The Journal of hand surgery, European volume最新文献

Introduction: The Narakas classification of brachial plexus birth injuries has been widely used but its validity for intraoperative classification of lower root injuries (C8-T1) is debated. This study introduces a new intraoperative classification and assesses its correlation with muscle function before and after operative repair of the brachial plexus.

Methods: The study reviewed 162 primary brachial plexus explorations over 19 years. Based on intraoperative findings, patients were categorized by injury patterns, A (C5-C6), B (C5-C7), C (C5-C8) and D (C5-T1), followed by the number of root avulsions. Preoperative and postoperative active movement scale scores, along with intraoperative findings, were compared in assessing lower root involvement.

Results: Ten cases were classified as injury type A, 42 as type B, 14 as type C, and 96 as D. Of 682 injured nerve roots, 189 were avulsed. With a mean follow-up of 5.4 years, the median preoperative total active movement scale score was 39 (IQR 24 to 54) and improved to 55 (IQR 44.25 to 70) at final postoperative follow-up. There was a decline in pre- and postoperative scores with increasing injury severity from A to D. Significant differences were observed between injury subtypes based on number of avulsions, notably in the injury D subgroup (p < 0.001). Horner's syndrome did not significantly impact final postoperative active movement scale scores after adjusting for injury types.

Conclusions: An intraoperative classification that specifies roots involved may better capture variability of brachial plexus birth injuries than the established Narakas system and align more closely with functional recovery. These findings emphasize the importance of intraoperative assessment to guide surgical decision-making.

Level of evidence: IV.

We present a 46-year-old man with pain in his left hand caused by entrapment of a bifid median nerve by an accessory belly of the flexor digitorum superficialis muscle in the midforearm. A literature review found this case to be novel.

Introduction: This study investigated the association between capitate morphology and the success rates of non-vascularized bone graft (NVBG) and vascularized bone graft (VBG) operations for scaphoid nonunion.

Methods: We retrospectively analysed 213 patients with established scaphoid non-union who underwent either non-vascularized bone graft (n = 75) or vascularized bone graft (n = 138). We analysed risk factors, including demographics, medical history, implant type, previous surgery, bone graft donor site and capitate morphology for their association with treatment outcome. We also assessed the relationship between capitate and scaphoid morphology in the uninjured wrists of 31 patients.

Results: The overall success rate was 81% for NVBG and 86% for VBG, with no significant difference. For NVBG, Type II capitate, age 40 or older and tobacco use were significant risk factors for failure. For VBG, only previous surgery was a significant risk factor. In uninjured wrists, a Type II capitate was associated with a significantly thinner scaphoid waist and a lower waist index than a Type I capitate.

Conclusion: Our study introduces a new radiographic classification of capitate morphology and establishes its significant association with scaphoid morphology. Beyond traditional factors, capitate morphology can help to assess scaphoid morphology and potentially infer vascularity, aiding the selection of the most appropriate bone graft type for treating scaphoid non-union.

Level of evidence: III.

Introduction: Amyloid deposition in the tenosynovium and transverse carpal ligament, and particularly cardiac involvement, are rare in patients with carpal tunnel syndrome; however, the prevalence may be underreported. This prospective study assessed the prevalence of amyloid deposits in the synovium and transverse carpal ligament and whether dual-site sampling improved detection. Risk factors for a positive test and asymptomatic cardiac involvement were also investigated.

Methods: In a prospective cohort of 100 consecutive patients undergoing carpal tunnel release, intraoperative biopsies were taken from the tenosynovium and the transverse carpal ligament and examined using Congo red and immunohistochemistry staining. Concordance between biopsy sites was assessed, and independent predictors for a positive test were evaluated by multivariable logistic regression. Amyloid-positive patients underwent cardiac assessments, including cardiac biomarkers and ^99mTc-pyrophosphate scintigraphy.

Results: Amyloid deposition was present in 62 patients. Concordance between biopsy sites was 91%. Older age, male sex, bilateral carpal tunnel syndrome, multiple trigger fingers, and spinal stenosis independently predicted tissue amyloid. Asymptomatic cardiac amyloid deposition was identified in eight patients: three fulfilled criteria for cardiac amyloidosis and five demonstrated scintigraphic uptake with preserved function.

Conclusion: Amyloid deposition in carpal tunnel syndrome was common in our study population, and subclinical cardiac involvement was not rare. Dual-site biopsy improved detection compared with the single-site sampling, and we recommend this routinely during carpal tunnel release. If not feasible, we recommend prioritizing older or male patients and those with bilateral carpal tunnel syndrome, multiple trigger fingers or spinal stenosis. Multiple trigger fingers may indicate a systemic process and high amyloid/cardiac risk.

Level of evidence: III.

Background: The optimal management of children with a suspected scaphoid fracture and normal radiographs is unclear. Traditionally, children have been treated with empiric cast immobilization or with early CT or MRI to avoid missing an occult fracture. An early range of motion (ROM) protocol for these children may be an alternative strategy.

Methods: We conducted a prospective study to test the feasibility and potential benefits of an early ROM protocol for children with a clinically suspected scaphoid fracture but normal radiographs. Participants were evaluated at 6 weeks and, for those with a confirmed fracture on CT, at 26 weeks after injury.

Results: Of the 39 children (median age 12.2 years; interquartile range 10.6 to 13.8 years), 15 had a scaphoid fracture confirmed on CT. Participant retention rate was 36 of 39 (92%; 95% CI: 80 to 97%) at 6 weeks, and 12 of 15 (80%; 95% CI: 55 to 93%) at 26 weeks. Participants tolerated the protocol without concerns. There were no instances of non-union, avascular necrosis, or other adverse events.

Conclusion: An early ROM protocol for children with suspected scaphoid fractures but normal radiographs may reduce overtreatment and dependence on advanced imaging. Further study is feasible and required.

Level of evidence: III.

A prospective cohort study of patients with finger injuries found that patient reported outcomes showed improvement over 6 months but did not return to pre-injury levels. The Patient Evaluation Measure was the most sensitive of the outcome measures used.

Our technique of pollicization incorporates that described by Kozin with modifications by Mennen and Al-Qattan. We studied the outcome of this technique using three different outcome scores. In total, 16 index finger pollicizations were assessed by the Reach Out! score, the Percival score and the Thumb Grasp and Pinch Assessment score. The mean Reach Out! score was 16 and the mean Percival and Thumb Grasp and Pinch Assessment scores were 18 and 43 respectively. Patients with radial longitudinal deficiencies had worse outcomes on the Percival score. The Blauth classification of thumb hypoplasia had no significant effect on the outcome scores. The three scores correlated well with each other. The age at pollicization showed a significant correlation with the Thumb Grasp and Pinch Assessment and Percival scores. The outcomes of our technique were good and similar to other techniques.Level of evidence: IV.

The perception of patient reliability may create surgical decision-making biases amongst hand surgeons. In this study, anonymous surveys were distributed to hand surgeons to understand how patient 'reliability' is defined and how it alters treatment decisions. Participants rated the importance of patient factors in assessing reliability, then completed fictional clinical vignettes detailing histories of patients undergoing elective surgery. Suspected substance usage and history of mental illness were rated as important factors in determining reliability, while gender and race were rated as not important. Physicians were significantly less likely to recommend surgery and exhibited less confidence in their recommendations when presented with a patient with a history of mental illness (p < 0.001) or suspected substance usage (p = 0.003). These findings suggest that while race and gender may not explicitly impact surgical decision-making, biases related to mental illness and substance use do affect treatment decisions and confidence levels. Recognizing these biases is critical for ensuring equitable care, and future efforts should explore strategies to mitigate their impact on surgical recommendations. Level of evidence: IV.

Introduction: Periprosthetic joint infections (PJIs) of the trapeziometacarpal joint of the thumb are rare but challenging complications of arthroplasty. Currently, no hand-specific guidelines exist. This study aimed to develop consensus-based recommendations for their diagnosis and management.

Methods: A three-round Delphi process was conducted with seven European hand surgeons experienced in trapeziometacarpal joint arthroplasty. Consensus was defined as ⩾80% agreement (strong) and 65-79% (moderate). A scoping literature review of hand and large-joint PJIs was performed to support expert statements.

Results: All suspected infections were recommended to be managed surgically, with strong support for debridement and prosthesis neck exchange in acute infections. Trapeziectomy was endorsed as a salvage strategy in acute and chronic cases. Six weeks of antibiotic therapy, initiated intravenously and followed by oral administration, was strongly recommended. Amoxicillin/clavulanate and clindamycin were preferred empirical agents. The use of rifampicin was conditionally supported in confirmed Staphylococcus aureus infections. A 12-week interval between intraarticular corticosteroid injection and prosthesis implantation was recommended.

Discussion: This Delphi process, supported by literature review, provides the first structured guidance for the management of PJIs of the trapeziometacarpal joint of the thumb. Recommendations align with principles from large-joint infection management but are tailored to the anatomical and clinical context of the hand. These statements establish a practical framework for clinical decision-making and highlight priorities for future research.

Level of evidence: IV.