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Pierrie SN, Gaston RG, Loeffler BJ. Current Concepts in Upper-Extremity Amputation. J Hand Surg Am 2018; 43:657-667. [PMID: 29871787 DOI: 10.1016/j.jhsa.2018.03.053] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 03/30/2018] [Indexed: 02/02/2023]
Abstract
Advances in motor vehicle safety, trauma care, combat body armor, and cancer treatment have enhanced the life expectancy and functional expectations of patients with upper-extremity amputations. Upper-extremity surgeons have multiple surgical options to optimize the potential of emerging prosthetic technologies for this diverse patient group. Targeted muscle reinnervation is an evolving technique that improves control of myoelectric prostheses and can prevent or treat symptomatic neuromas. This review addresses current strategies for the care of patients with amputations proximal to the wrist with an emphasis on recent advancements in surgical techniques and prostheses.
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Bean B, Cook S, Loeffler BJ, Gaston RG. High-Pressure Water Injection Injuries of the Hand May Not Be Trivial. Orthopedics 2018; 41:e245-e251. [PMID: 29377050 DOI: 10.3928/01477447-20180123-04] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 11/30/2017] [Indexed: 02/03/2023]
Abstract
High-pressure water injection injuries of the hand are uncommon, and there is limited literature to guide their treatment. The ideal management of these injuries, whether nonoperative with close observation or early surgical debridement, remains unknown. The authors retrospectively identified a cohort of patients with high-pressure water injection injuries to the hand during a 16-year period. Data collected included demographics, location of injection, hand dominance, type of treatment, need for additional surgery, and complications. The authors attempted to reach all patients by phone and email to assess long-term motion loss, sensation loss, and chronic pain. Nineteen patients met the inclusion criteria. The nondominant hand was involved in 84% and the index finger in nearly half. Two of 10 patients in the early surgery group required additional procedures, including a trigger finger release and serial debridements for Pseudomonas infection. Three of 9 patients without early debridement eventually required surgery, including debridement of a septic flexor tenosynovitis, fingertip amputation, and metacarpophalangeal disarticulation. Sixteen percent of patients developed infection, and 1 patient developed compartment syndrome. This is the largest reported cohort of both operatively and nonoperatively treated high-pressure water injection injuries to the hand. This is the first report of amputation as a complication. Infection and delayed presentation portend a poor outcome. Complications may arise even after early surgical debridement, and long-term sequelae are common. These injuries are not inherently benign and warrant immediate medical attention, early antibiotics, and a low threshold for close observation or surgical debridement. [Orthopedics. 2018; 41(2):e245-e251.].
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Costas B, Coleman S, Kaufman G, James R, Cohen B, Gaston RG. Efficacy and safety of collagenase clostridium histolyticum for Dupuytren disease nodules: a randomized controlled trial. BMC Musculoskelet Disord 2017; 18:374. [PMID: 28854973 PMCID: PMC5577662 DOI: 10.1186/s12891-017-1713-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 08/10/2017] [Indexed: 12/14/2022] Open
Abstract
Background To determine the safety and efficacy of collagenase clostridium histolyticum (CCH) injection for the treatment of palmar Dupuytren disease nodules. Methods In this 8-week, double-blind trial, palpable palmar nodules on one hand of adults with Dupuytren disease were selected for treatment. Patients were randomly assigned using an interactive web response system to receive a dose of 0.25 mg, 0.40 mg, or 0.60 mg (1:1:1 ratio) and then allocated to active treatment (CCH) or placebo (4:1 ratio). All patients and investigators were blinded to treatment. One injection was made in the selected nodule on Day 1. Caliper measurements of nodule length and width were performed at screening and at Weeks 4 and 8. Investigator-reported nodular consistency and hardness were evaluated at baseline and Weeks 1, 4, and 8. Investigator-rated patient improvement (1 [very much improved] to 7 [very much worse]) and patient satisfaction were assessed at study end. Results In the efficacy population (n = 74), percentage changes in area were significantly greater with CCH 0.40 mg (−80.1%, P = 0.0002) and CCH 0.60 mg (−78.2%, P = 0.0003), but not CCH 0.25 mg (−58.3%, P = 0.079), versus placebo (−42.2%) at post-treatment Week 8. Mean change in nodular consistency and hardness were significantly improved with CCH versus placebo at Weeks 4 and 8 (P ≤ 0.0139 for all). At Week 8, investigator global assessment of improvement was significantly greater with CCH 0.40 mg and 0.60 mg (P ≤ 0.0014) but not statistically significant with CCH 0.25 mg versus placebo (P = 0.13). Most patients were “very satisfied” or “quite satisfied” with CCH 0.40 mg and 0.60 mg. Contusion/bruising (50.0% to 59.1%) was the most common adverse event with CCH treatment. Conclusion In patients with Dupuytren disease, a single CCH injection significantly improved palmar nodule size and hardness. The safety of CCH was similar to that observed previously in patients with Dupuytren contracture. Trial registration ClinicalTrials.gov identifier: NCT02193828. Date of trial registration: July 2, 2014 to December 5, 2014
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Tait MA, Bracey JW, Gaston RG. Acute Scaphoid Fractures: A Critical Analysis Review. JBJS Rev 2016; 4:01874474-201609000-00003. [PMID: 27760075 DOI: 10.2106/jbjs.rvw.15.00073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Nondisplaced scaphoid fractures can be effectively treated nonoperatively, with union rates approaching or, in some series, exceeding the rates attained with operative intervention. The evidence supports equal outcomes when using a short arm or long arm cast for the closed treatment of nondisplaced scaphoid fractures. Also, equivalent outcomes have been demonstrated with or without a thumb spica component to the cast. Operative intervention is the recommended treatment for displaced scaphoid fractures. Advanced imaging should be obtained if clinical suspicion is present for a scaphoid fracture with negative radiographs more than 2 weeks after the injury. In some settings, it may even be more cost-effective to obtain advanced imaging sooner.
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Gaston RG. An Update on Upper Extremity Tendon Transfers. Hand Clin 2016; 32:xiii. [PMID: 27387087 DOI: 10.1016/j.hcl.2016.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Abstract
Opposition is the placement of the thumb opposite the fingers into a position from which it can work. This motion requires thumb palmar abduction, flexion, and pronation, which are provided by the abductor pollicis brevis, flexor pollicis brevis (FPB), and opponens pollicis. In the setting of a median nerve palsy, this function is typically lost, although anatomic variations and the dual innervation of the FPB may prevent complete loss at times. There are multiple well described and accepted tendon transfers to restore opposition, none of which have been proven to be superior to the others.
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Abstract
Power and tip pinch are an integral part of intrinsic hand function that can be significantly compromised with dysfunction of the ulnar nerve. Loss of power pinch is one component that can significantly affect an individual's ability to perform simple daily tasks. Tip pinch is less affected, as this task has significant contributions from the median nerve. To restore power pinch, the primary focus must be on restoring the action of the adductor pollicis primarily, and if indicated the first dorsal interosseous muscle and flexor pollicis brevis.
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Gaston RG. In Reply. J Hand Surg Am 2016; 41:e157-8. [PMID: 27265764 DOI: 10.1016/j.jhsa.2016.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 03/24/2016] [Indexed: 02/02/2023]
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Brannan PS, Gaston RG, Loeffler BJ, Lewis DR. Complications With the Use of BMP-2 in Scaphoid Nonunion Surgery. J Hand Surg Am 2016; 41:602-8. [PMID: 27013317 DOI: 10.1016/j.jhsa.2016.01.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 01/21/2016] [Accepted: 01/22/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE In an effort to improve fracture healing and decrease the need for autologous bone graft, products such as recombinant human bone morphogenetic protein (rhBMP-2) have been developed and used in both spine and nonspine surgery. There is a paucity of literature regarding the use of rhBMP-2 in scaphoid nonunion surgery with very little reporting on the complications associated with its use. The objective of this study was to retrospectively review the complications documented for a case series of patients treated with revision fixation, bone graft, and rhBMP-2 in revision scaphoid nonunion surgery. METHODS We retrospectively reviewed 6 cases of scaphoid nonunion revision surgery comprising open reduction and internal fixation (ORIF). All cases were performed for persistent nonunion after a previous scaphoid ORIF. All patients were treated with revision screw fixation, bone graft, and rhBMP-2. Union was determined by computed tomography in all cases. Complications of nonunion, heterotopic bone formation, delayed wound healing, functional loss of motion, and need for revision surgery are reported. RESULTS Between 2011 and 2014, 6 cases in which rhBMP-2 was used in revision scaphoid nonunion surgery were identified. All patients had failed an initial attempt at ORIF after delayed union or nonunion. The time from injury to index ORIF ranged from 3 months to 4 years (mean, 24 months). Revision surgery with rhBMP-2 was performed at an average of 6 months from the index ORIF. Of the 6 cases, 2 had resultant persistent nonunion. Both underwent scaphoid excision and midcarpal arthrodesis. Four cases developed notable heterotopic ossification (one of which required revision surgery). One patient had a loss of functional motion after the revision surgery. There were no cases of delayed wound healing. Only one of the 6 patients healed without complications. CONCLUSIONS In this case series, the use of rhBMP-2 in scaphoid nonunions was associated with a higher complication rate than reported in previous studies. Surgeons performing off-label use of rhBMP-2 should be aware of the potential for complications including heterotopic ossification. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Abstract
Background: Understanding the position-specific musculoskeletal forces placed on the body of athletes facilitates treatment, prevention, and return-to-play decisions. While position-specific injuries are well documented in most major sports, little is known about the epidemiology of position-specific injuries in National Association for Stock Car Automobile Racing (NASCAR) drivers and pit crew. Purpose: To investigate position-specific upper extremity injuries in NASCAR drivers and pit crew members. Study Design: Descriptive epidemiological study. Methods: A retrospective chart review was performed to assess position-specific injuries in NASCAR drivers and pit crew members. Included in the study were patients seen by a single institution between July 2003 and October 2014 with upper extremity injuries from race-related NASCAR events or practices. Charts were reviewed to identify the diagnosis, mechanism of injury, and position of each patient. Results: A total of 226 NASCAR team members were treated between July 2003 and October 2014. Of these, 118 injuries (52%) occurred during NASCAR racing events or practices. The majority of these injuries occurred in NASCAR changers (42%), followed by injuries in drivers (16%), carriers (14%), jack men (11%), fuel men (9%), and utility men (8%). The majority of the pit crew positions are at risk for epicondylitis, while drivers are most likely to experience neuropathies, such as hand-arm vibration syndrome. The changer sustains the most hand-related injuries (42%) on the pit crew team, while carriers commonly sustain injuries to their digits (29%). Conclusion: Orthopaedic injuries in NASCAR vary between positions. Injuries in NASCAR drivers and pit crew members are a consequence of the distinctive forces associated with each position throughout the course of the racing season. Understanding these forces and position-associated injuries is important for preventive measures and facilitates diagnosis and return-to-play decisions so that each team can function at its maximal efficiency.
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Gaston RG, Larsen SE, Pess GM, Coleman S, Dean B, Cohen BM, Kaufman GJ, Tursi JP, Hurst LC. The Efficacy and Safety of Concurrent Collagenase Clostridium Histolyticum Injections for 2 Dupuytren Contractures in the Same Hand: A Prospective, Multicenter Study. J Hand Surg Am 2015. [PMID: 26216077 DOI: 10.1016/j.jhsa.2015.06.099] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate efficacy and safety of concurrent administration of 2 collagenase clostridium histolyticum (CCH) injections to treat 2 joints in the same hand with Dupuytren fixed flexion contractures (FFCs). METHODS Patients with 2 or more contractures in the same hand caused by palpable cords participated in a 60-day, multicenter, open-label, phase 3b study. Two 0.58 mg CCH doses were injected into 1 or 2 cords in the same hand (1 injection per affected joint) during the same visit. Finger extension was performed approximately 24, 48, or 72 or more hours later. Changes in FFC and range of motion, incidence of clinical success (FFC ≤ 5°), and adverse events (AEs) were summarized. RESULTS The study enrolled 715 patients (725 treated joint pairs), and 714 patients (724 joint pairs) were analyzed for efficacy. At day 31, mean total FFC (sum of 2 treated joints) decreased 74%, from 98° to 27°. Mean total range of motion increased from 90° to 156°. The incidence of clinical success was 65% in metacarpophalangeal joints and 29% in proximal interphalangeal joints. Most treatment-related AEs were mild to moderate, resolving without intervention; the most common were swelling of treated extremity, contusion, and pain in extremity. The incidence of skin lacerations was 22% (160 of 715). Efficacy and safety were similar regardless of time to finger extension. CONCLUSIONS Collagenase clostridium histolyticum can be used to effectively treat 2 affected joints concurrently without a greater risk of AEs than treatment of a single joint, with the exception of skin laceration. The incidence of clinical success in this study after 1 injection per joint was comparable to phase 3 study results after 3 or more injections per joint. Two concurrent CCH injections may allow more rapid overall treatment of multiple affected joints, and the ability to vary the time between CCH injection and finger extension may allow physicians and patients greater flexibility with scheduling treatment.
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Abstract
This article reviews the most common complications associated with the management of carpal fractures. Discussion focuses on the recognition of commonly "missed" fractures and fracture patterns and the negative sequelae that can result from these delayed diagnoses. The pitfalls of conservative treatment of specific carpal fractures are reviewed, and the most common complications resulting from the operative management of carpal injuries are described.
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Döring ACD, Hageman MGJS, Mulder FJ, Guitton TG, Ring D, Akabudike NM, Bainbridge L, Balfour GW, Bamberger H, Barreto CJR, Baskies M, Baxamusa T, Behrman M, Benhaim P, Blazar P, Boler JM, Boretto JG, Boyer M, Calfee RP, Cassidy C, Costanzo RM, Darowish M, de Bedout R, Desilva G, Di Giovanni JF, Dodds S, Erickson JM, Luis Felipe NE, Fernandes C, Fricker RM, Frykman GK, Garcia AE, Gaston RG, Gilbert RS, Grafe MW, Greenberg JA, Grunwald H, Guidera P, Hammert WC, Hauck R, Helgemo S, Hernandez GR, Hofmeister E, Hutchison RL, Ilyas A, Jacoby SM, Jebson P, Jones CM, Kakar S, Kaplan FTD, Kaplan S, Katolik L, Kennedy SA, Kessler MW, Kimball HL, Kirkpatrick DK, Klinefelter R, Kraan G, Lane LB, Lattanza L, Lee K, Malone KJ, Manke C, Martineau PA, Matiko J, McAuliffe J, McCabe SJ, McKee DM, Metzger C, Mitchell S, Wolf JM, Nancollas M, Nelson DL, Nolla J, Nyszkiewicz R, Ortiz JA, Overbeck JP, Owens PW, Papandrea R, Paz L, Castillo AP, Polatsch D, Press GM, Richard MJ, Rizzo M, Rozental TD, Ruchelsman D, Semenkin OM, Shatford R, Sierra FJA, Siff T, Spath C, Spruijt S, Sutker B, Swigart C, Taras J, Tavakolian JD, Terrono AL, Tolo ET, Walsh CJ, Walter FL, Watkins B, Weiss L, Wills BP, Wilson C, Wilson CJ, Wint J, Young C. Trigger finger: assessment of surgeon and patient preferences and priorities for decision making. J Hand Surg Am 2014; 39:2208-13.e2. [PMID: 25283491 DOI: 10.1016/j.jhsa.2014.08.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 08/03/2014] [Accepted: 08/07/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To test the null hypothesis that there are no differences in the priorities and preferences of patients with idiopathic trigger finger (TF) and hand surgeons. METHODS One hundred five hand surgeons of the Science of Variation Group and 84 patients with TF completed a survey about their priorities and preferences in decision making regarding the management of TF. The questionnaire was structured according the Ottawa Decision Support Framework for the development of a decision aid. RESULTS Patients desired orthotics more and surgery less than physicians. Patients and physicians disagreed on the main advantage of several treatment options for TFs and on disadvantages of the treatment options. Patients preferred to decide for themselves after receiving advice, whereas physicians preferred a shared decision. Patients preferred booklets, and physicians opted for Internet and video decision aids. CONCLUSIONS Comparing patients and hand surgeons, there were some differences in treatment preferences and perceived advantages and disadvantages regarding idiopathic TF-differences that might be addressed by a decision aid. CLINICAL RELEVANCE Information that helps inform patients of their options based on current best evidence might help them understand their own preferences and values, reduce decisional conflict, limit surgeon-to-surgeon variations, and improve health.
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Brar R, Owen JR, Melikian R, Gaston RG, Wayne JS, Isaacs JE. Reattachment of flexor digitorum profundus avulsion: biomechanical performance of 3 techniques. J Hand Surg Am 2014; 39:2214-9. [PMID: 25227598 DOI: 10.1016/j.jhsa.2014.07.054] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 07/10/2014] [Accepted: 07/12/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate whether inclusion of the volar plate in repair of flexor digitorum profundus avulsions increases the strength of the repair and resists gapping. METHODS Cadaveric fingers (n = 18) were divided into 3 equal groups. The first technique involved 2 micro-suture anchors only (A). The second used only volar plate repair (VP). The third group was a hybrid, combining a micro-suture anchor with volar plate augmentation (AVP). Specimens were loaded cyclically to simulate passive motion rehabilitation before being loaded to failure. Clinical failure was defined as 3 mm of gapping, and physical failure as the highest load associated with hardware failure, suture breakage, anchor pullout, or volar plate avulsion. RESULTS Gapping throughout cycling was significantly greater for the A group than VP and AVP with no difference detected between VP and AVP groups. Gapping exceeded 3 mm during cycling of 3 A specimens, but in none of the VP or AVP specimens. Load at clinical and physical failure for A was significantly lower than for VP and AVP, whereas no difference was detected between VP and AVP. CONCLUSIONS In this cadaveric model, incorporating the volar plate conferred a significant advantage in strength, increasing the mean load to physical failure by approximately 100 N. CLINICAL RELEVANCE According to previous biomechanical studies, current reconstructive strategies for flexor digitorum profundus zone I avulsions are not strong enough to withstand active motion rehabilitation. We demonstrated the potential use of volar plate augmentation and the prospective advantageous increase in strength in this cadaveric model. In vivo performance and effects on digital motion are not known.
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Abstract
This article provides a philosophic overview of the management of athletes at all levels from high school to professional. It further reviews sports-specific injury patterns and position-specific injury patterns. This aspect is crucial, as many injuries may be relatively common for specific sports but rare in the general population, so recognition of these injuries requires a high degree of suspicion. The guiding principles of management are also discussed.
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Hageman MGJS, Kinaci A, Ju K, Guitton TG, Mudgal CS, Ring D, Adams J, Arbelaez GF, Aspard T, Balfour GW, Bamberger HB, Barreto RJC, Baskies M, Batson WA, Baxamusa T, de Bedout R, Beldner S, Benhaim P, Benson L, Boretto GJ, Boyer M, Dee Byrd G, Calfee RP, Zambrano GC, Cassidy C, Catalano L, Chivers K, Costanzo RM, Dantuluri P, DeSilva G, Dodds S, Evans JP, Felipe NEL, Fernandes C, Fischer TJ, Fischer J, Fricker MR, Frykman GK, Garcia AE, Gaston RG, Di Giovanni JF, Goldfarb CA, Grafe MW, Grunwald H, Hammert WC, Hauck R, Hernandez RG, Hofmeister E, Hutchison RL, Ilyas A, Isaacs J, Jacoby SM, Jebson P, Jones CM, Jones M, Kakar S, Kalainov DM, Kaplan TD, Kaplan S, Katolik L, Kennedy SA, Kessler MW, Kimball HL, Kraan G, Martineau PA, McAuliffe J, McCabe SJ, McKee DM, Merrell G, Metzger C, Nancollas M, Nelson DL, Nyszkiewicz R, Ortiz JA, Owens PW, Palmer JM, Paz L, Pess G, Polatsch D, Raia FJ, Richard MJ, Rizzo M, Rozental, Ruchelsman D, Semenkin OM, Sierra AJF, Siff T, Sodha S, Spath C, Spruijt S, Stackhouse TF, Swigart C, Szabo R, Taras J, Tavakolian J, Terrono A, Varecka TF, Wahegaonkar AL, Walsh CJ, Walter FL, Weiss L, Wills BP, Wilson C, Wilson C, Wolf JM, Wood M, Young C. Carpal tunnel syndrome: assessment of surgeon and patient preferences and priorities for decision-making. J Hand Surg Am 2014; 39:1799-1804.e1. [PMID: 25087865 DOI: 10.1016/j.jhsa.2014.05.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 05/22/2014] [Accepted: 05/23/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE This study tested the null hypothesis that there are no differences between the preferences of hand surgeons and those patients with carpal tunnel syndrome (CTS) facing decisions about management of CTS (ie, the preferred content of a decision aid). METHODS One hundred three hand surgeons of the Science of Variation Group and 79 patients with CTS completed a survey about their priorities and preferences in decision making regarding the management of CTS. The questionnaire was structured according the Ottawa Decision Support Framework for the development of a decision aid. RESULTS Important areas on which patient and hand surgeon interests differed included a preference for nonpainful, nonoperative treatment and confirmation of the diagnosis with electrodiagnostic testing. For patients, the main disadvantage of nonoperative treatment was that it was likely to be only palliative and temporary. Patients preferred, on average, to take the lead in decision making, whereas physicians preferred shared decision making. Patients and physicians agreed on the value of support from family and other physicians in the decision-making process. CONCLUSIONS There were some differences between patient and surgeon priorities and preferences regarding decision making for CTS, particularly the risks and benefits of diagnostic and therapeutic procedures. CLINICAL RELEVANCE Information that helps inform patients of their options based on current best evidence might help patients understand their own preferences and values, reduce decisional conflict, limit surgeon-to-surgeon variations, and improve health.
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Gettys FK, Gaston RG. Timothy Syndrome: A Life-Threatening Syndactyly Association: A Case Report. JBJS Case Connect 2014; 4:e48. [PMID: 29252561 DOI: 10.2106/jbjs.cc.m.00131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Colantoni J, Chadderdon C, Gaston RG. Arthroscopic wafer procedure for ulnar impaction syndrome. Arthrosc Tech 2014; 3:e123-5. [PMID: 24749031 PMCID: PMC3986578 DOI: 10.1016/j.eats.2013.09.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 09/06/2013] [Indexed: 02/03/2023] Open
Abstract
Ulnar impaction syndrome is abutment of the ulna on the lunate and triquetrum that increases stress and load, causing ulnar-sided wrist pain. Typically, ulnar-positive or -neutral variance is seen on a posteroanterior radiograph of the wrist. The management of ulnar impaction syndrome varies from conservative, symptomatic treatment to open procedures to shorten the ulna. Arthroscopic management has become increasingly popular for management of ulnar impaction with ulnar-positive variance of less than 3 mm and concomitant central triangular fibrocartilage complex tears. This method avoids complications associated with open procedures, such as nonunion and symptomatic hardware. The arthroscopic wafer procedure involves debridement of the central triangular fibrocartilage complex tear, along with debridement of the distal pole of the ulna causing the impaction. Debridement of the ulna arthroscopically is taken down to a level at which the patient is ulnar neutral or slightly ulnar negative. Previous studies have shown good results with relief of patient symptoms while avoiding complications seen with open procedures.
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Song JW, Waljee JF, Burns PB, Chung KC, Gaston RG, Haase SC, Hammert WC, Lawton JN, Merrell GA, Nassab PF, Yang LJS. An outcome study for ulnar neuropathy at the elbow: a multicenter study by the surgery for ulnar nerve (SUN) study group. Neurosurgery 2014; 72:971-81; discussion 981-2; quiz 982. [PMID: 23426153 DOI: 10.1227/neu.0b013e31828ca327] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Many instruments have been developed to measure upper extremity disability, but few have been applied to ulnar neuropathy at the elbow (UNE). OBJECTIVE We measured patient outcomes following ulnar nerve decompression to (1) identify the most appropriate outcomes tools for UNE and (2) to describe outcomes following ulnar nerve decompression. METHODS Thirty-nine patients from 5 centers were followed prospectively after nerve decompression. Outcomes were measured preoperatively and at 6 weeks, 3 months, 6 months, and 12 months postoperatively. Each patient completed the Michigan Hand Questionnaire (MHQ), Carpal Tunnel Questionnaire (CTQ), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires. Grip, key-pinch strength, Semmes-Weinstein monofilament, and 2-point discrimination were measured. Construct validity was calculated by using Spearman correlation coefficients between questionnaire scores and physical and sensory measures. Responsiveness was assessed by standardized response means. RESULTS Key-pinch (P = .008) and Semmes-Weinstein monofilament testing of the ulnar ring (P < .001) and small finger (radial: P = .004; ulnar: P < .001) improved following decompression. Two-point discrimination improved significantly across the radial (P = .009) and ulnar (P = .007) small finger. Improved symptoms and function were noted by the CTQ (preoperative CTQ symptom score 2.73 vs 1.90 postoperatively, P < .001), DASH (P < .001), and MHQ: function (P < .001), activities of daily living (P = .003), work (P = .006), pain (P < .001), and satisfaction (P < .001). All surveys demonstrated strong construct validity, defined by correlation with functional outcomes, but MHQ and CTQ symptom instruments demonstrated the highest responsiveness. CONCLUSION Patient-reported outcomes improve following ulnar nerve decompression, including pain, function, and satisfaction. The MHQ and CTQ are more responsive than the DASH for isolated UNE treated with decompression.
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Burns PB, Kim HM, Gaston RG, Haase SC, Hammert WC, Lawton JN, Merrell GA, Nassab PF, Yang LJ, Chung KC. Predictors of functional outcomes after simple decompression for ulnar neuropathy at the elbow: a multicenter study by the SUN study group. Arch Phys Med Rehabil 2013; 95:680-5. [PMID: 24252584 DOI: 10.1016/j.apmr.2013.10.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 10/31/2013] [Accepted: 10/31/2013] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To identify predictors of surgical outcome for ulnar neuropathy at the elbow (UNE). DESIGN Prospective cohort followed for 1 year. SETTING Clinics. PARTICIPANTS Patients diagnosed with UNE (N=55). INTERVENTION All subjects had simple decompression surgery. MAIN OUTCOME MEASURES The primary outcome measure was patient-reported outcomes, such as overall hand function through the Michigan Hand Outcomes Questionnaire (MHQ). Predictors included age, duration of symptoms, disease severity, and motor conduction velocity across the elbow. RESULTS Multiple regression models with change in the overall MHQ score as the dependent variable showed that at 3 months postoperative time, patients with <3 months duration of symptoms showed 12 points (95% confidence interval [CI], 0.9-23.5) greater improvement in MHQ scores than those with ≥3 months symptom duration. Less than 3 months of symptoms was again associated with 13 points (95% CI, 2.9-24) greater improvement in MHQ scores at 6 months postoperative, but it was no longer associated with better outcomes at 12 months. A worse baseline MHQ score was associated with significant improvement in MHQ scores at 3 months (coefficient, -0.38; 95% CI, -.67 to -.09), and baseline MHQ score was the only significant predictor of 12 month MHQ scores (coefficient, -.40; 95% CI, -.79 to -.01). CONCLUSIONS Subjects with <3 months of symptoms and worse baseline MHQ scores showed significantly greater improvement in functional outcomes as reported by the MHQ. However, duration of symptoms was only predictive at 3 or 6 months because most patients recovered within 3 to 6 months after surgery.
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Capo JA, Kuremsky MA, Gaston RG. Fractures of the lesser sesamoids: case series. J Hand Surg Am 2013; 38:1941-4. [PMID: 24011721 DOI: 10.1016/j.jhsa.2013.06.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 06/27/2013] [Accepted: 06/28/2013] [Indexed: 02/02/2023]
Abstract
We present 3 cases of sesamoid fractures involving the index, ring, and little finger metacarpophalangeal joints. These injuries present similar to more common sprains of the finger metacarpophalangeal joint and may be difficult at times to appreciate on standard posteroanterior and lateral x-rays. Oblique images can aid in making the diagnosis at times. Whereas we still recommend immobilization as the initial treatment for these injuries, all 3 of our cases failed nonoperative management and eventually required sesamoid excision.
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Gaston RG, Robinson EP. e-Prescribe meaningful use requirement. J Hand Surg Am 2012; 37:839-40; quiz 841. [PMID: 22305732 DOI: 10.1016/j.jhsa.2011.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Revised: 12/04/2011] [Accepted: 12/12/2011] [Indexed: 02/02/2023]
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Puckett BN, Gaston RG, Lourie GM. A novel technique for the treatment of recurrent cubital tunnel syndrome: ulnar nerve wrapping with a tissue engineered bioscaffold. J Hand Surg Eur Vol 2011; 36:130-4. [PMID: 21045022 DOI: 10.1177/1753193410384690] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to assess subjective and objective outcomes in treating recurrent cubital tunnel at secondary neurolysis by nerve wrapping with a tissue engineered three-dimensional biomatrix. Five patients with a mean age of 44.1 years and an average follow-up of 13.3 months were included in the study. All patients had improvement in visual analogue scales. Four patients that had preoperative intrinsic atrophy with clawing had no clawing or intrinsic atrophy at final follow-up. Postoperatively, four of the five patients had two-point discrimination of 5 mm. Grip strength on average increased 90%. Three patients had an excellent outcome, one patient had a good outcome, and one patient had a fair outcome. All five patients said they would have surgery again.
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