted TWA using a three-point registration method improved the accuracy of implant placement, even when performed by a less experienced surgeon.

Clinical relevance: Augmented reality technology may assist less experienced surgeons in performing technically demanding procedures, such as TWA, with improved accuracy.

Purpose: Scaphotrapeziotrapezoid osteoarthritis (STT-OA) may be related to the progression of carpal instability. This study analyzed the radiographic carpal indices in wrists with varying grades of STT-OA to investigate an association between the severity of STT-OA and the occurrence of dorsal intercalated segment instability (DISI), and to identify radiographic characteristics of carpal instability associated with STT-OA.

Methods: We retrospectively measured carpal indices in 135 wrists with STT-OA (Crosby's classification grade 2, 62; grade 3, 73). Carpal indices measured included radiolunate (RL), radioscaphoid (RS), scapholunate (SL), and lunocapitate (LC) angles and SL distance. We compared the values of these carpal indices and the occurrence of DISI between the STT-OA grade 2 and grade 3 groups. We evaluated the presence of radiographic OA in other joints. In the wrists with DISI, we further investigated the relationship between the RL angle and other carpal angles.

Results: The RL and RS angles of grade 3 patients with STT-OA were smaller than those of grade 2 patients. The LC angle of grade 3 was greater than that of grade 2. DISI was identified in 3 grade 2 wrists (5%), and 44 grade 3 wrists (60%). None of the wrists had an SL angle >70°, a widened SL distance (>3mm), or radiographic OA in the RS joint. In the 47 wrists with DISI, there was a negative correlation between RL and LC angles, and positive correlation between RL and RS angles.

Conclusions: We found an association between the severity of STT-OA and occurrence of DISI, and identified unique characteristics of this carpal instability, which include an extended position of the scaphoid, a normal SL angle, and no development of RS-OA.

Type of study/level of evidence: Differential diagnosis/symptom prevalence study IV.

Purpose: First dorsal compartment tendonitis is a common cause of radial wrist pain. Initial treatments include corticosteroid injections, bracing, and anti-inflammatory medications, with surgical release reserved for persistent symptoms. This study investigated the efficacy of injections and intervention-free survival time.

Methods: Patients at a single academic institution with first dorsal compartment tendonitis treated with at least one corticosteroid injection between 2014 and 2024 were included. Primary events were defined as a repeat injection or operative release. Time between injection and primary event was recorded and analyzed using the Kaplan-Meier product limit method.

Results: Overall, 2,122 hands received a corticosteroid injection for first dorsal compartment tendonitis. With one injection, 66.5% of cases had no further intervention, which increased to 81.0% with two injections. Following an initial injection, 6.7% of cases progressed to surgery at a median of 111 days, and 26.8% had repeat injections. Intervention-free rates were 97% at 6 weeks, 87% at 3 months, and 75% at 6 months. After a second injection, 18.8% had a third injection at a median of 122 days, and 33.6% underwent surgical release. In the group with more than one injection, intervention-free rates were 97% at 6 weeks, 85% at 3 months, and 64% at 6 months.

Conclusions: A high proportion of patients with first dorsal compartment tendonitis appear to have symptom relief in response to corticosteroid injections. A second corticosteroid injection is less effective in reducing the need for operative release or repeat injection. Patients with first dorsal compartment tendonitis should be advised that corticosteroid injections generally provide relief and mitigate the need for repeat interventions.

Type of study/level of evidence: Prognostic IV.

Purpose: Radioscapholunate (RSL) fusion is a motion-preserving limited wrist fusion treatment option for symptomatic radiocarpal arthritis; however, there is no consensus regarding the need for excision of the distal scaphoid or triquetrum. This study aimed to determine the impact of distal scaphoid excision (DSE) and triquetrum excision (TE) in RSL fusion and compare the outcomes and complications.

Methods: A systematic review of the literature was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and relevant clinical studies on RSL fusion were retrieved from Scopus, MEDLINE, and Embase. Meta-analysis with a random-effects model was used to assess the functional and clinical outcomes, including range of motion; grip strength; Disabilities of Arm, Shoulder, and Hand scores; visual analog scale pain scores; and Patient-Rated Wrist Evaluation scores. The rates of complications were analyzed.

Results: The analysis included a total of 24 studies involving 477 wrists, of which, 49% had RSL fusion alone, 41% had RSL fusion with DSE, and 10% had RSL fusion with DSE and TE. Meta-analysis demonstrated improved postoperative flexion and radial deviation in wrists with DSE compared to those without, by 8° and 3°, respectively. The incidence of nonunion was significantly lower in wrists with DSE and wrists with DSE and TE. The incidence of secondary midcarpal osteoarthritis was the lowest in wrists with DSE, but highest in wrists with DSE and TE.

Conclusions: Excision of the distal scaphoid resulted in slightly increased ranges of wrist flexion and radial deviation and reduced the rates of nonunion and secondary midcarpal osteoarthritis in RSL fusion. Patients who have had combined DSE and TE, demonstrated an increased incidence of secondary midcarpal degeneration.

Type of study/level of evidence: Therapeutic IV.

Purpose: To evaluate the impact of preoperative osteoporosis on rates of revision and reoperation for patients with rheumatoid arthritis (RA) who underwent primary metacarpophalangeal (MCP) arthroplasty with silicone or pyrocarbon implants.

Methods: We retrospectively identified all primary silicone and pyrocarbon MCP arthroplasties performed in patients with RA at our institution over an 18-year period. Patient osteoporosis status was determined according to the National Bone Health Alliance criteria. We report survival free from revision (implant removal or replacement) and all-cause reoperation (including revisions) in these groups. We used cluster-robust, multivariable Cox proportional hazards models to analyze osteoporosis as a risk factor for revision and all-cause reoperation and report subgroup analysis for pyrocarbon and silicone implants.

Results: The osteoporosis group included 200 joints (168 silicone, 32 pyrocarbon) in 56 patients with a mean follow-up of 7.9 years. The nonosteoporosis group included 129 joints (93 silicone, 36 pyrocarbon) in 42 patients with a mean follow-up of 10 years. With pyrocarbon implants, the osteoporosis group had lower 10-year survival free from revision (58% vs 100%) and all-cause reoperation (40% vs. 81%) than the nonosteoporosis group. In multivariable analysis of pyrocarbon implants, osteoporosis was associated with increased hazard for revision (HR, 11.0; 95% CI, 1.27-95.8) and all-cause reoperation (HR, 3.4; 95% CI, 1.2-10.3). With silicone implants, there was no difference in 10-year survival free from revision (88% in osteoporosis, 89% in nonosteoporosis) or all-cause reoperation (85% osteoporosis, 85% nonosteoporosis). Osteoporosis did not affect risk for silicone implant revision or reoperation.

Conclusions: Osteoporosis is associated with increased risk for pyrocarbon implant revision and all-cause reoperation in RA patients, though the precise effect size is unknown. Silicone MCP arthroplasty remains a durable option for patients with RA regardless of osteoporosis status.

Type of study/level of evidence: Therapeutic IV.