Preoperative Indicators of the Effectiveness of Surgical Release in Patients with de Quervain Disease: A Prospective Cohort Study

BACKGROUND

A significant proportion of patients report persistent pain after surgical release for de Quervain disease (DQ). This study aimed to investigate the effectiveness of a surgical release for DQ and to identify the preoperative factors associated with pain after a surgical release for DQ.

METHODS

This prospective cohort study included 707 patients who underwent surgical release and completed a visual analogue scale questionnaire (VAS; range 0 to 100). We used a paired t test to analyze the effectiveness of the surgical release on pain at 3 months postoperatively compared with the preoperative measure. A hierarchical multivariable linear regression model was created to investigate the contribution of patient-related and disease-related characteristics to postoperative pain.

RESULTS

All VAS domains showed improvement after surgical release. On average, the mean VAS pain decreased by 44 points (95% CI, 42, 46). Smoking (B = 6.37; P < 0.01), younger age (B = -0.35; P < 0.01), longer duration of complaints (B = 0.13; P < 0.01), concomitant surgery (B = 14.40; P < 0.01), and higher VAS pain scores at intake (B = 0.15; P < 0.01) were associated with worse VAS pain scores postoperatively. Together, the variables explained 11% of the variance in mean VAS pain score at 3 months follow-up.

CONCLUSIONS

This study confirms that surgical treatment for DQ significantly reduces patient-reported pain. Smoking, younger age, concomitant surgery, duration of complaints, and higher VAS pain scores at intake are associated with worse patient-reported pain 3 months after surgical release. However, the small effects suggest that these factors should not be considered the only important factors.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Clinical outcomes after primary repair for thumb ulnar collateral ligament ruptures: a systematic review and meta-analysis

There is no consensus on the best surgical technique for treating thumb ulnar collateral ligament (UCL) ruptures. This systematic review and meta-analysis investigates which primary repair technique and postoperative immobilization protocol result in the best clinical outcomes. A literature search was conducted in Embase, Medline ALL Ovid, Web of Science Core Selection and Cochrane Central Register of Controlled Trials. Pain, stability, tip pinch strength, key pinch strength, grip strength, return to work and metacarpophalangeal joint range of motion were collected as postoperative outcomes. In total, 29 studies were included. All surgical techniques resulted in satisfactory clinical outcomes, with no significant differences between bone anchor reinsertion, suture fixation, K-wire fixation and a combination of techniques. K-wire immobilization resulted in worse postoperative pain, but similar stability compared to immobilization without a K-wire. Clinical outcomes after thumb UCL repair are excellent, with no differences in clinical outcomes noted among surgical techniques.

Surgical Techniques in Non-Traumatic Midcarpal Instability: Evaluating the Dorsal Capsulodesis and Three-Ligament Tenodesis Technique

BACKGROUND

Surgical management of midcarpal instability (MCI), also referred to as carpal instability nondissociative, remains controversial due to limited evidence on different techniques. This study aimed to assess and compare differences in patient-reported pain, hand and wrist function, patient satisfaction, range of motion, and return to work in patients with non-traumatic MCI who underwent surgical treatment either through dorsal wrist capsulodesis or three-ligament tenodesis (3LT).

METHODS

Patients with MCI and persisting complaints after conservative therapy treated with 3LT or dorsal capsulodesis were included. Patients with posttraumatic instability were excluded. Primary endpoints included the Patient Rated Wrist Evaluation (PRWE) and Satisfaction with Treatment Result Questionnaire at 12 months postoperative. All data were retrospectively analyzed.

RESULTS

A total of 91 patients treated with dorsal capsulodesis and 21 treated with 3LT between December 2011 and December 2019 were included. At twelve months postoperative, both treatment groups reported significant improvements in pain and function scores. However, at three months postoperative, the dorsal capsulodesis group exhibited significantly better outcomes, followed by a greater return to work (72%) compared to the 3LT group (50%). However, the capsulodesis group demonstrated a decreased range of motion at three months which was restored at 12 months postoperative. No significant difference in satisfaction with treatment was observed.

CONCLUSIONS

Both 3LT and dorsal capsulodesis demonstrate promising results for addressing non-traumatic MCI. However, considering the quicker recovery and faster return to work associated with dorsal capsulodesis, we recommend favoring capsulodesis over 3LT when both surgical options are deemed suitable for the patient.

LEVEL OF EVIDENCE

III.

Incision techniques for trigger thumb release: a comparison of outcomes of four types of skin incision

Although trigger thumb release is commonly performed, there is no consensus on the optimal skin incision. This study aimed to compare outcomes of four incision techniques, including V-shaped, oblique, transverse and longitudinal incisions. Outcomes included the Michigan Hand Outcomes Questionnaire, satisfaction with the treatment and postoperative complications. The results of 875 patients who underwent trigger thumb release were assessed. All groups demonstrated improvement in self-reported hand function (range of 10-14 points), pain (25-27 points) and aesthetics (4-7 points) from baseline to 3 months postoperatively with no differences between incision techniques. Of the patients, 76% reported good or excellent satisfaction with the outcome of treatment. Satisfaction and complication rates of the different incision techniques were similar. These findings imply that there is no clear benefit of one type of incision over another for trigger thumb release, suggesting that surgeons may use the technique of their preference.Level of evidence: III.

Phantom Limb Pain and Painful Neuroma After Dysvascular Lower-Extremity Amputation: A Systematic Review and Meta-Analysis

BACKGROUND

Phantom limb pain (PLP) and symptomatic neuroma can be debilitating and significantly impact the quality of life of amputees. However, the prevalence of PLP and symptomatic neuromas in patients following dysvascular lower limb amputation (LLA) has not been reliably established. This systematic review and meta-analysis evaluates the prevalence and incidence of phantom limb pain and symptomatic neuroma after dysvascular LLA.

METHODS

Four databases (Embase, MEDLINE, Cochrane Central, and Web of Science) were searched on October 5th, 2022. Prospective or retrospective observational cohort studies or cross-sectional studies reporting either the prevalence or incidence of phantom limb pain and/or symptomatic neuroma following dysvascular LLA were identified. Two reviewers independently conducted the screening, data extraction, and the risk of bias assessment according to the PRISMA guidelines. To estimate the prevalence of phantom limb pain, a meta-analysis using a random effects model was performed.

RESULTS

Twelve articles were included in the quantitative analysis, including 1924 amputees. A meta-analysis demonstrated that 69% of patients after dysvascular LLA experience phantom limb pain (95% CI 53-86%). The reported pain intensity on a scale from 0-10 in LLA patients ranged between 2.3 ± 1.4 and 5.5 ± .7. A single study reported an incidence of symptomatic neuroma following dysvascular LLA of 5%.

CONCLUSIONS

This meta-analysis demonstrates the high prevalence of phantom limb pain after dysvascular LLA. Given the often prolonged and disabling nature of neuropathic pain and the difficulties managing it, more consideration needs to be given to strategies to prevent it at the time of amputation.

The effectiveness of acellular nerve allografts compared to autografts in animal models: A systematic review and meta-analysis

BACKGROUND

Treatment of nerve injuries proves to be a worldwide clinical challenge. Acellular nerve allografts are suggested to be a promising alternative for bridging a nerve gap to the current gold standard, an autologous nerve graft.

OBJECTIVE

To systematically review the efficacy of the acellular nerve allograft, its difference from the gold standard (the nerve autograft) and to discuss its possible indications.

MATERIAL AND METHODS

PubMed, Embase and Web of Science were systematically searched until the 4th of January 2022. Original peer reviewed paper that presented 1) distinctive data; 2) a clear comparison between not immunologically processed acellular allografts and autologous nerve transfers; 3) was performed in laboratory animals of all species and sex. Meta analyses and subgroup analyses (for graft length and species) were conducted for muscle weight, sciatic function index, ankle angle, nerve conduction velocity, axon count diameter, tetanic contraction and amplitude using a Random effects model. Subgroup analyses were conducted on graft length and species.

RESULTS

Fifty articles were included in this review and all were included in the meta-analyses. An acellular allograft resulted in a significantly lower muscle weight, sciatic function index, ankle angle, nerve conduction velocity, axon count and smaller diameter, tetanic contraction compared to an autologous nerve graft. No difference was found in amplitude between acellular allografts and autologous nerve transfers. Post hoc subgroup analyses of graft length showed a significant reduced muscle weight in long grafts versus small and medium length grafts. All included studies showed a large variance in methodological design.

CONCLUSION

Our review shows that the included studies, investigating the use of acellular allografts, showed a large variance in methodological design and are as a consequence difficult to compare. Nevertheless, our results indicate that treating a nerve gap with an allograft results in an inferior nerve recovery compared to an autograft in seven out of eight outcomes assessed in experimental animals. In addition, based on our preliminary post hoc subgroup analyses we suggest that when an allograft is being used an allograft in short and medium (0-1cm, > 1-2cm) nerve gaps is preferred over an allograft in long (> 2cm) nerve gaps.

Reconstruction of an early stage SLAC wrist with the 3-LT procedure: A controversial reappraisal

OBJECTIVE

We hypothesized that the three-ligament tenodesis (3-LT) procedure is still sufficient - even in scapholunate advanced collapse (SLAC) cases - to reduce pain and improve wrist function. We compared patient-reported outcomes of scapholunate interosseus ligament (SLIL) injury patients with SLAC to SLIL injury patients treated with 3-LT, and then to patients who received proximal row carpectomy (PRC), as a control group.

METHOD

We included all patients with a traumatic SLIL injury and associated SLAC components treated with 3-LT and completed Patient Reported Wrist Evaluation (PRWE) questionnaires preoperative and at 12 months follow-up. First, we compared matched patients with SLIL injury and SLIL injury with SLAC, stage 1-3, who received 3-LT. Second, we compared patients who received 3-LT, with patients who underwent PRC, while having SLAC stage 2-3.

RESULTS

We compared 51 patients with SLAC to 95 with SLIL injury who had a 3-LT procedure, and 10 3-LT patients were compared to 18 patients undergoing PRC, given SLAC 2-3. In both analyses, the PRWE scores had significantly improved in all groups, however no significant differences in PRWE were found between 3-LT in SLIL injury and SLIL injury with SLAC, 6.9 points (95% CI [-14.92; 1.22], p = 0.096) and between 3-LT and PRC, given SLAC stage 2-3, 15.1 points (not enough power).

CONCLUSION

There is no difference in PRWE between matched SLIL injury patients with or without degenerative changes treated with a 3-LT. Therefore, the 3-LT procedure seems to be a viable treatment option for patients with early-stage SLAC wrist.

LEVEL OF EVIDENCE

Therapeutic III.

Educating Future Generations of Surgeons across Borders: Novel Global Linked Hybrid Live Cadaveric Peripheral Nerve Surgical Training Course

Background

This study aimed to evaluate a novel, multi-site, technology-facilitated education and training course in peripheral nerve surgery. The program was developed to address the training gaps in this specialized field by integrating a structured curriculum, high-fidelity cadaveric dissection, and surgical simulation with real-time expert guidance.

Methods

A collaboration between the Global Nerve Foundation and Esser Masterclass facilitated the program, which was conducted across three international sites. The curriculum was developed by a panel of experienced peripheral nerve surgeons and included both text-based and multimedia resources. Participants' knowledge and skills were assessed using pre- and postcourse questionnaires.

Results

A total of 73 participants from 26 countries enrolled and consented for data usage for research purposes. The professional background was diverse, including hand surgeons, plastic surgeons, orthopedic surgeons, and neurosurgeons. Participants reported significant improvements in knowledge and skills across all covered topics (p < 0.001). The course received a 100% recommendation rate, and 88% confirmed that it met their educational objectives.

Conclusions

This study underscores the potential of technology-enabled, collaborative expert-led training programs in overcoming geographical and logistical barriers, setting a new standard for globally accessible, high-quality surgical training. It highlights the practical and logistical challenges of multi-site training, such as time zone differences and participant fatigue. It also provides practical insights for future medical educational endeavors, particularly those that aim to be comprehensive, international, and technologically facilitated.

Anatomy of the Superficial Radial Nerve and Its Target Nerves for Targeted Muscle Reinnervation: An Anatomical Cadaver Study

BACKGROUND

Targeted muscle reinnervation (TMR) is a surgical procedure for treating symptomatic neuroma, in which the neuroma is removed and the proximal nerve stump is coapted to a donor motor branch innervating a nearby muscle. This study aimed to identify optimal motor targets for TMR of the superficial radial nerve (SRN).

METHODS

Seven cadaveric upper limbs were dissected to describe the course of the SRN in the forearm and motor nerve supply-number, length, diameter, and entry points in muscle of motor branches-for potential recipient muscles.

RESULTS

The radial nerve provided three (three of six) motor branches, two (two of six) motor branches, or one (one of six) motor branch to the brachioradialis muscle, entering the muscle 21.7 ± 17.9 to 10.8 ± 15 mm proximal to the lateral epicondyle. One (one of seven), two (three of seven), three (two of seven), or four (one of seven) motor branches innervated the extensor carpi radialis longus muscle, with entry points 13.9 ± 16.2 to 26.3 ± 14.9 mm distal from the lateral epicondyle. In all specimens, the posterior interosseous nerve gave off one motor branch to the extensor carpi radialis brevis, which divided into two or three secondary branches. The distal anterior interosseus nerve was assessed as a potential recipient for TMR coaptation and had a freely transferable length of 56.4 ± 12.7 mm.

CONCLUSIONS

When considering TMR for neuromas of the SRN in the distal third of the forearm and hand, the distal anterior interosseus nerve is a suitable donor target. For neuromas of the SRN in the proximal two-thirds of the forearm, the motor branches to the extensor carpi radialis longus, extensor carpi radialis brevis, and brachioradialis are potential donor targets.

Treatment Delay in Patients Undergoing Headache Surgery (Nerve Decompression Surgery)

Background

Although headache surgery has been shown to be an effective treatment option for refractory headache disorders, it has not been included as part of the headache disorder management algorithm by non-surgical providers. This study aims to evaluate the delay in surgical management of patients with headache disorders. In addition, a cost comparison analysis between conservative and operative treatment of headache disorders was performed, and the surgical outcomes of headache surgery were reported.

Methods

Among 1112 patients who were screened, 271 (56%) patients underwent headache surgery. Data regarding the onset of headache disorder and pre- and postoperative pain characteristics were prospectively collected. To perform a cost comparison analysis, direct and indirect costs associated with the conservative treatment of headache disorders were calculated.

Results

The median duration between onset of headache disorder symptoms and headache surgery was 20 (8.2-32) years. The annual mean cost of conservative treatment of headache disorders was $49,463.78 ($30,933.87-$66,553.70) per patient. Over the 20-year time period before surgery, the mean cost was $989,275.65 ($618,677.31-$1,331,073.99). In comparison, the mean cost of headache surgery was $11,000. The median pain days per month decreased by 16 (0-25) (p<0.001), the median pain intensity reduced by 4 (2-7) (p<0.001), and the median pain duration decreased by 11 hours (0-22) (p<0.001).

Conclusion

This study shows that patients experience symptoms of headache disorders for an average of 20 years prior to undergoing headache surgery. Surgical treatment not only significantly improves headache pain but also reduces healthcare costs and should be implemented in the management algorithm of headache disorders.

Sensory nerve transfers in the upper limb after peripheral nerve injury: a scoping review

Nerve transfer for motor nerve paralysis is an established technique for treating complex nerve injuries. However, nerve transfer for sensory reconstruction has not been widely used, and published research on this topic is limited compared to motor nerve transfer. The indications and outcomes of nerve transfer for the restoration of sensory function remain unproven. This scoping review examines the indications, outcomes and complications of sensory nerve transfer. In total, 22 studies were included; the major finding is that distal sensory nerve transfers are more successful than proximal ones in succeeding protective sensation. Although the risk of extension of the sensory deficit with donor site loss and morbidity from neuromas remain a barrier to wider adoption, these complications were not reported in the review. Further, the scarcity of studies and small patient series limit the ability to determine sensory nerve transfer success. However, sensory restoration remains an opportunity for surgeons to pursue.Level of evidence: II.

Feasibility of Ultrasound Measurements of Peripheral Sensory Nerves in Head and Neck Area in Healthy Subjects

Background

Current diagnostic methods for nerve compression headaches consist of diagnostic nerve blocks. A less-invasive method that can possibly aid in the diagnosis is ultrasound, by measuring the cross-sectional area (CSA) of the affected nerve. However, this technique has not been validated, and articles evaluating CSA measurements in the asymptomatic population are missing in the current literature. Therefore, the aim of this study was to determine the feasibility of ultrasound measurements of peripheral extracranial nerves in the head and neck area in asymptomatic individuals.

Methods

The sensory nerves of the head and neck in healthy individuals were imaged by ultrasound. The CSA was measured at anatomical determined measurement sites for each nerve. To determine the feasibility of ultrasound measurements, the interrater reliability and the intrarater reliability were determined.

Results

In total, 60 healthy volunteers were included. We were able to image the nerves at nine of 11 measurement sites. The mean CSA of the frontal nerves ranged between 0.80 ± 0.42 mm2 and 1.20 ± 0.43 mm2, the mean CSA of the occipital nerves ranged between 2.90 ± 2.73 mm2 and 3.40 ± 1.91 mm2, and the mean CSA of the temporal nerves ranged between 0.92 ± 0.26 mm2 and 1.40 ± 1.11 mm2. The intrarater and interrater reliability of the CSA measurements was good (ICC: 0.75-0.78).

Conclusions

Ultrasound is a feasible method to evaluate CSA measurements of peripheral extracranial nerves in the head and neck area. Further research should be done to evaluate the use of ultrasound as a diagnostic tool for nerve compression headache.

Patient-Reported Outcomes and Function after Surgical Repair of the Ulnar Collateral Ligament of the Thumb

PURPOSE

The purpose of this study was to report prospectively collected patient-reported outcomes of patients who underwent open thumb ulnar collateral ligament (UCL) repair and to find risk factors associated with poor patient-reported outcomes.

METHODS

Patients undergoing open surgical repair for a complete thumb UCL rupture were included between December 2011 and February 2021. Michigan Hand Outcomes Questionnaire (MHQ) total scores at baseline were compared to MHQ total scores at three and 12 months after surgery. Associations between the 12-month MHQ total score and several variables (i.e., sex, injury to surgery time, K-wire immobilization) were analyzed.

RESULTS

Seventy-six patients were included. From baseline to three and 12 months after surgery, patients improved significantly with a mean MHQ total score of 65 (standard deviation [SD] 15) to 78 (SD 14) and 87 (SD 12), respectively. We did not find any differences in outcomes between patients who underwent surgery in the acute (<3 weeks) setting compared to a delayed setting (<6 months).

CONCLUSIONS

We found that patient-reported outcomes improve significantly at three and 12 months after open surgical repair of the thumb UCL compared to baseline. We did not find an association between injury to surgery time and lower MHQ total scores. This suggests that acute repair for full-thickness UCL tears might not always be necessary.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Two-, Three-, or Four-Corner Arthrodesis for Midcarpal Osteoarthritis: A Systematic Review and Meta-Analysis

PURPOSE

Several limited midcarpal arthrodeses have been used in the treatment of midcarpal osteoarthritis as part of scapholunate advanced collapse and scaphoid nonunion advanced collapse. There is no consensus on whether two-carpal arthrodesis (2CA), three-carpal arthrodesis (3CA), bicolumnar arthrodesis, or four-carpal arthrodesis (FCA) results in the best outcomes. The objective of this study was to determine whether there is a difference in outcomes in patients undergoing FCA, 3CA, 2CA, or bicolumnar arthrodesis for midcarpal osteoarthritis.

METHODS

A systematic review and meta-analysis were performed in multiple databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting the four surgical techniques were included. The primary outcomes were postoperative visual analog scale pain score, the Disabilities of the Arm, Shoulder, and Hand score, and the Mayo Wrist Score. The secondary outcomes were active range of motion, grip strength, and reported complications.

RESULTS

Of 2,270 eligible studies, 80 articles were selected, including a total of 2,166 wrists. The visual analog scale pain scores for both the 2CA and FCA groups reached an adequate pain reduction based on the Patient Acceptable Symptom Scale. The Disabilities of the Arm, Shoulder, and Hand score was also comparable between these two groups. The 2CA group also showed a significantly better active range of motion than the FCA group for both flexion-extension and radioulnar deviation arc. The incidence of nonunion was 6.9% in the FCA group compared with 10.0% in the 2CA group.

CONCLUSIONS

Although the 2CA procedure has a theoretical advantage over the FCA method, the analysis of data showed that generally, these techniques have similar outcomes and complications. Therefore, both (2CA and FCA) are good options for midcarpal osteoarthritis in scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Multiple Compression Syndromes of the Same Upper Extremity: Prevalence, Risk Factors, and Treatment Outcomes of Concomitant Treatment

PURPOSE

Multiple nerve compression syndromes can co-occur. Little is known about this coexistence, especially about risk factors and surgical outcomes. Therefore, this study aimed to describe the prevalence of multiple nerve compression syndromes in the same arm in a surgical cohort and determine risk factors. Additionally, the surgical outcomes of concomitant treatment were studied.

METHODS

The prevalence of surgically treated multiple nerve compression syndromes within one year was assessed using a review of patients' electronic records. Patient characteristics, comorbidities, and baseline scores of the Boston Carpal Tunnel Questionnaire were considered as risk factors. To determine the treatment outcomes of simultaneous treatment, patients who underwent concomitant carpal tunnel release (CTR) and cubital tunnel release (CubTR) were selected. The treatment outcomes were Boston Carpal Tunnel Questionnaire scores at intake and at 3 and 6 months after the surgery, satisfaction 6 months after the surgery, and return to work within the first year.

RESULTS

A total of 7,867 patients underwent at least one nerve decompression between 2011 and 2021. Of these patients, 2.9% underwent multiple decompressions for the same upper extremity within one year. The risk factors for this were severe symptoms, younger age, and smoking. Furthermore, the treatment outcomes of concomitant CTR and CubTR did not differ from those of CubTR alone. The median time to return to work after concomitant treatment was 6 weeks. Patients who underwent CTR or CubTR alone returned to work after 4 weeks.

CONCLUSIONS

Approximately 3% of the patients who underwent surgical treatment for nerve compression syndrome underwent decompression for another nerve within 1 year. Patients who report severe symptoms at intake, are younger, or smoke are at a greater risk. Patients with carpal and cubital tunnel syndrome may benefit from simultaneous decompression. The time to return to work may be less than if they underwent decompressions in separate procedures, whereas their surgical outcomes are comparable with those of CubTR alone.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

[The surgical treatment of peripheral neuromas]

Peripheral neuromas are a prevalent problem following nerve injury or certain surgical interventions like limb amputation. It is important to consider a peripheral neuroma when a patient experiences pain in the innervation area of a peripheral sensory or mixed nerve (branch), especially following trauma or amputation. Adequate recognition of a painful neuroma is crucial to treat patients satisfactorily for their invalidating and chronic symptoms. We want to emphasize that surgical intervention can be an effective and permanent treatment for symptomatic neuromas. The standard surgical treatment is neuroma excision and burying of the nerve stump in adjacent muscle. However, there is a shift towards new and active techniques like Targeted Muscle Reinnervation, of which future comparative research will have to demonstrate whether it is more effective in treating peripheral neuroma pain than conventional surgery.

[The surgical treatment of peripheral neuromas]

Peripheral neuromas are a prevalent problem following nerve injury or certain surgical interventions like limb amputation. It is important to consider a peripheral neuroma when a patient experiences pain in the innervation area of a peripheral sensory or mixed nerve (branch), especially following trauma or amputation. Adequate recognition of a painful neuroma is crucial to treat patients satisfactorily for their invalidating and chronic symptoms. We want to emphasize that surgical intervention can be an effective and permanent treatment for symptomatic neuromas. The standard surgical treatment is neuroma excision and burying of the nerve stump in adjacent muscle. However, there is a shift towards new and active techniques like Targeted Muscle Reinnervation, of which future comparative research will have to demonstrate whether it is more effective in treating peripheral neuroma pain than conventional surgery.

Prevalence of complications and association with patient-reported outcomes after trapeziectomy with a Weilby sling: A cohort study

PURPOSE

The primary aim of this study was to report complications during the first year after trapeziectomy with Weilby sling using a standardized tool designed by the International Consortium for Health Outcome Measures. The secondary aim was to determine the association of complications and patient-reported outcomes 12 months after surgery.

METHODS

We included patients who underwent trapeziectomy with Weilby sling between November 2013 and December 2018. All complications during the first year were scored using the International Consortium for Health Outcomes Measurement Complications in Hand and Wrist conditions (ICHAW) tool. Pain and hand function were measured before surgery and 12 months after surgery using the Michigan Hand Outcomes Questionnaire (MHQ). Minimally Important Change thresholds of 18.6 for MHQ pain and 9.4 for MHQ function were used to determine clinical importance.

RESULTS

Of 531 patients after trapeziectomy with Weilby sling, 65% had an uneventful recovery, 16% experienced ICHAW Grade 1 deviations only, and 19% experienced Grade 2 or 3 deviations, including requiring antibiotics, corticosteroid injections, or additional surgery. On average, patients improved in pain and hand function, even in the presence of ICHAW events. Although all ICHAW grades were associated with poorer patient-reported outcomes 12 months after surgery, Grade 2 and 3 exceeded the Minimally Important Change threshold for pain and/or function.

CONCLUSIONS

In 531 patients, 65% had an uneventful recovery, 16% experienced ICHAW Grade 1 deviations only, and 19% experienced grade 2 or 3 deviations. We recommend describing Grade 1 as "adverse protocol deviations" and grade 2 and 3 as complications, because of clinically relevant poorer patient-reported outcomes 12 months after surgery. The ICHAW is a promising tool to evaluate systematically and compare complications in hand surgery, although we recommend further evaluation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Comparing Patient-Reported Outcomes on Three-Ligament Tenodesis between Partial and Complete Scapholunate Ligament Injuries: A Cohort Study

PURPOSE

Multiple studies report outcomes after 3-ligament tenodesis (3-LT) in treating traumatic scapholunate interosseous ligament injury (SLIL). However, investigators do not differentiate between patients with partial or complete SLIL injury. The relation between the extent of SLIL disruption and surgical outcomes and if this should be considered when treating a patient with SLIL injury remains unknown. We aimed to evaluate differences in patient-rated wrist evaluation (PRWE) scores, satisfaction and return to work between patients with partial or complete chronic traumatic SLIL injury treated with 3 ligament tenodesis at 12 months after surgery.

METHODS

All patients with chronic SLIL injury (partial and complete) who were treated with 3-LT at our clinic and received the same postoperative management between December 2011 and December 2019 were studied. Only patients who had completed the PRWE and return to work questionnaires preoperatively and 12 months after surgery were included. Patients were allocated to the partial (classified as Geissler 2 or 3) or complete SLIL injury group (classified as Geissler 4) by retrospectively assessing wrist arthroscopy reports.

RESULTS

Thirty-nine patients with partial and 90 with complete SLIL injuries were included. At 1-year follow-up, PRWE scores had significantly improved in both groups. When adjusting for clinical baseline characteristics, there was no statistically significant difference between patients with partial or complete SLIL injury. Patients with complete SLIL injury had a 70% higher return to work within the first 12 months after 3-LT; however, satisfaction with the treatment result was similar for both study groups 1 year after surgery.

CONCLUSIONS

Patients with complete and partial traumatic SLIL injury report better PRWE total scores at 12 months after 3-LT, but there was no statistically significant difference between the groups in PRWE scores or satisfaction with the treatment result.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Routinely-Collected Outcomes of Proximal Row Carpectomy

PURPOSE

To describe patient-reported pain and function 12 months after proximal row carpectomy (PRC). Secondary outcomes included return to work, grip strength, range of wrist motion, satisfaction with treatment results, and complications.

METHODS

This cohort study was part of the British Society for Surgery of the Hand Studyathon 2021, using ongoing routinely-collected data of 304 eligible patients who underwent PRC (73% scapholunate advanced collapse, 11% scaphoid nonunion advanced collapse wrist; 11% Kienböck, 5% other indications) from Xpert Clinics, the Netherlands between 2012-2020. The primary outcome was the Patient Rated Wrist/Hand Evaluation total score (range, 0-100, lower scores indicate better performance).

RESULTS

Of the 304 patients, the primary outcome was available in 217 patients. The total Patient Rated Wrist/Hand Evaluation score improved from 60 (95% confidence interval [CI], 57-63) to 38 (95% CI, 35-41) at 3 months, and 26 (95% CI, 23-29) at 12 months. The pain and function subscales improved by 18 (95% CI, 17-20) and 16 (95% CI, 14-18) points, respectively. At 12 months, 82% had returned to work at a median time of 12 (95% CI, 9-14) weeks following PRC. Grip strength did not improve. Wrist flexion and extension demonstrated a clinically irrelevant decrease. Satisfaction with treatment result was excellent in 27% of patients, good in 42%, fair in 20%, moderate in 6%, and poor in 5%. Complications occurred in 11% of patients, and conversion to wrist arthroplasty occurred in 2 patients.

CONCLUSION

A clinically relevant improvement in patient-reported pain and function was observed at 3 months after PRC, with continued improvement to 12 months. These data can be used for shared-decision making and expectation management.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Prevalence and Risk Factors for Postoperative Complications Following Open A1 Pulley Release for a Trigger Finger or Thumb

PURPOSE

Although A1 pulley release is an effective treatment to reduce pain and improve hand function, complications may occur. More insight into risk factors for complications is essential to improve patient counseling and potentially target modifiable risk factors. This study aimed to identify factors associated with complications following A1 pulley release.

METHODS

Patients completed baseline questionnaires, including patient characteristics, clinical characteristics, and the Michigan Hand outcomes Questionnaire. We retrospectively reviewed medical records to identify complications classified using the International Consortium for Health Outcome Measurement Complications in Hand and Wrist conditions tool. Grade 1 complications comprise treatment with additional hand therapy, splinting, or analgesics, grade 2 treatment with antibiotics or steroid injections, grade 3A minor surgical treatment, grade 3B major surgical treatment, and grade 3C complex regional pain syndrome. Logistic regression analyses were performed to examine the contribution of patient characteristics, clinical characteristics, and patient-reported outcome measurement scores to complications.

RESULTS

Of the included 3,428 patients, 16% incurred a complication. The majority comprised milder grades 1 (6%) and 2 (7%) complications, followed by more severe grades 3B (2%), 3C (0.1%), and 3A (0.1%) complications. A longer symptom duration (standardized odds ratio [SOR], 1.09), ≥3 preoperative steroid injections (SOR, 3.22), a steroid injection within 3 months before surgery (SOR, 2.02), and treatment of the dominant hand (SOR, 1.34), index finger (SOR, 1.65), and middle finger (SOR, 2.01) were associated with a higher complication rate.

CONCLUSION

This study demonstrates that ≥3 preoperative steroid injections and a steroid injection within 3 months before surgery were the most influential factors contributing to complications. These findings can assist clinicians during patient counseling and may guide preoperative treatment. We recommend that clinicians should consider avoiding steroid injections within 3 months before surgery and to be reluctant to perform >2 steroid injections.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Factors associated with self-reported pain and hand function following surgical A1 pulley release

Surgical A1 pulley release can considerably reduce pain and improve hand function, but individual outcomes are highly variable. This study aimed to identify factors contributing to self-reported pain and hand function 3 months postoperatively. We included 2681 patients who had received surgical treatment for a trigger finger or thumb and who completed the Michigan Hand outcomes Questionnaire (MHQ). Hierarchical linear regression models were used to investigate patient and clinical characteristics associated with postoperative pain and hand function. For both pain and hand function, the most influential factors associated with worse outcomes were worse MHQ scores at baseline (β 0.38 and 0.33, respectively) and ≥3 preoperative steroid injections (β -0.36 and -0.35). These factors indicated that patients with severe preoperative symptoms represent a group with a more advanced disease that is more difficult to treat. These findings can assist clinicians in patient counselling, expectation management and decision-making about the timing of the intervention.Level of evidence: II.

Management of Recurrent Carpal Tunnel Syndrome: Systematic Review and Meta-Analysis

PURPOSE

Few comparisons have been performed between the outcomes of surgical techniques for recurrent carpal tunnel syndrome. Using a meta-analysis, this study aimed to compare the outcomes of different surgical techniques using the Boston Carpal Tunnel Questionnaire (BCTQ) and visual analog scale (VAS) for pain as outcomes.

METHODS

The following categories were used to define the study's inclusion criteria: population, intervention, comparator, outcomes, and study design. Studies were examined by 2 reviewers, and the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines were followed. The studies were assigned to 1 of the following treatment groups: decompression with or without neurolysis, autologous fat transfer, hypothenar fat pad, pedicled or free flap, and "other." For our primary outcome, we compared improvement using the BCTQ and VAS for pain between the treatment groups. For our secondary outcome, postoperative BCTQ and VAS pain values were compared.

RESULTS

Fourteen studies were included: 5 case series with postoperative data only and 9 pre-post studies without a control group. With regard to our primary outcome, the studies reported an average improvement of 1.2 points (95% confidence interval [CI][1.5, 0.9]) on a scale of 1-5 on the symptoms severity scale (SSS) of the BCTQ, 1.9 points (95% CI [1.37, 0.79]) on a scale of 1-5 on the function severity scale of the BCTQ, and 3.8 points (95% CI [4.9, 2.6]) on a scale of 1-10 on the VAS for pain. We only found significantly lesser improvement in the "other" treatment group than in the hypothenar fat pad group and autologous fat transfer group using the SSS. The hypothenar fat pad group had the best reported postoperative SSS score of 1.75 (95% CI [1.24, 2.25]), function severity scale score of 1.55 (95% CI [1.20, 1.90]), and VAS pain score of 1.45 (95% CI [0.83, 2.07]).

CONCLUSIONS

All the techniques showed clinically important improvements in all the outcomes. We found lesser improvement in the "other" treatment group than in the hypothenar fat pad group and autologous fat transfer group using the SSS. We found that the hypothenar fat pad group had the best reported postoperative values in our secondary analysis.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The prevalence, incidence, and progression of radiographic thumb base osteoarthritis in a population-based cohort: the Rotterdam Study

OBJECTIVE

To describe the prevalence, incidence, and progression of radiographic thumb carpometacarpal (CMC-1) and trapezioscaphoid (TS) radiographic osteoarthritis (ROA) in the general Dutch population aged ≥55y.

DESIGN

Data were from the first and second cohort of the Rotterdam Study (1990-2005, 4-12 years follow-up, age 55+). Participants underwent bilateral radiographs at baseline (N = 7792) and follow-up (N = 3804), read for Kellgren-Lawrence (K-L) grade. ROA was defined on the joint level as K-L grade ≥2. The prevalence was assessed at baseline, incidence at follow-up in those free of ROA at baseline, and progression in those with ROA. Differences based on sex and age were evaluated using logistic regression models.

RESULTS

At baseline, 1977 (25.3%) had CMC-1 ROA and 1133 (14.5%) TS ROA. The prevalence was higher in females for CMC-1 (aOR = 1.98 95%CI [1.77-2.21]) and TS ROA (aOR = 2.00 [1.74-2.29]) and increased for every year of age (CMC-1 ROA 1.08 [1.07-1.08]) (TS ROA 1.06 [1.05-1.07]). Most (437/512; 85.4%) incident cases of CMC-1 ROA (2994 at risk) were mild (K-L = 2), whereas most (145/167; 86,8%) incident cases of TS ROA (3311 at risk) were moderate to severe (K-L = 3/4). CMC-1 ROA progression was mostly (88/100; 88.0%) seen in the K-L 2 group at baseline, whereas that was (4/17; 23.5%) for TS ROA.

CONCLUSION

CMC-1 ROA and TS ROA are prevalent in the general Dutch population. While incident CMC-1 ROA was primarily mild, incident TS ROA was more often moderate to severe. CMC-1 ROA was a strong predictor for incident TS ROA.

Perilunate Injury Timing and Treatment Options: A Systematic Review

Introduction  Perilunate injuries are uncommon yet challenging and often missed injuries, representing 7% of all carpal traumas. Two types of injuries can be identified as follows: perilunate dislocations (PLD) and perilunate fracture-dislocations (PLFD). The purpose of this study was to conduct a systematic review and meta-analysis to establish which surgical treatment is superior for patients with perilunate injuries and the significance of delayed treatment. Methods  A total of 2056 articles were screened, and 16 articles were included. Risk of bias for case-control series and case series were assessed through the National Institute of Health study quality assessment tool. Qualitative outcomes of clinical scores for hand function were compared between different time points (acute, < 7 days; delayed 7-45 days; chronic > 45 days), open and closed reduction, and PLD and PLFD. Results  Overall, the clinical outcome scores of patients treated within 7 days are good. The results suggest that closed reduction and internal fixation (CRIF) offers slightly better outcomes than open reduction and internal fixation (ORIF) for PLFD. Patients treated 6 weeks or more after the initial injury seem to have the worst overall outcomes than patients in the acute or delayed setting. The results suggest that patients with chronic PLD have even worse outcomes than patients with chronic PLFD. Conclusions  Timing of surgery is essential for an optimal outcome. When there is a delay of treatment, the outcomes are inferior to those treated acutely. Early referral to centralized treatment units for perilunate injuries would allow for targeted treatment and facilitate research on this difficult wrist injury.

Outcome of Simple Decompression of Primary Cubital Tunnel Syndrome Based on Patient-Reported Outcome Measurements

PURPOSE

To evaluate the patient-reported outcome measures of patients with primary cubital tunnel syndrome and to assess whether they are affected by preoperative symptom severity.

METHODS

Patients who underwent simple decompression for primary cubital tunnel syndrome were selected from a prospectively maintained database. Outcome measurements consisted of the Boston Carpal Tunnel Questionnaire at intake and at 3 and 6 months after surgery. Also, 6 months after surgery, the patients received a question about their satisfaction with the treatment result. To determine a possible influence of preoperative symptom severity on postoperative outcomes, the sample was divided into quartiles based on symptom severity at intake.

RESULTS

One hundred and forty-five patients were included in the final analysis. On average, all patients improved on the Boston Carpal Tunnel Questionnaire. The subgroup of patients with the mildest symptoms at intake did not improve significantly on symptom severity but did improve significantly on their functional status. In addition, the patients with the most severe symptoms at intake did improve on both aspects. Moreover, no difference in satisfaction with treatment result between the severity of symptoms at intake was found.

CONCLUSIONS

The patients with the mildest symptoms at intake may not improve on symptom severity, but they do improve on functional status after simple decompression for cubital tunnel syndrome. In addition, patients with the most severe symptoms at intake do improve on both symptom severity and functional status. Moreover, all patients reported to be equally satisfied with the treatment result, which suggests that satisfaction is not dependent on the symptom severity at intake. Even those patients with both the mildest symptoms before surgery and the least improvement still seem to benefit from simple decompression.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Nerve recovery from treatment with a vascularized nerve graft compared to an autologous non-vascularized nerve graft in animal models: A systematic review and meta-analysis

Background

Treatment of nerve injuries proves to be a worldwide clinical challenge. Vascularized nerve grafts are suggested to be a promising alternative for bridging a nerve gap to the current gold standard, an autologous non-vascularized nerve graft. However, there is no adequate clinical evidence for the beneficial effect of vascularized nerve grafts and they are still disputed in clinical practice.

Objective

To systematically review whether vascularized nerve grafts give a superior nerve recovery compared to non-vascularized nerve autografts regarding histological and electrophysiological outcomes in animal models.

Material and methods

PubMed and Embase were systematically searched. The inclusion criteria were as follows: 1) the study was an original full paper which presented unique data; 2) a clear comparison between a vascularized and a non-vascularized autologous nerve transfer was made; 3) the population study were animals of all genders and ages. A standardized mean difference and 95% confidence intervals for each comparison was calculated to estimate the overall effect. Subgroup analyses were conducted on graft length, species and time frames.

Results

Fourteen articles were included in this review and all were included in the meta-analyses. A vascularized nerve graft resulted in a significantly larger diameter, higher nerve conduction velocity and axonal count compared to an autologous non-vascularized nerve graft. However, during sensitivity analysis the effect on axonal count disappeared. No significant difference was observed in muscle weight.

Conclusion

Treating a nerve gap with a vascularized graft results in superior nerve recovery compared to non-vascularized nerve autografts in terms of axon count, diameter and nerve conduction velocity. No difference in muscle weight was seen. However, this conclusion needs to be taken with some caution due to the inherent limitations of this meta-analysis. We recommend future studies to be performed under conditions more closely resembling human circumstances and to use long nerve defects.

Higher incidences of neuropathic pain and altered sensation following radial forearm free flap: A systematic review

BACKGROUND

The radial forearm free flap (RFFF) has been used extensively for complex tissue defect reconstructions; however, the potential for significant donor-site morbidity remains a major drawback. Despite an abundance of literature on donor-site morbidities, no consensus has been reached on exact incidences of sensory morbidities that vary largely between 0% and 46%. Incidences of neuropathic pain in the donor site following RFFF still lack, even though clinical experience shows it often occurs. Therefore, the purpose of this systematic review was to identify the incidence of neuropathic pain and altered sensation in the hand following harvesting of a RFFF.

METHODS

A systematic search was performed in multiple databases (Embase, Medline, Cochrane, Web of Science, and Google Scholar). Studies from 1990 onwards that reported donor-site morbidities following harvest of the RFFF were included. Analyzed parameters included hand pain, hypoesthesia, cold intolerance, hyperesthesia, neuroma formation, paresthesia, sharp sensation loss, light sensation loss, and defect closure.

RESULTS

Of the 987 selected studies, 51 eligible articles were selected. The mean level of evidence was 3 (SD 0.6). Twenty articles reported pain as a donor-site morbidity, and the mean incidence of pain reported was 23% (SD 7.8). Hypoesthesia was reported by 37 articles and had a mean incidence of 34% (SD 25). Locations of pain and hypoesthesia included, amongst others, the area of the radial sensory nerve and the skin graft area. The mean incidences of cold intolerance and hyperesthesia were 13% (SD 13) and 16% (SD 15), respectively.

CONCLUSION

The results of this systematic review suggest that 23% of all patients are dealing with neuropathic pain in the donor-site following harvest of an RFFF. Future studies should therefore focus on the prognostic factors and preventive measures of neuropathic pain to further improve clinical outcomes of this widely used flap.

Warm Weather and Surgical Site Infections: A Meta-analysis

Seasonal variability, in terms of warm weather, has been demonstrated to be a significant risk factor for surgical site infections (SSIs). However, this remains an underexposed risk factor for SSIs, and many clinicians are not aware of this. Therefore, a systematic review and meta-analysis has been conducted to investigate and quantify this matter.

METHODS

Articles were searched in Embase, Medline Ovid, Web of Science, Cochrane Central, and Google Scholar, and data were extracted from relevant studies. Meta-analysis used random effects models to estimate and compare the pooled odds ratios (OR) and corresponding confidence intervals (CIs) of surgery performed during the warmest period of the year and the colder period of the year.

RESULTS

The systematic review included 20 studies (58,599,475 patients), of which 14 studies (58,441,420 patients) were included for meta-analysis. Various types of surgical procedures across different geographic regions were included. The warmest period of the year was associated with a statistically significant increase in the risk of SSIs (OR 1.39, 95%CI: [1.34-1.45], P < 0.0001). Selection of specific types of surgical procedures (eg, orthopedic or spinal surgery) significantly altered this increased risk.

CONCLUSIONS

The current meta-analysis showed that warm weather seasons are associated with a statistically significant risk increasement of 39% in developing SSIs. This significant risk factor might aid clinicians in preoperative patient information, possible surgical planning adjustment for high risk patients, and potentially specific antibiotic treatments during the warmer weather seasons that could result in decrease of SSIs.

Are Patient Expectations and Illness Perception Associated with Patient-reported Outcomes from Surgical Decompression in de Quervain's Tenosynovitis?

BACKGROUND

Psychological factors such as depression, pain catastrophizing, kinesiophobia, pain anxiety, and more negative illness perceptions are associated with worse pain and function in patients at the start of treatment for de Quervain's tenosynovitis. Longitudinal studies have found symptoms of depression and pain catastrophizing at baseline were associated with worse pain after treatment. It is important to study patients opting for surgery for their condition because patients should choose surgical treatment based on their values rather than misconceptions. Psychological factors associated with worse patient-reported outcomes from surgery for de Quervain's tenosynovitis should be identified and addressed preoperatively so surgeons can correct any misunderstandings about the condition.

QUESTION/PURPOSE

What preoperative psychosocial factors (depression, anxiety, pain catastrophizing, illness perception, and patient expectations) are associated with pain and function 3 months after surgical treatment of de Quervain's tenosynovitis after controlling for demographic characteristics?

METHODS

This was a prospective cohort study of 164 patients who underwent surgery for de Quervain's tenosynovitis between September 2017 and October 2018 performed by 20 hand surgeons at 18 centers. Our database included 326 patients who underwent surgery for de Quervain's tenosynovitis during the study period. Of these, 62% (201 of 326) completed all baseline questionnaires and 50% (164 of 326) also completed patient-reported outcomes at 3 months postoperatively. We found no difference between those included and those not analyzed in terms of age, sex, duration of symptoms, smoking status, and workload. The mean ± SD age of the patients was 52 ± 14 years, 86% (141 of 164) were women, and the mean duration of symptoms was 13 ± 19 months. Patients completed the Patient-Rated Wrist Evaluation (PRWE), the VAS for pain and function, the Patient Health Questionnaire for symptoms of anxiety and depression, the Pain Catastrophizing Scale, the Credibility/Expectations Questionnaire, and the Brief Illness Perceptions questionnaire at baseline. Patients also completed the PRWE and VAS for pain and function at 3 months postoperatively. We used a hierarchical multivariable linear regression model to investigate the relative contribution of patient demographics and psychosocial factors to the pain and functional outcome at 3 months postoperatively.

RESULTS

After adjusting for demographic characteristics, psychosocial factors, and baseline PRWE score, we found that only the patient's expectations of treatment and how long their illness would last were associated with the total PRWE score at 3 months postoperatively. More positive patient expectations of treatment were associated with better patient-reported pain and function at 3 months postoperatively (ß = -2.0; p < 0.01), while more negative patient perceptions of how long their condition would last were associated with worse patient-reported pain and function (timeline ß = 2.7; p < 0.01). The final model accounted for 31% of the variance in the patient-reported outcome at 3 months postoperatively.

CONCLUSION

Patient expectations and illness perceptions are associated with patient-reported pain and functional outcomes after surgical decompression for de Quervain's tenosynovitis. Addressing misconceptions about de Quervain's tenosynovitis in terms of the consequences for patients and how long their symptoms will last should allow patients to make informed decisions about the treatment that best matches their values. Prospective studies are needed to investigate whether addressing patient expectations and illness perceptions, with decision aids for example, can improve patient-reported pain and function postoperatively in those patients who still choose surgery for de Quervain's tenosynovitis.

LEVEL OF EVIDENCE

Level III, therapeutic study.

[Nerve transfer in patients with tetraplegia: improvement in hand function]

Reconstruction of arm and hand function in patients with a cervical spinal cord injury can improve their quality of life. Elbow extension, wrist extension, grip function and opening of the hand can be reconstructed. Traditionally, this has been done through tendon transpositions. Nerve transfer is a new technique. A functioning motor nerve branch is moved and connected to a muscle or muscle group damaged by the spinal cord injury. This technique has several advantages. Multiple functions can be restored by one nerve transfer, no long-term hand-rehabilitation is required and there is no risk of adhesions of the transposition. The most important disadvantage is the recovery time, as a results of the slow ingrowth of the nerve transfer, which takes at least 12 to 18 months. For each spinal cord injury patient, an individual action plan must be made, because not every patient has the same options and these are sometimes very limited.

Free muscle flap coverage as last resort for therapy-resistant neuropathic pain in the upper extremity: A long-term retrospective follow-up study

BACKGROUND

Persistent neuropathic pain severely impacts physical functioning and quality of life (QoL). However, optimal surgical management of persistent neuropathic pain remains unclear. Extensive neurolysis with subsequent free muscle flap coverage, a new surgical procedure for neuropathic pain in the upper extremity, can be performed as a final option to establish pain reduction.

METHODS

All consecutive patients who received extensive microsurgical neurolysis with subsequent free muscle flap for persistent neuropathic pain in the upper extremity between 2007 and 2014 were identified. Patient-reported upper extremity function and QoL were assessed using three questionnaires (36-item short-form health survey (SF-36), the disabilities of the arm, shoulder, and head questionnaire, and the Michigan hand outcomes questionnaire).

RESULTS

Fifteen patients were identified; 80% had neuropathic pain in the upper extremity due to nerve injury and a median of 3.0 previous surgeries (range 1-6). Sixty-seven percent developed some kind of complication, flap loss occurred in 22%, and all received a new free flap (one failed again). At last follow-up, pre- and postoperative visual analog scale (VAS) scores significantly differed (p = 0.002), and the median VAS at last follow-up was 1.5. Ten patients (67%) responded to the questionnaires after a median follow-up of 5.7 year (range 2.6-7.3 years). Patients on average reported poorer SF-36 "Physical Component Score" (PCS) and "Bodily Pain" compared to Dutch norms. Forty percent of patients reported still having always (very) severe pain. However, 64% had a postoperative decrease of at least 3.0 on VAS.

CONCLUSION

Extensive neurolysis with free muscle flap coverage for persistent neuropathic pain in the upper extremity showed a positive effect on pain reduction on short-term follow-up, and also at five-year follow-up. The impact of pain on functional outcomes remained. Nevertheless, 60% of the patients still experience sufficient pain reduction.

An anatomical study on the effectiveness of Arthrex Mini TightRope® ligament reconstruction in an unstable trapeziometacarpal joint

INTRODUCTION

Laxity in the trapeziometacarpal (TMC) joint is a debilitating condition usually affecting a young population. It can be treated operatively with ligament reconstruction. The purpose of this study was to determine the effectiveness of the Arthrex Mini TightRope^® in reinforcing the stabilizing ligaments in an unstable TMC joint without decreasing the range of motion of the thumb. This method was compared with the "gold standard" published by Eaton and Littler in 1973.

MATERIALS AND METHODS

Six fresh frozen arms from five cadavers were included. TMC joint laxity was measured on stress view radiographs as the ratio of the radial subluxation (RS) of the first metacarpal in relation to the trapezium, by the first metacarpal articular width (AW) (as described by Wolf in 2009). Measurements of the pre- and post-operative range of motion (ROM) were performed and compared.

RESULTS

Both the Arthrex Mini TightRope^® and the Eaton-Littler stabilization improved the stability of the TMC joint. The pre-operative laxity value (ratio RS/AW) of 0.27 was significantly (P = 0.02) improved by each of the surgical interventions (Eaton-Littler RS/AW = 0.05 and Tightrope RS/AW = 0.09). The pre- and post-operative range of motion was not significantly different by each of the surgical interventions. There were no significant differences between the two stabilizing methods regarding laxity or range of motion.

CONCLUSION

The Arthrex Mini TightRope^® provided a good stabilization method for the TMC joint in this anatomical model without compromising the range of motion.

Outcome of flexor digitorum superficialis opponensplasty for Type II and IIIA thumb hypoplasia

This study reports on outcomes of the flexor digitorum superficialis tendon transfer from the ring finger in Type II and IIIA hypoplastic thumbs. We included 22 patients with 27 involved hands: 16 Type II thumbs and five Type IIIA treated by transfer and six non-operated Type II thumbs. The outcomes were assessed by range of motion, strength, sensibility, joint stability and patient/parent satisfaction. Compared with normative data, the range of motion was diminished in all patient groups. Opposition strength in operated Type II thumbs was significantly better than in non-operated thumbs. Grip strength, pinch strength, tripod strength and key pinch strength were approximately 50% of normal in Type II thumbs and 35% in Type IIIA thumbs. Metacarpophalangeal joint stability was restored in all operated Type II thumbs and in 40% of Type IIIA thumbs. We conclude that the flexor digitorum superficialis tendon transfer of the ring finger is a good functioning opponensplasty in both Type II and IIIA thumbs. The transfer provides excellent stability of the metacarpophalangeal joint in Type II thumbs.

LEVEL OF EVIDENCE

Level IV.

Outcome of two types of surgical correction of the extra phalanx in triphalangeal thumb: is there a difference?

The surgical strategy of treatment of the opposable triphalangeal thumb is correction of the radio-ulnar deviation, reduction of the additional length and joint stabilization. The commonest procedures are: (1) removal of the extra phalanx and stabilization of the remaining joint; and (2) a combined reduction osteotomy with resection of the distal joint followed by arthrodesis. We treated 20 patients (33 hands). In 17 hands the extra phalanx was removed, and in 16 hands we used the combined osteotomy procedure of distal joint removal and arthrodesis. None of the patients in either group had an unstable interphalangeal joint. The mean radial or ulnar deviation in the interphalangeal joint was 5° degrees and 9°, respectively. Mean active flexion in the interphalangeal joint was 35° and 46°, respectively, in the two groups. Results for both procedures are similar, for both objective measures and self-rated function and activities of daily living. Either surgical approach seems reliable.Therapeutic, Level of evidence: Level III.

Identification of independent risk factors for flap failure: A retrospective analysis of 1530 free flaps for breast, head and neck and extremity reconstruction

Reconstructive microsurgery is a powerful method of treating various complex defects. However, flap loss remains a possibility, leading to additional surgery, hospitalisation and costs. Consequently, it is important to know which factors lead to an increased risk of flap failure, so that measures can be undertaken to reduce this risk. Therefore, we analysed our results over a 20-year period to identify risk factors for flap failure after breast, head and neck and extremity reconstruction. The medical files of all patients treated between 1992 and 2012 were reviewed. Patient characteristics, surgical data and post-operative complications were scored, and independent risk factors for flap loss were identified. Reconstruction with a total of 1530 free flaps was performed in 1247 patients. Partial and total flap loss occurred in 5.5% and 4.4% of all free flaps, respectively. In all flaps, signs of compromised flap circulation were a risk factor for flap failure. More specifically, the risk factors for flap failure in breast reconstruction were previous radiotherapy, venous anastomosis revision, gluteal artery perforator (GAP) flap choice and post-operative bleeding. In head and neck reconstruction, pulmonary co-morbidity and anastomosis to the lingual vein or superficial temporal artery were risk factors, whereas a radial forearm flap reduced the risk. In extremity reconstruction, diabetes, prolonged anaesthesia time and post-operative wound infection were risk factors. Independent pre-, intra- and post-operative risk factors for flap failure after microvascular breast, head and neck and extremity reconstruction were identified. These results may be used to improve patient counselling and to adjust treatment algorithms to further reduce the chance of flap failure.

Thumb strength in all types of triphalangeal thumb

Strength is regarded as normal in patients with an opposable triphalangeal thumb. Our clinical impression is, however, that intrinsic musculature is probably affected in all forms of triphalangeal thumb. Therefore, we established the strength of 38 thumbs in patients with a triphalangeal thumb. Patients were excluded if the intrinsic musculature was enhanced or if osteotomies of the first metacarpal were performed. On average, strength of all thumb functions was significantly diminished, up to 63% for opposition strength. Strength of the power grip was on average 70%. As shown in this study, strength of the musculature of the thumb is affected in all types of triphalangeal thumb. Although strength of the thumb is diminished, in the investigated group it is apparently sufficient in daily life, as these individuals did not seek surgical enhancement. However, reconstructive procedures that enhance intrinsic musculature must be considered in all types of triphalangeal thumb.

Visual feedback and weight reduction of a grip strength dynamometer do not increase reliability in healthy children

STUDY DESIGN

Test-retest reliability study on grip strength in children.

INTRODUCTION

Measuring grip strength in children is difficult because of the weight and size of the instrument, brief attention span, and possible lack of task understanding. Therefore, adaptations to the measurement protocols to improve reliability would be very important for research and clinical evaluation.

PURPOSE

In this study, we compared the reliability of a grip strength dynamometer (Lode dynamometer, Lode BV, Groningen, The Netherlands) using three different protocols.

METHODS

Test-retest reliability of the American Society of Hand Therapists protocol in 104 healthy children (4-12 years) was compared with the reliability in 63 healthy children of a visual feedback protocol and a suspension protocol reducing weight of the instrument.

RESULTS

For the total group, intraclass correlation coefficients for the dominant and nondominant hands were 0.95-0.97 for all protocols, indicating that all three protocols were reliable.

CONCLUSION

No statistically significant difference was found among the reliability of the different protocols, but the suspension protocol produced small but significantly higher force levels.

LEVEL OF EVIDENCE

Not applicable.

Implications for treatment of variations in length of the first metacarpal in different types of triphalangeal thumbs

Abnormal function in the triphalangeal thumb is partly due to its extra length, which is due not only to the extra phalanx, but also to differences in the length of the first metacarpal. This study investigated whether the additional length of the first metacarpal is influenced by the growth plate location alone, or also by the type of triphalangeal thumb. Fifty-nine hands in 37 patients with triphalangeal thumbs were examined for thumb type (delta 31, trapezoid nine and full type 19), growth plate location and relative length of the first metacarpal. The first metacarpals in all three types of triphalangeal thumbs were significantly longer than in the normal population. The length of the first metacarpal was related to the site of the growth plate. The type of triphalangeal thumb did not affect the length. These findings suggest that a corrective procedure on the first metacarpal should be considered in all types of triphalangeal thumbs.

Growth diagrams for grip strength in children

Grip strength dynamometers often are used to assess hand function in children. The use of normative grip strength data at followup is difficult because of the influence of growth and neuromuscular maturation. As an alternative, infant welfare centers throughout the world use growth diagrams to observe normative growth. The aim of this study was to develop similar growth diagrams for grip strength in children. We measured the grip strength, hand dominance, gender, height, and weight of 225 children, 4 to 12 years old. We developed separate statistical models for both hands of boys and girls for drawing growth curves. Grip strength increased with age for both hands. For the whole group, the dominant hand produced higher grip strength than the nondominant hand and boys were stronger than girls. The grip strength of boys and girls differed between 2 and 19 N for the different age groups. Because grip strength measurements are accompanied by a rather large variance, the growth diagrams (presenting a continuum in grip strength) make it possible to better observe grip strength development with time corresponding to a more exact age. Depending on the accuracy needed, the use of one combined diagram could be considered.

LEVEL OF EVIDENCE

Level II, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Age-specific reliability of two grip-strength dynamometers when used by children

BACKGROUND

The Jamar dynamometer and the Martin vigorimeter, two instruments often used to assess grip strength, have good validity and reliability when employed to evaluate adults. Grip strength measurements are often performed to assess children with hand disorders. However, the reliability of these measurements when used to assess children under the age of twelve years is unknown. In addition, it is not clear whether reliability differs between younger and older children. The purpose of this study was to establish test-retest reliability for different age groups and to determine which instrument is the most reliable.

METHODS

One hundred and four children from a primary school were included. Subjects were divided into three groups: four to six, seven to nine, and ten to twelve years of age. The grip strength of both hands was measured with the Lode dynamometer (equivalent to the Jamar dynamometer) and with the Martin vigorimeter. The mean of three maximum voluntary contractions was recorded for all measurements. A retest was performed after a mean interval of twenty-nine days.

RESULTS

In the total group, the intraclass correlation coefficient for the Lode dynamometer was 0.97 (95% confidence interval, 0.95 to 0.98) for the dominant hand and 0.95 (95% confidence interval, 0.92 to 0.96) for the nondominant hand and the intraclass correlation coefficient for the Martin vigorimeter was 0.84 (95% confidence interval, 0.77 to 0.89) for the dominant hand and 0.86 (95% confidence interval, 0.80 to 0.90) for the nondominant hand. The intraclass correlation coefficients in the different age groups were lower than those in the total group because of a lower between-subject variation. The normalized smallest detectable difference between the test and retest values was approximately 25% for the Lode dynamometer and approximately 31% for the Martin vigorimeter.

CONCLUSIONS

Both the Lode dynamometer and the Martin vigorimeter are reliable instruments with which to measure the grip strength of children under twelve years of age; however, the Lode dynamometer has better test-retest reliability. Furthermore, comparison of the smallest detectable differences showed the Lode dynamometer to be a more accurate instrument.

A classification system of radial polydactyly: inclusion of triphalangeal thumb and triplication

PURPOSE

Radial polydactyly is a congenital anomaly with a wide range of manifestations. Current classifications do not have the capacity to classify all different types of radial polydactyly when combined with triphalangeal components. The objective of this study was to test an adjusted classification and nomenclature that allows classification of triphalangeal components and triplication in radial polydactyly.

METHODS

Patients from 1993 to 2006 with radial polydactyly (N = 104), a total of 121 affected hands, were identified from the hospital database. All x-rays were carefully examined and classified according to the existing classifications for radial polydactyly and a modified classification. In the modified nomenclature, Wassel's level of duplication is preserved. Type VII and VIII are assigned for partial or complete duplication of the carpal bones according to Buck-Gramcko. Triplication and triphalangeal components can be assigned to each type of radial polydactyly by suffixes. Symphalangism, deviation, and hypoplasia can also be classified. Triplication on different levels of the thumb is classified by determining and including the different types of the original Wassel classification.

RESULTS

Eighteen thumbs could not be classified according to existing classifications for radial polydactyly with triphalangeal components or triplication. Using the proposed classification, all patients could be classified.

CONCLUSIONS

We propose a modified classification that is a practical and utilitarian scheme for nomenclature of radial polydactyly and that may assist comparison of treatment outcomes and individual cases.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Triplicated thumbs: a rarity?

SUMMARY

Triplication of the thumb is supposed to be a rare condition and a complex form of radial polydactyly. However, we encountered an unusually high number of triplicated thumbs at our unit. Is triplication of the thumb indeed a rare condition? In our study, 121 patients with radial polydactyly were recorded between 1933 and 2005. In nine patients of this group, triplicated thumbs, either unilateral or bilateral, were identified. This complex type of radial polydactyly occurs in various forms. A total of 11 triplicated thumbs were found, and all cases were combined with triphalangeal components. Only one of these 11 triplicated thumbs could be classified according to currently used classifications. In all cases, aberrant rays were excised, thumb length and alignment restored by osteotomies, joints were stabilised, tendons reinserted and nails and nail walls corrected if necessary. Also, in all cases, a correction of triphalangeal components was carried out. Triplications are a rarity, and have only been presented in single case reports. We found that triplicated thumbs are not so rare. The likely explanation for this is the identification of a genetic isolate (a deformity located at chromosome 7q36) with radial polydactyly and triphalangeal thumbs in the southwest region of the Netherlands. Treatment for the presented triplicated thumbs was based on the same general principles as for less complex forms of radial polydactyly (i.e. to assemble useful elements of the separate [partial] thumbs to reconstruct one functioning, stable thumb).

Long-term functional outcome and satisfaction after radial forearm free flap reconstructions of intraoral malignancy resections

PURPOSE

Evaluation of objective and subjective functional follow-up results of intraoral radial forearm free flap reconstructions.

METHODS

A total of 149 patients had received radial forearm free flaps between January 1996 and December 2005. Seventy-two patients completed a European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-H&N35 (EORTC H&N35) in the follow-up study. Patients were divided according to location of defect (anterior or posterior) or irradiation. Thirty-nine patients with anterior positioned flaps received standardised physical examinations.

RESULTS

Flap survival was 99.3%. Complications were divided in early (<2 weeks; 23%) and late complications (20%). Most common complications were dehiscence or fistula, responding well to conservative treatment. Analysis of questionnaire subscales showed no statistically significant differences between anterior and posterior defects. Irradiation showed significant impairment for the ability to smell and taste. No important donor site impairment was found.

CONCLUSION

The radial forearm free flap is an adequate method for reconstructions after resection of intraoral malignancies. Subjective functional outcome seemed to be defined by adjuvant radiotherapy, patient coping and, to a lesser extent, flap bulk for anterior defects.

The effect of the epiphyseal growth plate on the length of the first metacarpal in triphalangeal thumb

PURPOSE

Triphalangeal thumb is characterized as a congenital difference of the thumb with an extra phalanx. Additional thumb length is attributed mostly to the extra phalanx. The influence of the epiphyseal plate positions on growth in congenital hand anomalies is unclear. The purpose of this article was to compare the length of the first metacarpal in triphalangeal thumbs with the length of the same bone in normal thumbs and to investigate the influence of the often aberrant metacarpal epiphyseal plates on the length of the triphalangeal thumb metacarpal during growth.

METHODS

The positions of the epiphyseal plate and the relative length of the first metacarpal were examined retrospectively in 37 patients with triphalangeal thumb. Ratios of the measurements were calculated (metacarpal II/metacarpal I) and compared with a normal population. Subjects were divided into 3 groups based on the position of the epiphyseal plate (double, proximal, distal).

RESULTS

The distally placed growth plate was the most common variety, present in 22 of patients, followed by the proximal position in 14, and double epiphyseal plates in 6. All ratios of patients with triphalangeal thumb were significantly smaller than those of a normal population, indicating a longer first metacarpal in this condition. First metacarpals in triphalangeal thumb with double epiphyses grew disproportionately more than those of a normal population, whereas those with distal epiphyses grew disproportionately less than normal. First metacarpals with proximal epiphyses grew at the same rate as normal first metacarpals.

CONCLUSIONS

In this study population the most common growth plate location was distal whereas the most common location in the normal population is proximal. The different positions of the epiphyseal plates correlate with growth differences in patients with triphalangeal thumb.

Treatment of the triphalangeal thumb

Triphalangeal thumb is a thumb with 3 phalanges and has an estimated incidence of 1 in 25,000 live births. Clinical presentation of triphalangeal thumb can vary considerably. Most strikingly is the long finger-like thumb with clinodactyly, in the same plane as the fingers and may or may not present with an extra thumb. Anatomically, the extra phalanx can have different shapes, from wedge to rectangular. Furthermore, the involved joints, ligaments, muscles, and tendons of the first ray, from distal interphalangeal joint to radiocarpal joint, can be hypoplastic, malformed, or absent with varying degrees of stiffness or instability. Also, the first web can be insufficient, and radial polydactyly as well as other hand deformities can be present. The aim of surgical treatment is to try to reconstruct or correct the anatomic difference and at the same time provide a more acceptable appearance. In our series, depending on the malformation, operations varied from removal of the delta phalanx with ligament reconstruction to multiple osteotomies and rebalancing as well as pollicization. Complications are mostly related to structures that have not been reconstructed or corrected during operation. Results in these often complex cases can be rewarding if the surgeon has sufficient knowledge of the underlying anatomic differences.

Closure of the donor site of the free radial forearm flap: a comparison of full-thickness graft and split-thickness skin graft

INTRODUCTION

Donor-site complications of free radial forearm flaps (FRFF) after closure with a split-thickness skin graft (STSG) have been reported repeatedly. Different types of closure of the donor site have been advocated to reduce donor-site complications. In our practice, a V-Y closure with a local full-thickness skin graft (FTG) is performed generally.

PURPOSE

A retrospective follow-up study was performed comparing subjective and objective outcomes of FTG versus STSG closure. FRFF donor site closure in 34 head and neck cancer patients (15 STSG, 19 FTG) was studied.

RESULTS

Both methods of closure showed good function, sensibility, and esthetic outcome. No statistical differences between the 2 methods could be shown.

CONCLUSION

V-Y local donor site closure is a good technique which prevents an additional donor site scar and discomfort when performing an STSG closure.

Internal anatomy of the communicating branch between the ulnar and median nerves in the hand and its relevance to volar digital sensibility

We studied the microanatomy of the communicating branch between the ulnar and median nerves in 26 adult cadaver hands to explain diminished sensibility in the fourth and fifth fingers we had observed in 2 patients after complete transection of the median nerve. Two new variations of the communicating branch were observed. In the first variation the communicating branch originated proximally from the third common digital nerve to distally join the ring finger ulnar digital nerve and the small finger radial digital nerve. In the second variation the ramus communicans traversed perpendicularly between the third and fourth common digital nerves with a crossover of nerve fibers.

Anatomic study of the ramus communicans between the ulnar and median nerves

The communicating branch between the fourth and third common digital nerves in the palm of the hand was studied. The incidence and branching pattern were studied in 53 dissected cadaveric hands. The "danger zone" in which the nerve is at risk during surgery was established using morphometric data. A communicating branch was found in 50 hands. It originated proximally from the fourth common digital nerve to join the third common digital nerve distally in 44 hands and traversed perpendicularly between the third and fourth common digital nerves in 4 hands. In the 2 remaining hands the branch left the third common digital nerve proximally to join the fourth digital common nerve distally. In 90% of the hands the ramus communicans crossed over in the middle third of the palm of the hand. As a cautious measure, hand surgeons should take into account that this structure could cross over anywhere in the middle three fifths of the palm.