The Hand最新文献

Background: Much has been written about the diagnosis and treatment of soft tissue mallet injuries. However, there has been little regarding the characteristics of this injury affecting patients' prognosis. The purpose of this prospective study was to identify factors influencing the outcome of treatment of soft tissue mallet injuries.

Methods: Patients diagnosed with soft tissue mallet injuries were enrolled prospectively in a protocol of dorsal splinting for 6 to 12 weeks, followed by weaning over 2 weeks and then evaluated at 6, 9, and ≥12 months.

Results: Thirty-seven patients (38 digits) completed the study. Treatment success was defined as a final extensor lag of <15° and failure as a final extensor lag of ≥15°. Those failing splint treatment were older compared with those successfully treated. Patient compliance was significantly associated with a successful outcome. Factors that did not significantly affect success included time to treatment, initial injury severity, splinting duration, sex, and ligamentous laxity. Disabilities of Arm, Shoulder, and Hand scores >0 were not associated with treatment failure. Radiographic and clinical extension lag were statistically comparable.

Conclusions: This study shows strong association between the success of splint treatment, younger patient age, and compliance with the treatment protocol. Despite this finding, most patients did not report any functional limitations, irrespective of the treatment success. In contrast to prior results, time to treatment and initial extensor lag did not significantly affect treatment success.

Background: Stenosing flexor tenosynovitis is commonly treated by injection of corticosteroids into the flexor tendon sheath. However, there is no consensus in the literature regarding the optimal technique, specifically when not utilizing ultrasound guidance. Here, we present a cadaver study in which 3 common techniques of flexor sheath injection were compared with regard to their accuracy and safety profiles.

Methods: Fifteen fresh-frozen cadaver hands (60 digits) were evenly divided into 3 groups (20 digits per group). Digits in each group were injected with methylene blue dye using 1 of the 3 techniques (palmar-to-bone, palmar supra-tendinous, and mid-axial). The fingers were then dissected and were inspected for location of dye, as well as injury to tendon or digital nerves.

Results: The mid-axial technique demonstrated the greatest accuracy with the highest rate of all intra-sheath injection, 15 of 20 digits (75%), while the palmar-to-bone technique produced the most combined intra- and extra-sheath injections, 13 of 20 digits, (65%) and the palmar supra-tendinous technique resulted in the most all extra-sheath injections, 9 of 20 digits (45%). The difference in rates of all intra-sheath injection was significant (P = .01). The mid-axial technique also produced the fewest intra-tendinous injections 0 of 20, although this result did not reach statistical significance (P = .15).

Conclusions: Compared to other common non-image guided flexor tendon sheath injection techniques, the mid-axial injection technique was found to be the most accurate in producing all intra-sheath injection and least likely to result in intra-tendinous injection.

Background: Trapezial pommel, or ulnar osteophyte positioned at the vertex of the saddle-shaped facet, is a consistent structural appearance in osteoarthritis (OA) of the first carpometacarpal. This study investigates its relation to radiographic measures (modified Eaton staging and thumb OA [ThOA] index) and wear patterns (trapezial surface morphology and cartilaginous eburnation).

Methods: In all, 137 whole trapezia were explanted from 116 patients and evaluated for Eaton staging, morphology (saddle, cirque, or dish), and eburnation (degree of cartilaginous effacement) of the articular surface of the trapezium. In total, 131 Robert's views and 126 stress views were reviewed by 2 blinded senior surgeons for ThOA index and pommel size. Statistical analyses included Spearman correlation and linear regression.

Results: Standardized pommel size achieved good intrarater reliability (correlation coefficient: 0.80-0.98) and moderate interrater reliability (correlation coefficient: 0.60-0.67). The ThOA index and pommel size were significantly correlated across Robert's (r_s = 0.51) and stress views (r_s = 0.64). The ThOA index better distinguished between stages compared with pommel size. All the radiographic measures inversely correlated with preserved cartilage and varied across morphologies. Pommel size differed significantly between dish and saddle, and the ThOA index was significantly different between all morphologies when using stress views.

Conclusions: We reliably quantified the pommel feature and demonstrated significant correlations with other radiographic and topologic measures of arthritic disease. If future studies can demonstrate that the pommel is a pathogenic process in ThOA and its correction can curb disease progression, the identification of the pommel feature may help guide targeted intervention.

When evaluating the available literature on the diagnosis and management of triangular fibrocartilage complex tears (TFCC), ulnar tears comprise the major focus of TFCC literature. Radial-sided (Class 1D) tears are seldom researched or discussed. The purpose of this study was to review the methods for identifying and treating radial-sided TFCC lesions, by examining the anatomy of the TFCC, the pathology of its radial portion, diagnostic techniques, and both surgical and nonoperative treatments. The avascular nature of the radial TFCC may influence its healing potential. Magnetic resonance arthrogram is the gold standard for non-invasively diagnosing a radial-sided tear. Non-operative management should be exhausted prior to surgical intervention, which commonly involves an inside-out repair involving radial trans-osseous sutures. Still, the literature is limited by patient sample size and therefore requires a greater population of class 1-D tears to confirm optimal diagnostic and treatment methods.

Background: Distal triceps ruptures are rare, and complete ruptures are commonly treated with surgery. Studies of patients in small cohorts with distal triceps tear have reported outcomes and risk factors; however, large-scale data are scant. This study seeks to determine current trends, outcomes, and risk factors of distal triceps tears.

Methods: Within a large insurance claims database, distal triceps repair patients were identified through Current Procedural Terminology coding with concomitant distal triceps International Classification of Diseases, 9th Revision/10th Revision diagnosis codes and 1-year active status before and after surgery. Demographics, total costs, 90-day complications, and revision rates within 1 year of index surgery were analyzed. Logistic regression was performed for revision and complication rates using sex, age, and comorbidities (anabolic steroid use, diabetes, ischemic heart disease, tobacco use, rheumatoid arthritis, and chronic kidney disease).

Results: A total of 8143 patients were included in the cohort. Male patients and patients aged 40 to 59 years comprised most of the study population. The postoperative complication rate was 5.8%, and the 1-year revision rate was 2.6%. Male sex, age >60 years, ischemic heart disease, rheumatoid arthritis, and chronic kidney disease were statistically significant risk factors for higher 90-day complication rates. Anabolic steroid use significantly increased the risk of surgical revision.

Conclusions: Distal triceps repairs in this large cohort study occur most frequently in men aged 40 to 59 years. Complications are generally low, with age >60 years, male sex, ischemic heart disease, rheumatoid arthritis, and chronic kidney disease as risk factors for 90-day complications and prior anabolic steroid use as a risk factor for 1-year revision surgery. This information can help to improve education and expectations of this procedure.

Background: Cost and compliance are 2 factors that can significantly affect the outcomes of non-operative and operative treatment of trigger finger (TF) and both may be influenced by social factors. The purpose of this study was to investigate socioeconomic disparities in the surgical treatment for TF.

Methods: Adult patients (≥18 years old) were identified using International Classification of Diseases 9 and 10 Clinical Modification diagnostic codes for TF and Current Procedural Terminology (CPT) procedural codes (CPT: 26055) in the New York Statewide Planning and Research Cooperative System database. Each diagnosis was linked to procedure data to determine which patients went on to have TF release. A multivariable logistic regression was performed to assess the likelihood of receiving surgery. The variables included in the analysis were age, sex, race, social deprivation index (SDI), Charlson Comorbidity Index, and primary insurance type. A P-value < .05 was considered significant.

Results: Of the 31 411 TF patients analyzed, 8941 (28.5%) underwent surgery. Logistic regression analysis showed higher odds of receiving surgery in females (odds ratio [OR]: 1.108) and those with workers compensation (OR: 1.7). Hispanic (OR: 0.541), Asian (OR: 0.419), African American (OR: 0.455), and Other race (OR: 0.45) had decreased odds of surgery. Medicaid (OR: 0.773), Medicare (OR: 0.841), and self-pay (OR: 0.515) reimbursement methods had reduced odds of receiving surgery. Higher social deprivation was associated with decreased odds of surgery (OR: 0.988).

Conclusions: There are disparities in demographic characteristics among those who receive TF release for trigger finger related to race, primary insurance, and social deprivation.

Background: Prescription opioid abuse in the United States has risen substantially over the past 2 decades. Narcotic prescription refill restrictions may paradoxically be contributing to this epidemic. We investigated a novel, refill-based opioid prescription method to determine whether it would alter postoperative narcotic distribution or consumption.

Methods: In this randomized controlled trial, patients undergoing internal fixation of distal radius fractures or thumb carpometacarpal joint arthroplasty received either a single prescription for all postoperative narcotics (control arm) or the same amount of pain medication divided into 3 equal prescriptions to be filled as needed (experimental arm). Outcomes included total narcotics dispensed, measured in morphine milligram equivalents (MME) through a prescription monitoring program, patient-reported opioid consumption versus opioid not consumed, and a satisfaction survey.

Results: Forty-eight participants were enrolled; 25 were randomized to the control arm and 23 to the experimental arm. At 8 weeks post-op, fewer opioids had been dispensed to the experimental arm (177 ± 94 vs 287 ± 123 MME, P = .0025). At 6-week follow-up, the experimental arm reported lower narcotic consumption (124 ± 105 vs 214 ± 110 MME, P = .0131). Subanalysis of the independent surgeries yielded similar results. Some patients reported insurance issues when filling subsequent prescriptions. Consequently, although 100% of control arm patients reported good pain control, only 82.6% of experimental arm patients said likewise (P = .0455).

Conclusions: This randomized clinical trial demonstrated that patients obtained and consumed fewer narcotics when postoperative opioids were given in a refill-based prescription method. More research is needed to determine whether this opioid distribution method is reproducible, translatable, and feasible.

Background: The goals of this study are to describe the reoperation rates in patients who underwent Wilson osteotomy compared with patients who underwent carpometacarpal (CMC) arthroplasty for early-stage arthritis and to evaluate the factors influencing the patient-reported outcomes.

Methods: Retrospectively, 52 patients who underwent surgery for stage I/II osteoarthritis of the thumb carpometacarpal were identified, consisting of 17 (33%) patients who underwent Wilson osteotomy and 35 (67%) who underwent carpometacarpal arthroplasty. A total of 28 (55%) patients completed the outcome questionnaires, consisting of 11 (39%) patients who underwent Wilson osteotomy and 17 (61%) patients who underwent carpometacarpal arthroplasty. We performed a multivariable linear regression model to identify factors associated with the Numeric Rating Scale (NRS) pain intensity at final follow-up.

Results: Among the patients who underwent CMC arthroplasty, 2 had a reoperation. Among the patients who underwent Wilson osteotomy, 3 had a reoperation. Among the patients who completed the outcome questionnaires, the median quick Disabilities of the Arm, Shoulder and Hand score was 10 and the median NRS Pain Intensity score was 0. In multivariable analysis, the postoperative Patient-Reported Outcomes Measurement Information System Pain Interference (PROMIS PI) was independently associated with higher postoperative NRS pain scores.

Conclusion: In younger patients with stage I/II CMC osteoarthritis, Wilson osteotomy may be a reasonable alternative to CMC arthroplasty. Outcomes were similar between both groups at mid-term follow-up, with only a slightly higher pain score in the osteotomy group. In patients with stage I/II carpometacarpal osteoarthritis, the PROMIS PI is the main factor indicating successful outcomes.

Background: Frailty, quantified using the 5-item modified frailty index (mFI-5), has been shown to predict adverse outcomes in orthopaedic surgery. The utility in total elbow arthroplasty (TEA) patients is unclear. We evaluated if increasing frailty would correlate with worse postoperative outcomes.

Methods: A retrospective assessment of patients in the American College of Surgeons National Surgery Quality Improvement Program undergoing primary TEA was performed. The mFI-5 was calculated by assigning 1 point for each comorbidity (diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functionally dependent health status). Poisson regression was used to evaluate mFI-5 scores on complications, length of stay (LOS), and adverse discharge. A significance threshold was at P < .05.

Results: In total, 609 patients were included; 34.5% (n = 210) were not frail (mFI = 0), 44.0% (n = 268) were slightly frail (mFI = 1), and 21.5% (n = 131) were frail (mFI ≥ 2). As mFI score increased from 0 to ≥ 2, the following rates increased: any complication (9.0%-19.8%), major complication (11.0%-20.6%), cardiac complication (0.0%-2.3%), hematologic complication (3.3%-9.2%), adverse discharge (2.9%-22.9%), and LOS from 2.08 to 3.97 days (all P < .048). Following adjustment, Poisson regression demonstrated patients with a mFI ≥ 2 had increased risk of major complication (risk ratio [RR]: 2.13; P = .029), any complication (RR: 2.49; P = .032), Clavien-Dindo IV complication (RR: 5.53; P = .041), and adverse discharge (RR: 5.72; P < .001).

Conclusions: Frailty is not only associated with longer hospitalizations, but more major complications and non-home discharge. The mFI-5 is a useful risk stratification that may assist in decision-making for TEA.

Background: Type B ulnar polydactyly is one of the most commonly encountered congenital hand differences and can be treated with ligation or excision. The purpose of this study was to determine what factors families consider in selecting treatment for their child with type B ulnar polydactyly.

Methods: We reviewed treatment outcomes and administered a survey by telephone to parents of children with type B ulnar polydactyly treated at a pediatric hospital between 2015 and 2020. We assessed satisfaction, reasons for choosing treatment, and post-management complications.

Results: The families of 70 of the 156 consecutive treated patients were successfully contacted and agreed to participate (45% response rate). The mean follow-up was 27 months. Twenty-eight chose in-office suture ligation and 42 chose excision. Rapid treatment was prioritized by those who opted for in-office ligation (P = .044). The complication rate for suture ligation was significantly higher than excision (P < .0001), with the most common complication being a residual remnant (nubbin or neuroma stump) (64%). Respondents with residual remnant reported significantly less satisfaction with the appearance of their child's hand (P < .001) and with treatment outcomes (P = .028) compared to those without residual remnants.

Conclusions: Factors considered by parents in choosing type of treatment for type B ulnar polydactyly vary and may be significantly influenced by the surgeon. Although the majority of parents remain extremely satisfied with their child's outcome regardless of management type, time to treatment plays a determinative role in parents opting for ligation rather than excision in the operating room.