Journal of Hand Surgery-American Volume最新文献

Purpose: The use of magnetic resonance imaging (MRI) for evaluation of scaphoid nonunion may be an example of low-value imaging for the treatment of scaphoid nonunion. The purpose of this study was to investigate variation in MRI use for scaphoid nonunion, the association of MRI with a vascularized bone graft (VBG) and to develop consensus on MRI use for scaphoid nonunion.

Methods: We identified patients >18 years of age who underwent scaphoid nonunion surgery between 2010 and 2019 using a claims database. Patients who had, and did not have, an MRI within 90 days prior to their diagnosis of scaphoid nonunion were included and a multivariable analysis was performed to evaluate variation in MRI and VBG use. Subsequently, a literature review was performed, and a preliminary consensus statement was developed pertaining to the routine use of MRI for scaphoid nonunion. A consortium of nine hand surgeons evaluated the importance, feasibility, usability, and scientific acceptability of the statement through a modified RAND Coroporation/University of California, Los Angeles Delphi. Panelists evaluated the statement in two voting rounds with an intervening face-to-face discussion.

Results: We identified 1,324 eligible patients with surgical repair of a scaphoid nonunion. Two hundred and sixty-three (19.9%) underwent an MRI within 90 days prior to surgery. Differences in age, insurance type, and comorbidity burden existed between patients who received MRI and those who did not. The MRI cohort was more likely to receive VBG (10.6%) compared to those without an MRI (4.7%). Panelists agreed on the voting domains of the consensus statement and therefore the statement, "There is no benefit of routine MRI/MRA in the treatment of scaphoid nonunion with or without presumed avascular necrosis," was considered valid.

Conclusions: MRI use within 90 days of surgical repair of scaphoid nonunion varies, is associated with greater rates of VBG use, and may represent low-value imaging given the lack of sufficient evidence on this topic.

Clinical relevance: As MRI use for scaphoid nonunion varies and may represent low-value imaging, a validated consensus statement may help guide the evaluation of patients with scaphoid nonunion.

Purpose: Total wrist arthroplasty has become a viable alternative to arthrodesis. Wrist arthrodesis is not necessarily the final surgery for many of the patients because some patients never accept the residual pain and reduced function that accompanies a stiff wrist. The purpose of this study was to evaluate the clinical performance (pain, function, and satisfaction) of rearticulation, as well as the complications and reoperations of the procedure in a prospective unselected case series of patients.

Methods: Twelve (7 men) patients with a mean age of 53 (42-67) years were converted to a total wrist arthroplasty at a mean of 8 (3-17) years after wrist arthrodesis. The patients had undergone 53 wrist surgeries prior to rearticulation.

Results: One wrist with a periprosthetic fracture of the ulna and a loose distal radioulnar joint arthroplasty that had been removed during the conversion was finally fused a second time. At follow-up 7 (2-16) years after conversion, increased wrist active range of motion (0°-98°), supination (75°-85°), reduced Patient-Rated Wrist Evaluation score (56-30), and reduced visual analog scale pain scores were found. All arthroplasties were radiologically stable, well-fixed and osseointegrated. None regretted the surgery knowing the outcome.

Conclusions: Conversion from total wrist arthrodesis to a modern wrist arthroplasty is feasible, yielding good functional results, significant pain relief, and stable implants.

Type of study/level of evidence: Therapeutic IV.

Purpose: Although studies have demonstrated that locked screws with a length of 75% of the radius width are sufficient for the treatment of extra-articular fractures of the distal radius, the application of this principle to intra-articular fractures is less well-understood. This study aimed to evaluate the biomechanical properties of different types of volar plate fixation constructs for the treatment of distal radius fractures in the presence of a dorsal critical corner fragment.

Methods: A dorsal critical corner fracture was created in 18 synthetic distal radius models. The fragment was stabilized with one of three constructs: a posteroanterior integrated compression screw (group 1) or volar locking screws with a length of 90% or 75% of the volar/dorsal width of the radius (groups 2 and 3, respectively). For the biomechanical evaluation, a load was applied to the lunate facet. Fixation stiffness and loads to produce clinical and catastrophic failures were compared among the groups.

Results: The stiffness (N/mm) was 67.8 (SD, 14.7), 64.9 (SD, 8.63), and 65.8 (SD, 36.02) for groups 1, 2, and 3, respectively. The load required to generate a catastrophic displacement was 532.9 (SD, 142.32), 307.4 (SD, 101.51), and 230.8 N (SD, 77.68) for groups 1, 2, and 3, respectively. The load required to produce a 2-mm translation of the fixed fragment was 127.9 N (SD, 28.8) for group 1, 119.7 (SD, 11.78) for group 2, and 127.6 N (SD, 46.2) for group 3.

Conclusions: Significantly greater load is required for catastrophic failure after fixation of a dorsal critical corner fracture with an integrated compression screw; however, it provides similar stiffness and load to failure for 2 mm of translation.

Clinical relevance: For the treatment of intra-articular distal radius fractures with dorsal critical corner fragments, an integrated compression screw may be considered for rigid fixation of the fragment to support early return to daily activities.

Purpose: The scapholunate ligament (SLL) is the most frequently injured wrist ligament. The aim of this study was to investigate cellular and extracellular changes within the SLL following injury.

Methods: Fifteen SLLs were harvested, ranging between 39 days to 20 years from time of injury. These specimens were subject to immunohistochemical analysis to characterize their vascular and collagen constitution.

Results: Of the 15 ligaments, 4 were harvested <3 months from injury, and 11 harvested >3 months from injury. The mean type I collagen density was 45.6% (25.2% to 55.9%) in all specimens. The mean type III collagen density was 47% (38.2% to 51.8%) of the ligament area in specimens <3 months after injury and 30.6% (13.3% to 44.1%) in those >3 months after injury. Type III collagen density was highest in the volar subunit. Type I collagen decreased only minimally in specimens taken within 2 years of injury. The increase in the type I:III collagen ratio reflected the decline in type III collagen. Blood vessels were found in 13 of 15 specimens. Mean vessel density for all specimens was 1.3% (0% to 7.1%), with the highest density of 1.8% (0% to 10%) in the volar subunit. The vessel density decreased from 2.9% (1.3% to 4.3%) to 1.6% (0% to 10%) in the volar subunit in specimens harvested >3 months after injury.

Conclusions: Mean type III collagen density decreased with time, most notably within the volar subunit. Mean type I collagen density held comparatively stable in ligaments taken within 2 years from injury. Blood vessels were detected in 87% of specimens, with the highest density in the volar subunit.

Clinical relevance: The SLL displays a collagen profile similar to other ligaments with favorable healing capacity. The volar subunit possessed a collagen ratio and vessel density that may suggest its acute repair and inclusion in reconstructive techniques has merit.