Patient-reported 'treatment injuries' after hand surgery. A review of 1321 claims submitted to the Norwegian system of patient injury compensation 2007-2017.

OBJECTIVE: Hand surgery makes up a large proportion of procedures, ranging from simple to complex. Increased complexity places greater demand on hand surgery competence. Furthermore, when surgical expertise is not matched to the procedure complexity, treatment injuries might occur. The purpose of this study was to assess patient-reported claims submitted to The Norwegian System of Patient Injury Compensation (NPE). METHODS: We examined all hand surgery claims submitted to NPE between 1 January 2007 and 30 June 2017. NPE records patient demography and variables, such as diagnosis, type of injury, injury location, the reason for the compensation claim, and whether a claim was accepted or rejected. RESULTS: NPE received 1321 claims related to treatment injuries from hand surgery at a steady rate throughout the study period. A total of 532 claims were accepted (40.3%). The approval rate for trauma cases was significantly higher than for elective cases (45.5 vs. 34.2%, p < .05). The most common diagnoses were hand fractures, dislocations and ligament injuries, carpal tunnel syndrome and arthrosis of the first carpometacarpal joint. Tendon injuries had the highest percentage of accepted claims (52.6%). The most common reason for claims being accepted was 'failure of treatment'. 19.7% of these involved a disability percentage >15%. Elective surgery accounted for ⅔ of the approved disability cases. CONCLUSIONS/INTERPRETATION: This is the first national study of patient-reported injuries after hand surgery treatment in Norway. The proportion of accepted claims is similar to that seen for orthopaedics. Acceptance levels were, however, higher for hand trauma cases than for disorders treated electively. ABBREVIATIONS: NPE: Norwegian system of patient injury compensation; SD: standard deviation; CT: computed tomography; MRI: magnetic resonance imaging; UiT: University of Tromsø - Arctic University of Norway.

Wrist malpractice claims in Northern Norway 2005-2014. Lessons to be learned.

Rough weather conditions in the subarctic areas of Norway may influence on the risk of wrist fracture. We implemented data from the Norwegian System of Patient Injury Compensation (NPE). All claims due to wrist surgery, performed at the public hospitals in Northern Norway, during 2005-2014 were analyzed. We employed the ICD-10 classification codes S52.5 (fracture of distal end of radius) and S52.6 (fracture of distal end of radius and ulna). Treatment was defined by NCSP codes. 84 patients (0.3%) complained. Females complained four times more often than males did (P = 0.005) and received five times more frequently a compensation (P < 0.001). NPE accepted 34 claims (40%) for injury compensation (0.1% of patients). The percentage of claims accepted for compensation decreased from 48% to 30% during study period, probably due to delay in filling claims. The main causes of complains were pain, reduced range of motion, malfunction and weakness (35/84). The main causes of compensation were "operative treatment should have been performed" (14/34) and "wrong operative method applied" (13/34). The mean amount per compensation was €14,927 (€0-€52,995). Stonger focus on quality of care, updated guidelines and shared decission-making may reduce the number og complains and compensations.

Treatment of wrist fractures 2009-14. / Behandling av håndleddsbrudd 2009 ­ 14.

BACKGROUND: The purpose of the study was to conduct a systematic analysis based on data from the Norwegian Patient Registry and describe the incidence and treatment of wrist fractures among adults, at national level and in the catchment areas of the various regional health authorities. MATERIAL AND METHOD: A search was conducted in the Norwegian Patient Registry for all patients aged ≥ 18 years with diagnosis codes for wrist fractures in the period 2009­2014. Age, sex and type of treatment were recorded. The results are presented as rates adjusted for age and sex for the catchment areas of Norway's 21 regional health authorities. RESULTS: In the period 2009­2014, a total of 75 132 patients aged ≥ 18 years were registered as having a wrist fracture. Almost 1/3 of these patients received operative treatment. During this period, the age- and sex-adjusted rate of wrist fractures in Norway averaged 244 per 100 000 inhabitants per year. Operation rates varied across catchment areas by a factor of three, and the use of plates by a factor of nine. INTERPRETATION: We found great variation in clinical practice, which is reflected in differences in operation rates and choice of surgical method across the catchment areas to which the patients belong.

External Fixation and Adjuvant Pins Versus Volar Locking Plate Fixation in Unstable Distal Radius Fractures: A Randomized, Controlled Study With a 5-Year Follow-Up.

PURPOSE: To determine whether volar locking plates (VLP) are superior to external fixation (EF) with adjuvant pins in unstable distal radius fractures after 5 years of follow-up. METHODS: We randomized 111 unstable distal radius fractures to treatment with either a VLP or EF using adjuvant pins. The patients' mean age was 54 years (range, 20-84 y). Twenty patients were lost to follow-up. At 5 years, 91 patients (82%) were assessed using the visual analog scale (VAS) pain score, Mayo wrist score, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, range of motion, and radiological evaluation. The QuickDASH score at 5 years was the primary outcome measure. RESULTS: The QuickDASH score was not statistically significantly different between the groups (VLP 10 vs EF 13) at 5 years. Patients with VLP had statistically significant better supination (85° vs 81°), better radial deviation (18° vs 16°), and less radial shortening (1 mm vs 2 mm). For AO/OTA type C2 fractures, the VLP had statistically significant better supination (84° vs 78°), flexion (64° vs 56°), grip strength (34 kg vs 28 kg), Mayo wrist score (92 vs 76), and less ulnar shortening (1 mm vs 3 mm). The QuickDASH score in the C2 subset analysis showed a difference of 10 (VLP 8 vs EF 18), but this was not statistically significant. In the VLP group, 11 patients (21%) had their plates removed owing to surgically related complications. In the EF group, 5 patients had proximal radial scar correction surgery owing to skin contracture. CONCLUSIONS: The findings were satisfactory for both groups at 5 years. The VLP provided statistically significantly better results for several clinical outcomes in the C2 subset analysis. However, 21% of the VLPs were removed because of surgical complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Treatment of congenital syndactyly of the fingers.

BACKGROUND: Syndactyly or webbed fingers is one of the most common congenital malformations of the upper extremities, but it comprises few new cases annually. The purpose of treatment is to enhance hand function. METHOD: The article is based on current text books and literature searches in PubMed as well as the authors' clinical experience within this field. RESULTS: The purpose of surgical treatment is to separate the fingers and reconstruct a webspace. It is difficult to indicate exact treatment results because of large variations in the extent of the deformity. For syndactyly involving only soft tissue (simple syndactyly), a good functional result is achieved with a less than 10% risk of complications. Syndactyly where also the bones have fused (complex syndactyly) or where there is additional bone formation between two digital rays (complicated syndactyly), gives a poorer functional outcome and a higher risk of complications. Gradual stretching of the tissue using a distraction device enables separation of fingers one was previously reluctant to separate. INTERPRETATION: It should be possible to expect safe separation with a good and independent function of the fingers with surgical treatment. The parents should be informed that the surgical treatment is a reconstructive procedure that may require secondary corrections.

Volar locking plates versus external fixation and adjuvant pin fixation in unstable distal radius fractures: a randomized, controlled study.

PURPOSE: To determine whether volar locking plates are superior to external fixation with adjuvant pins in the treatment of unstable distal radius fractures. METHODS: A total of 111 unstable distal radius fractures were randomized to treatment with external fixation (EF) using adjuvant pins or with a volar locking plate (VLP). The mean age of the patients was 54 years (range, 20-84 y). Seven patients were lost to follow-up. At 1 year, 104 patients were assessed with a visual analog scale pain score, Mayo wrist score, Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH), range of motion, and radiological evaluation. The QuickDASH score at 52 weeks was the primary outcome measure. RESULTS: The operative time in the EF group was 77 minutes, compared with 88 minutes in the VLP group. At 52 weeks, patients with VLPs had a higher Mayo wrist score (90 vs. 85), better supination (89° vs. 85°), and less radial shortening (+1.4 mm vs. +2.2 mm). There were more patients with pain over the ulnar styloid in the EF group (16 vs 6 patients). For AO type C2/C3, the patients with VLPs had better supination (90° vs. 76°) and less ulnar shortening (+1.1 mm vs. +2.8 mm). The complication rate was 30% in the EF group, compared with 29% in the VLP group. Eight (15%) plates were removed due to complications. The QuickDASH score was not significantly different between the groups. CONCLUSIONS: Although we did not find a significant difference between the groups for the QuickDASH score, we believe that our results support the use of VLPs for the treatment of unstable distal radius fractures. A serious concern is that some patients will have to have their plates removed; therefore, improving the surgical technique is important. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Treatment of distal radius fractures.

BACKGROUND: In light of the Norwegian Orthopaedic Association's wish to prepare guidelines for treatment of distal radius fractures, we have reviewed the knowledge base for the provision of such treatment. METHOD: The paper is based on systematic reviews of treatment of distal radius fractures from literature search in the following databases: the Cochrane Library, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE Cochrane), the Health Technology Assessment (HTA) database, PreMedline, Medline and Embase. RESULTS: There is evidence for recommending percutaneous pinning of unstable, dorsally displaced distal radius fractures rather than conservative treatment, but which pinning method is best remains uncertain. There is also documentation to support the use of external fixation rather than conservative treatment. There is insufficient documentation available to draw conclusions regarding the relative efficacy of the various methods of external fixation, but external fixation in combination with adjuvant pinning of the fracture fragment enhances the result compared to external fixation alone. The evidence indicates that plates may enhance functional short-term results for unstable distal radius fractures compared to external fixation. INTERPRETATION: There is evidence in support of differentiated treatment of distal radius fractures. However, many questions remain unanswered, and good prospective, randomised multi-centre trials are needed.

Posttraumatic reconstruction of the hand--a retrospective review of 87 toe-to-hand transfers compared with an earlier report.

PURPOSE: The purpose of this study was to retrospectively review the results of 87 toe-to-hand transfers performed in 73 procedures, compare them to the report published by the senior author in 1983, and confirm the hypothesis that results of toe-to-hand transfers at our center have improved over time. METHODS: The results of 87 toe-to-hand transfers performed between 1981 and 2001 were reviewed and compared with the results of 54 toe-to-hand transfers performed between 1974 and 1980. The measured parameters were type of reconstruction performed, anticoagulation therapy, vascular patency, frequency of secondary surgery, and strength of thumb reconstructions. RESULTS: In the recent time period, 11% of the procedures had complications with revascularization of the transferred digit, and long-term survival was seen in 98% of the toe-to-hand transfers. This is a significant improvement over earlier results, in which 33% of the cases had some microvascular compromise and the survival of grafts was lower (91%). Pinch strength for thumb reconstructions improved, and the number of secondary surgeries performed dropped, but neither of these parameters reached a significant level. Toes used for reconstruction changed, with an 18% decrease in use of big toe for thumb reconstruction and a similar increase in use of the second toe. For non-thumb digital reconstructions there was a 60% decrease in use of second and third toe combined, whereas use of the second toe alone increased similarly. CONCLUSIONS: This study showed reduction of the incidence of vascular compromise compared to the previous report. Improved strength of thumb reconstructions and reduced need for secondary surgery was also displayed. These findings are likely attributed to refinements in reconstructive procedures and operative techniques. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Human skin microcirculation after brachial plexus block evaluated by wavelet transform of the laser Doppler flowmetry signal.

BACKGROUND: The skin microcirculation may be evaluated noninvasively by laser Doppler flowmetry and iontophoresis with acetylcholine and sodium nitroprusside. Wavelet transform of the perfusion signal shows periodic oscillations of five characteristic frequencies in the interval 0.0095-1.6 Hz. The aim of the current study was to investigate alterations in skin microcirculation induced by brachial plexus block, with emphasis on the periodic oscillations. METHODS: Healthy nonsmokers undergoing hand surgery (n = 13) were anesthetized with brachial plexus block, using bupivacaine, lidocaine, and epinephrine. Skin microcirculation was evaluated by laser Doppler flowmetry and iontophoresis with acetylcholine and sodium nitroprusside before and after brachial plexus block. Wavelet transform of the perfusion signal was performed. As a control group, 10 healthy nonsmokers were included. RESULTS: In the anesthetized arm, skin perfusion after brachial plexus block increased from 19 (12-30) to 24 (14-39) arbitrary units (P < 0.01). A significant increase was also seen in the contralateral arm from 17 (14-32) to 20 (14-42) arbitrary units (P < 0.01). After brachial plexus block, spectral analysis revealed a significant reduction in relative amplitude of the oscillatory components within the 0.0095- to 0.021- (P < 0.001) and 0.021- to 0.052-Hz (P < 0.001) intervals in the anesthetized arm. CONCLUSION: Alterations in skin microcirculation induced by brachial plexus block can be evaluated by wavelet transform of the laser Doppler flowmetry signal. Brachial plexus block reduces the oscillatory components within the 0.0095- to 0.021- and 0.021- to 0.052-Hz intervals of the perfusion signal. These alterations are related to inhibition of sympathetic activity and a possible impairment of endothelial function.

Low-frequency oscillations of the laser Doppler perfusion signal in human skin.

Spectral analysis of the laser Doppler flow (LDF) signal in the frequency interval from 0.0095-2.0 Hz reveals blood flow oscillations with frequencies around 1.0, 0.3, 0.1, 0.04 and 0.01 Hz. The heartbeat, the respiration, the intrinsic myogenic activity of vascular smooth muscle, the neurogenic activity of the vessel wall and the vascular endothelium influence these oscillations, respectively. The first aim of this study was to investigate if a slow oscillatory component could be detected in the frequency area below 0.0095 Hz of the human cutaneous blood perfusion signal. Unstimulated basal blood skin perfusion and enhanced perfusion during iontophoresis with the endothelium-dependent vasodilator acetylcholine (ACh) and the endothelium-independent vasodilator sodium nitroprusside (SNP) were measured in healthy male volunteers and the wavelet transform was computed. A low-frequency oscillation between 0.005 and 0.0095 Hz was found both during basal conditions and during iontophoresis with ACh and SNP. Iontophoresis with ACh increased the normalized amplitude to a greater extent than SNP (P = 0.001) indicating modulation by the vascular endothelium. To gain further insight into the mechanisms for this endothelium dependency, we inhibited nitric oxide (NO) synthesis with N(G)-monomethyl-L-arginine (L-NMMA) and prostaglandin (PG) synthesis by aspirin. L-NMMA did not affect the increased response to ACh vs. SNP iontophoresis in the 0.005-0.0095-Hz interval (P = 0.006) but abolished the difference in the 0.0095-0.021-Hz interval (P = 0.97). Aspirin did not affect the difference in response to ACh and SNP in either of the two frequency intervals. Thus, other endothelial mechanisms, such as endothelium-derived hyperpolarizing factor (EDHF), might be involved in the regulation of this sixth frequency interval (0.005-0.0095 Hz).

Hand transplantation. A future clinical option?

Transplantation of a vascularized limb or its components is defined as composite tissue allotransplantation, and is one of the newest areas in surgery. To date, 24 hands have been transplanted onto 18 recipients. The initial results have been promising, and hand transplantation may become an important procedure for functional restoration of upper limbs. However, the ethical aspects of using chronic immunosuppression for a condition which is not life threatening have been the subject of debate. In this article, we review the field of composite tissue allotransplantation.

Enhanced endothelial activity reflected in cutaneous blood flow oscillations of athletes.

Functional alterations of vascular endothelial cells may be evaluated by analysing differences in effects of endothelium-dependent [acetylcholine (ACh)] and endothelium-independent [sodium nitroprusside (SNP)] vasodilators. We evaluated whether a dynamic approach using spectral analysis of the blood flow signal, resulting from the cutaneous red cell flux and recorded by the technique of laser Doppler flowmetry (LDF), can detect higher endothelial responsiveness in trained versus less trained individuals. There was a 1.6 times higher ACh-induced cutaneous perfusion in athletes than in controls ( P<0.05), both when evaluated as a mean value of the LDF signal or as the amplitudes of its spectral components. In the frequency interval from 0.009 to 1.6 Hz, ACh induced a 1.6 times higher average spectral amplitude ( P<0.01) in athletes compared with controls. ACh also induced a 1.6 times higher absolute spectral amplitude of the oscillator at around 0.01 Hz ( P<0.05) in the athletes compared with the controls, whereas the endothelial oscillation at around 0.01 Hz during basal unstimulated perfusion was 1.5 times higher ( P<0.01). There were no significant differences in absolute or relative amplitude during iontophoresis with SNP. These results indicate that athletes have higher endothelial activity than less trained individuals.

Regulation of human cutaneous circulation evaluated by laser Doppler flowmetry, iontophoresis, and spectral analysis: importance of nitric oxide and prostaglandines.

Nitric oxide (NO) and prostaglandines (PGs) are important in regulation of vascular tone and blood flow. Their contribution in human cutaneous circulation is still uncertain. We inhibited NO synthesis by infusing N(G)-monomethyl-L-arginine (L-NMMA) in the brachial artery (16 micromol/min for 5 min) and reversed it by intraarterial infusion of L-arginine (40 micromol/min for 7.5 min). PG synthesis was inhibited by the cyclooxygenase inhibitor aspirin (600 mg over 5 min intravenously). Basal cutaneous perfusion and perfusion responses during iontophoresis with the endothelium-dependent vasodilator acetylcholine (ACh) and the endothelium-independent vasodilator sodium nitroprusside (SNP) were recorded by laser Doppler flowmetry (LDF). We performed wavelet transforms of the measured signals. Mean spectral amplitude within the frequency interval from 0.0095 to 1.6 Hz and mean and normalized amplitudes of five intervals around 1, 0.3, 0.1, 0.04, and 0.01 Hz were analysed. The oscillations with frequencies around 1, 0.3, 0.1, and 0.04 Hz are influenced by the heartbeat, the respiration, the intrinsic myogenic activity of vascular smooth muscle, and the neurogenic activity of the vessel wall, respectively. We have previously shown that the oscillation with a frequency around 0.01 Hz is modulated by the vascular endothelium. L-NMMA reduced mean value of the LDF signal by approximately 20% (P = 0.0067). This reduction was reversed by L-arginine. Mean value of the LDF signals during ACh and SNP iontophoresis did not change after infusion of L-NMMA. Aspirin did not affect mean value of the LDF signal or the LDF signal during ACh or SNP iontophoresis. Before interventions the only significant difference between the effects of ACh and SNP was observed in the frequency around 0.01 Hz, where ACh increased normalized amplitude to a greater extent than SNP. L-NMMA abolished this difference, whereas it reappeared after infusion of L-arginine (P = 0.0084). Aspirin did not affect this difference (P = 0.006). We conclude that basal cutaneous blood flow and the endothelial dependency of the oscillation around 0.01 Hz are partly mediated by NO, but not by endogenous PGs. Other aspects of human cutaneous circulation studied are not regulated by NO or PGs.