The Hand最新文献

Introduction: Our study aims to characterize the results of Monteggia fractures treated in our practice and to determine factors associated with good or poor outcomes.

Methods: A retrospective review of children aged 17 and under with acute, subacute, or chronic Monteggia fractures who were treated at our institution was performed. The primary outcomes were initial reduction and maintenance of joint reduction, while the secondary outcomes were elbow flexion/extension and forearm supination/pronation.

Results: Seventeen patients with Monteggia fractures were identified. Two patients were excluded: 1 was lost to follow-up and 1 had congenital absence of the elbow flexors. Thus, our final cohort was 15 patients (acute n = 3, subacute n = 4, chronic group n = 8). Median final follow-up was 1.9 years (range = 34 days-8 years).

Conclusion: Preoperative range of motion (ROM) was the most important factor in determining postoperative ROM in this cohort of patients with chronic Monteggia fractures. All patients who presented with excellent preoperative ROM, regardless of their timing category, had an excellent ROM outcome. Time from initial injury also played an important role. All patients in the acute and subacute categories had good or excellent postoperative ROM. Patients who were further from the initial injury were more likely to present with worse preoperative ROM and, in turn, had worse outcomes with postoperative ROM.

Background: Gunshot injuries can be devasting, regardless of their location. However, ballistic injuries involving the upper extremity have not been thoroughly investigated. The goal of this study is to evaluate the injury patterns and outcomes of patients who sustained gunshot injuries to the hand.

Methods: A retrospective chart review of patients with gunshot injuries to the upper extremity at a single, level 1 trauma center between January 2016 and December 2017 was performed. Patient demographics and mechanisms of injuries were reviewed. The injury patterns, location, tendon/nerve involvement, and bony involvement were analyzed. Surgical interventions and long-term outcomes were reviewed. Outcomes were compared using the presence of fractures and nerve/tendon injuries as independent variables.

Results: In all, 32 patients met our inclusion criteria. Of these, 15 patients had gunshots to the hand, 10 patients to the fingers, and 7 patients involving both the finger and hand. In patients with isolated hand injuries, 60% had fractures and 53% had nerve/tendon injuries. The presence of fractures was associated with a 7.9-fold increase in tendon and nerve injuries (P = .032). Patients who sustained tendon/nerve injuries had significantly higher rates of permanent disability (P = .01). The presence of a fracture leads to a higher likelihood of long-term complications, although not statistically significant (P = .13).

Conclusion: Ballistic injuries to the hand are frequently associated with fractures and neurovascular and tendon injuries. The presence of fractures is associated with a higher incidence of nerve and tendon injuries. Involvement of these structures is linked to an increased risk of long-term disability.

Background: Diabetes is a well-established risk factor for severe digital infection, and patients are more likely to require digital amputation for adequate source control. This study aims to identify factors predictive of digital amputation compared with preservation in patients with diabetes who present with surgically treated finger infections.

Methods: Current Procedural Terminology (CPT) and International Classification of Diseases Versions 9 and 10 (ICD-9/10) databases from a single academic medical center were queried to identify patients with type 1 or type 2 diabetes mellitus who underwent surgical treatment in the operating room for treatment of a digital infection from 2010 to 2020. Electronic medical records were reviewed to obtain historical and acute clinical variables at the time of hospital presentation. Bivariate and multivariable regression were used to identify factors associated with amputation.

Results: In total, 145 patients (61 digital amputation, 84 digital preservation) met inclusion criteria for this retrospective cohort study. Mean hospital stay was 6 days, and the average patient underwent 2 operations. Multivariable analysis revealed that the presence of osteomyelitis, ipsilateral upper extremity dialysis fistula, end-stage renal disease, and vascular disease each had significant independent predictive value for amputation rather than digital preservation.

Conclusions: Digital amputation is common in the setting of diabetic finger infection. The 4 variables found to independently predict the outcome of amputation can be understood as factors which decrease the likelihood of successful digital salvage and increase the potential consequence of ongoing uncontrolled infection. Further study should focus on clinical factors affecting surgical decision making and how the treatment rendered affects patient outcomes.

Background: Lipomas are a rare cause of posterior interosseous nerve (PIN) compression. A systematic review of predictors for motor recovery has not been performed. This study sought to evaluate whether patient or lipoma characteristics are associated with motor recovery and could be used to determine when immediate tendon transfers at the time of excision should be performed.

Methods: Articles describing patients with forearm lipomas resulting in PIN compression with motor weakness were included. Patient age, gender, symptom duration, laterality and largest dimension of lipoma, surgical intervention, and motor recovery were identified. Article quality was assessed via the Methodological Index for Non-Randomized Studies criteria.

Results: Thirty articles reporting on 34 patients were identified. Average age was 58.2 years. Average largest lipoma dimension was 5.7 cm. All patients underwent lipoma removal, and 2 had concomitant tendon transfers. In all, 73.5% of patients had complete motor recovery at an average of 9.7 months. Patient age and largest dimension of lipoma, and duration of symptoms were not significant predictors of motor recovery. Symptom duration was a significant predictor of motor recovery in binary regression, particularly if < 18 months.

Conclusions: The majority of patients with PIN weakness secondary to lipoma are likely to have complete motor recovery after excision alone. Concomitant tendon transfers should be considered for patients symptomatic for greater than 18 months. Further, adequately powered, studies are required to stratify risk factors and evaluate other modalities to identify the minority of patients who would benefit from immediate tendon transfer.

Background: The purpose of this study was to evaluate the influence of socioeconomic factors on access to congenital hand surgery care, hospital admission charges, and analyze these geographic trends across regions of the country.

Methods: Retrospective cohort study was conducted of congenital hand surgery performed in the United States from 2010 through 2020 using the Pediatric Health Information System. Multivariate regression was used to analyze the impact of socioeconomic factors.

Results: During the study interval, 5531 pediatric patients underwent corrective surgery for congenital hand differences, including syndactyly repair (n = 2439), polydactyly repair (n = 2826), and pollicization (n = 266). Patients underwent surgery at significantly earlier age when treated at above-median case volume hospitals (P < .001). Patients with above-median income (P < .001), non-white race (P < .001), commercial insurance (P < .001), living in an urban community (P < .001), and not living in an underserved area (P < .001) were more likely to be treated at high-volume hospitals. Nearly half of patients chose to seek care at a distant hospital rather than the one locally available (49.5%, n = 1172). Of those choosing a distant hospital, most patients chose a higher-volume facility (80.9%, n = 948 of 1172). On multivariate regression, white patients were significantly more likely to choose a more distant, higher-volume hospital (P < .001).

Conclusions: Socioeconomic and geographic factors significantly contribute to disparate access to congenital hand surgery across the country. Patients with higher socioeconomic status are more likely to be treated at high-volume hospitals. Treatment at hospitals with higher case volume is associated with earlier age at surgery and decreased hospital admission charges.

Background: Upper-extremity limb loss has been associated with serious psychological sequelae. Despite advancements in surgical procedures and prostheses for upper limb amputees, it is critical to recognize the psychosocial component of these patients' care. Although the role of psychological factors in outcomes is increasingly acknowledged, little is known about the prevalence of depression and post-traumatic stress disorder (PTSD) in the civilian population after traumatic upper-extremity amputation.

Methods: In this retrospective observational single-center study, adult patients evaluated for traumatic upper limb amputations from 2016 to 2019 completed the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, Visual Analogue Scale, the Center for Epidemiologic Studies Depression Scale, and the Primary Care PTSD Screen during visits. All data underwent descriptive statistical analysis.

Results: Thirty-nine adult patients treated for upper-extremity traumatic amputation completed patient-reported outcomes (PROs) questionnaires. The median final follow-up time for our cohort was 17 months from amputation. Twenty patients (51%) screened positive for depression and 27 (69%) for PTSD during follow-up. The median time from amputation to first positive screening was 6.5 months for depression and 10 months for PTSD. The physical component score of Veterans RAND 12-Item Health Survey (VR-12) was significantly worse for patients with depression. The Median DASH and mental component score of VR-12 were significantly worse for patients with PTSD.

Conclusion: Upper-extremity limb loss has a significant impact on mental health, which in turn affects PROs. The high prevalence of depression and PTSD in traumatic upper-extremity amputees underscores the necessity for screening and multidisciplinary treatment.

Background: The purposes of this study were to analyze the trends in Oxford level of evidence (LOE), LOE of most-cited articles, and association between LOE and journal impact factor (IF) and SCImago Journal Rank (SJR) over a 10-year period (2009-2018) in 3 prominent hand surgery journals, specifically HAND, Journal of Hand Surgery (American Volume) (JHS), and Journal of Hand Surgery (European Volume) (JHSE).

Methods: All articles published from 2009 to 2018 in HAND, JHS, and JHSE were reviewed for assigned or available LOE. Data were pooled and analyzed for trends in LOE; relationship among IF, SJR, and LOE; and citation density.

Results: A total of 3921 total publications were tabulated from 2009 to 2018, with the majority of studies being level V (1700, 43%) and fewer studies being level I (146, 4%). Over the 10-year study period, there was no significant change in frequency of level I studies for any journal. HAND trended significantly toward higher LOE, JHS trended toward higher LOE, and JHSE trended toward decreased LOE without significance. Among all journals, the annual number of articles and the average LOE were independent significant predictors of IF and SJR. Statistically significant correlations were found between citation density and LOE for JHS and HAND.

Conclusions: Higher quality evidence is becoming more prevalent in the hand surgery literature over the past 10 years. Annual articles, average LOE, and level I and II and level IV articles were significant predictors of increasing IF and SJR.

Background: The transradial artery access is the benchmark approach in transradial percutaneous coronary intervention (TR-PCI). The purpose of this study was to evaluate the different complications, treatments, and outcome of upper extremity dysfunction following a TR-PCI.

Methods: This was a prospective cohort substudy of patients with access-site complications. The study population consisted of 433 patients treated with TR-PCI. Referral to the hand center was mandated if the patient experienced new-onset or increase of preexistent symptoms in the upper extremity. Patients were followed up to the last control visit (5-7 months after the index procedure) at the hand center. Outcome results were categorized in "symptom-free," "improvement of symptoms," and "no improvement."

Results: Forty-one (9% of total) patients underwent assessment at the hand center. Most frequent referral indication was pain in the intervention arm. Women, preexisting sensibility disorder, and osteoarthritis in the intervention arm were associated with increased odds of referral. The most common complications diagnosed were carpal tunnel syndrome (n = 18) and osteoarthritis (n = 15). Thirty patients required further medical treatment. Immobilization therapy was most applied. Seventeen (4% of total) patients had persisting symptoms despite medical treatment.

Conclusions: The occurrence of complications in the upper extremity after a TR-PCI is small. Despite medical treatment, symptoms persisted in 4% of all patients treated with TR-PCI. Possible explanations for the persisting symptoms are exacerbation of latent osteoarthritis and carpal tunnel syndrome by trauma-induced edema. Awareness of TR-PCI-induced complications among all specialists is essential to optimize patient care.

Background: Double crush (DC) syndrome patients presenting with C6-7 radiculopathy and median nerve compression in the carpal tunnel report greater nerve irritability and weakness postdecompression than isolated peripheral nerve decompression. We hypothesize that patient-reported outcome is inferior following release at both cervical spine and wrist versus a single site of decompression.

Methods: Patients that underwent either anterior cervical decompression and fusion (ACDF) for C6-C7 radiculopathy, carpal tunnel release (CTR), or both within 5 years (DC) were identified. A total of 477 patients were analyzed (157 DC, 203 CTR, and 117 ACDF). Post-operative outcome Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Neck Disability Index, and visual analog scale (VAS) scores were collected at an average of 2 years postoperatively.

Results: QuickDASH scores were higher in the DC group versus CTR group (36 vs 22, P < .0002). Postoperative disability in the ACDF group was significantly higher than the DC group (50 vs 36, P < .017). There were no differences between ACDF and DC groups in arm pain intensity, but the CTR group demonstrated significantly greater arm pain intensity than the DC group (5.7 vs 3.6, 10-point scale, P < .01).

Conclusions: Patients undergoing ACDF and CTR have greater postoperative disability than those undergoing CTR alone, but less postoperative functional disability and pain than ACDF alone, indicating cervical radiculopathy may contribute a greater proportion of long-term disability postoperatively. Additionally, CTR had greater postoperative arm pain than DC patients, potentially indicating high rates of undiagnosed cervical radiculopathy or other sources of arm pain in these patients.

Background: Platelet-rich plasma (PRP) or corticosteroid injections may be used to conservatively treat mild-to-moderate carpal tunnel syndrome (CTS). We evaluated the cost-effectiveness of PRP injections versus corticosteroid injections for the treatment of mild-to-moderate CTS.

Methods: Markov modeling was used to analyze the base-case 45-year-old patient with mild-to-moderate CTS, unresponsive to conservative treatments, never previously treated with an injection or surgery, treated with a single injection of PRP, or methylprednisolone/triamcinolone 40 mg/mL. Transition probabilities were derived from level-I/II studies, utility values from the Tufts University Cost-Effectiveness Analysis Registry reported using visual analog scale (VAS), Boston Carpal Tunnel Questionnaire Symptom severity (BCTQ-S), and Boston Carpal Tunnel Questionnaire Functional status (BCTQ-F), and costs from Medicare, published studies, and industry. Analyses were performed from healthcare/societal perspectives. Outcomes were incremental cost-effectiveness ratios (ICER) and net monetary benefits (NMB). Willingness-to-pay thresholds were $50 000 and $100 000. Deterministic/probabilistic sensitivity analyses were performed.

Results: From a healthcare perspective, compared to PRP injections, the ICER for corticosteroid injections measured by VAS: -$13.52/quality-adjusted-life-years (QALY), BCTQ-S: -$11.88/QALY, and BCTQ-F: -$16.04/QALY. PRP versus corticosteroid injections provided a NMB measured by VAS: $428 941.12 versus $375 788.21, BCTQ-S: $417 115.09 versus $356 614.18, and BCTQ-F: $421 706.44 versus $376 908.45. From a societal perspective, compared to PRP injections, the ICER for corticosteroid injections measured by VAS: -$1024.40/QALY, BCTQ-S: -$899.95/QALY, and BCTQ-F: -$1215.51/QALY. PRP versus corticosteroid injections provided a NMB measured by VAS: $428 171.63 versus $373 944.39, BCTQ-S: $416 345.61 versus $354 770.36, and BCTQ-F: $420 936.95 versus $375 064.63.

Conclusions: PRP injections were more cost-effective than methylprednisolone/triamcinolone injections from healthcare and societal perspectives for mild-to-moderate CTS.