State of the art review. Complications after carpal tunnel release.

Carpal tunnel release (CTR) is the most performed surgery of the upper extremity. It is effective but not without complications. This state-of-the-art review covers most common intra- and postoperative complications after CTR. As endoscopic carpal tunnel release (ECTR) has developed over time, severe complications, such as nerve lesions, have diminished. ECTR still has a higher risk on transient nerve lesions. Open CTR on the other hand has a higher incidence of wound-related problems, including scar tenderness, irrespective of incision used. Most complications, such as pillar pain and infection, are ill-defined in the literature, leaving the exact incidence unknown and proposing challenges in treatment. The same is true for failure of treatment. Optimizing the length and location of incisions has played a vital role in reducing intra- and postoperative complications in CTR. It is expected that technical advances, such as ultrasound-guided percutaneous carpal tunnel release, will continue to play a role in the future.Level of evidence: V.

From Data to Decisions: How AI Is Revolutionizing Clinical Prediction Models in Plastic Surgery.

SUMMARY: The impact of clinical prediction models within Artificial Intelligence (AI) and machine learning (ML) is significant. With its ability to analyze vast amounts of data and identify complex patterns, machine learning has the potential to improve and implement evidence-based plastic, reconstructive, and hand surgery. Among others, it is capable of predicting the diagnosis, prognosis, and outcomes of individual patients. This modeling aids daily clinical decision making, most commonly at the moment, as decision-support.Therefore, the purpose of this paper is to provide a practice guideline to plastic surgeons implementing AI in clinical decision-making or setting up AI research to develop clinical prediction models using the 7-step approach and the ABCD validation steps of Steyerberg et al. Secondly, we describe two important protocols which are in the development stage for AI research: 1) the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD) checklist, and 2) The PROBAST checklist to access potential biases.

A Threshold QuickDASH Score for Estimating a Diagnosis of Major Depression in Patients With Fingertip Injuries in the American and Dutch Population.

BACKGROUND: The aim was to determine the threshold Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score that estimates a diagnosis of major depression in patients with fingertip injuries in American and Dutch patients. METHODS: In this observational cross-sectional study, 112 patients with a recent fingertip injury measured symptoms of depression with the Patient Health Questionnaire and upper extremity disability with the QuickDASH. RESULTS: In the US cohort, 8 of 56 patients had an estimated diagnosis of major depression. A threshold value of QuickDASH of 50 showed a sensitivity of 88% and a specificity of 81%, with a negative predicting value (NPV) of 95% for an estimated diagnosis of major depression. In the Dutch cohort, 7 of 56 patients had an estimated diagnosis of major depression. The same threshold score of 50 had a sensitivity of 71%, a specificity of 63%, and an NPV of 94%. CONCLUSIONS: We have found a correlation between experienced loss of function and an estimated diagnosis of major depression in patients with a fingertip injury. Referral to the primary care physician for further evaluation of depression in these patients is advised.

Reoperation After Operative Treatment of Open Finger Fractures.

BACKGROUND: Our primary aim was to develop a prediction model for return to the operating room (OR) after open finger fractures by studying the reoperation rate of open finger fractures based on patient demographics, injury mechanism, injury severity, and type of initial surgical fixation. The secondary aim was to study the predictors for secondary surgery due to nonunion, postoperative infection, and secondary amputation. METHODS: In the retrospective chart review, 1321 open finger fractures of 907 patients were included. Demographic-, injury-, and treatment-related factors were gathered from medical records. RESULTS: We found that open fractures involving the thumb had lower odds of undergoing secondary surgery. Crush injury, proximal phalangeal fracture, arterial injury, other injured fingers, and other injuries to the ipsilateral hand were associated with higher odds of undergoing secondary surgery. However, the associated factors we identified were not powerful enough to create a predictive model. Other injury to the ipsilateral hand, vein repair, and external fixator as initial treatment were associated with postoperative nonunion. Crush injury and proximal phalangeal fracture were associated with postoperative infection. No factors were associated with secondary amputation. CONCLUSIONS: A quarter of open finger fractures will likely need more than one surgical procedure, especially in more severely injured fingers, due to crush or with vascular impairment. Furthermore, fractures involving the thumb have less reoperation, while fractures involving the proximal phalanx have poorest outcomes.

Dorsal Subluxation of the Proximal Interphalangeal Joint After Volar Base Fracture of the Middle Phalanx.

Background: Treatment decisions regarding volar base fractures of the middle phalanx depend on whether the proximal interphalangeal (PIP) joint is reduced. Our aim was to study the agreement among hand surgeons in determining whether the PIP joint fractures are subluxated and to study the factors associated with subluxation of these fractures. Methods: In this retrospective chart review, 413 volar base fractures of the middle phalanx were included. Demographic and injury-related factors were gathered from medical records and radiographs. Using a Web-based survey, interobserver agreement was determined among 105 hand surgeons on the assessment of PIP joint subluxation of a series of 26 cases. Using the cohort of 413 fractures, a threshold for percent articular involvement and relative fracture displacement that corresponds with subluxation of the PIP joint was analyzed. Results: We found moderate to substantial agreement between hand surgeons on subluxation (κ = 0.59, P < .0001) and an overall percent agreement of 85%. Percent articular involvement and relative fracture displacement were independently associated with subluxation of the PIP joint (P < .001). Percent articular involvement of 35% had a specificity of 90% and a negative predicting value (NPV) of 92% for joint subluxation. Relative fracture displacement of 35% had a specificity of 92% and an NPV of 94% for joint subluxation. Conclusions: Surgeons generally agree on whether a PIP joint is subluxated. Percent articular involvement and relative fragment displacement are objective measurements that can help characterize joint stability and assist with decision-making.

Reoperation After Operative Fixation of Proximal Interphalangeal Joint Fractures.

Background: The purpose of this study was to determine the reoperation rate and what factors are associated with reoperation of proximal interphalangeal (PIP) joint fractures. Methods: We identified 161 surgically treated PIP joint fractures between 2004 and 2015 at 2 academic medical systems. Demographic, injury, radiographic, and treatment data that might be associated with reoperation were collected. Bivariate analysis was performed. Factors identified during bivariate analysis with a P < .10 were entered into a multivariable logistic regression analysis. Results: Of the 161 fingers, 25 underwent revision surgery. Open fracture was independently associated with revision surgery. The most common indication for reoperation was joint stiffness (35%). In a subanalysis of 111 closed fractures, no factors were associated with revision surgery. Conclusions: Soft tissue injury is a major factor in reoperation after PIP joint fracture dislocation. Specific attention should be paid to persistent subluxation because this may predispose to early arthrosis.

Pathologic Fractures in Benign Neoplasms of the Fingers.

Background: To describe the rate and predictors of pathologic fractures in benign neoplasms of the finger, as variables from prediction models for pathologic fractures of the long bones of the extremities are not necessarily applicable to the bones of the hand. Methods: In this retrospective chart review, 69 histologically confirmed neoplasms affecting the bones of the fingers, 49 phalanges and 20 metacarpals, were identified in patients presenting at 2 urban hospitals over a 24-year period. Different variables were studied as possible predictors of pathologic fractures. Results: Forty-nine percent of the tumors presented as a pathologic fracture. The small finger was independently associated with pathologic fractures compared to the other fingers. Tumors of the metacarpal bones were the least likely to fracture compared to other bones. Conclusions: Almost half of neoplasms affecting the bones of the fingers presented initially with a pathologic fracture, most commonly the small finger. Therefore, a lower threshold for surgical treatment of a bone neoplasm affecting the small finger may be reasonable.

Revision Carpal Tunnel Release: Risk Factors and Rate of Secondary Surgery.

BACKGROUND: The first aim of this study was to determine the rate of revision carpal tunnel release in five urban hospitals over a period of 14 years. The secondary aim was to assess what demographic, condition-related, and treatment-related factors are associated with revision carpal tunnel release. METHODS: Between 2002 and 2015, 7464 patients underwent carpal tunnel release. After manually reviewing the medical records, the authors identified 113 patients who underwent revision surgery. Multivariable logistic regression analysis was performed to study association with demographics (age, sex, and race), unilateral or bilateral treated wrist(s) (including carpal tunnel release performed simultaneously and separately), and type of surgery (open or endoscopic). To gain further insight into these factors, a matched case-control analysis in a 1:3 ratio was performed. RESULTS: One hundred thirteen of 7464 patients (1.5 percent) underwent revision carpal tunnel surgery. The median (interquartile range) time to revision surgery was 1.23 years (0.47 to 3.89 years). In multivariable logistic regression analysis, older age, male sex, bilateral carpal tunnel release, and endoscopic carpal tunnel release were independently associated with higher odds for revision surgery. Multivariable conditional logistic regression of the matched case-control cohort showed that smoking and rheumatoid arthritis were independently associated with revision carpal tunnel release. Splint treatment before the initial surgery was independently associated with single carpal tunnel release. CONCLUSION: Endoscopic release, male sex, smoking, rheumatoid arthritis, and undergoing staged or simultaneous bilateral carpal tunnel release are risk factors for revision surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Obesity status is a risk factor for secondary surgery after neurolysis, direct nerve repair or nerve grafting in traumatic brachial plexus injury: a retrospective cohort study.

BACKGROUND: The objective of the study was to investigate the association between obesity and the presence of secondary surgery following neurolysis, direct nerve repair, or nerve grafting in patients with traumatic brachial plexus injury. METHODS: In this retrospective chart review spanning two Level I medical centers in a single metropolitan area, 57 patients who underwent neurolysis, direct nerve repair, or nerve grafting for brachial plexus injuries between 2002 and 2015 were identified. Risk regression analysis was used to evaluate the association between obesity status and secondary surgery. RESULTS: After controlling for the confounding variables of age, high energy injury, associated shoulder dislocation and associated clavicle fracture using multivariate regression (risk regression), the risk ratio of secondary surgery in obese patients compared to non-obese patients was 6.99 (P = 0.028). The most common secondary surgery was tendon or local muscle transfer. CONCLUSIONS: There is an increased risk of secondary surgery in obese patients compared to non-obese patients of the same age and with the same severity of injury. The increased risk may be due to challenges related to powering a heavier upper extremity. A weight reduction program might be considered as part of the preoperative strategy.

Postoperative Dorsal Proximal Interphalangeal Joint Subluxation in Volar Base Middle Phalanx Fractures.

Introduction This study was designed to assess factors associated with postoperative dorsal proximal interphalangeal (PIP) joint subluxation after operative treatment of volar base middle phalanx fractures. Our second purpose was to study the association between postoperative dorsal subluxation with postoperative arthritis. Materials and Methods We identified 44 surgically treated volar base PIP joint fractures with available pre- and postoperative radiographs between 2002 and 2015 at two academic medical systems with a median follow-up of 3.5 months. Demographic, injury, radiographic, and treatment data that might be associated with postoperative dorsal subluxation were collected. Three hand surgeons independently assessed subluxation and arthritis on radiographs. Bivariate analysis was performed to analyze our two study purposes. Results Six of 44 (14%) had postoperative dorsal subluxation after initial surgery. Bivariate analysis showed no factors with statistically significant association with postoperative subluxation, assessed independently by three hand surgeons on radiographs. Fifty per cent of the joints with postoperative arthritis had postoperative subluxation compared with 21% of joints without postoperative subluxation. No significant association was found between postoperative dorsal subluxation with postoperative arthritis. Conclusion The association of persistent subluxation and early arthrosis in dorsal PIP joint fracture dislocations needs further study. At this time, it is unclear in what ways persistent subluxation or arthrosis affects the rate of reoperation. Level of Evidence This is a therapeutic level IV study.

Intravenous Drug Use-Related Complications of the Hand and Upper Extremity.

BACKGROUND: In the last decade, there has been an increase in intravenous drug use (IVDU) and associated medical problems. Users commonly inject into their upper extremities, which can result in infection and other sequelae in this area. The goal of this study was to compare demographics and treatment for upper extremity infections between intravenous drug users and non-intravenous drug users over the past 10 years at 1 level I emergency department (ED). METHODS: This was a retrospective case-control study. All patients presenting to the ED with an upper extremity infection in 2005, 2010, and 2015 were identified using the ninth revision of the International Statistical Classification of Diseases and Related Health Problems and Current Procedural Terminology codes. Patients with an IVDU-related infection were identified by manually reviewing the medical record and matched with patients with non-IVDU-related infection on demographics. Patient-related factors, infection specifics, and treatment parameters were compared in both groups. RESULTS: The number of IVDU-related upper extremity infection cases presenting to the ED increased 126% over the 10-year period (65 cases in 2005, 109 cases in 2010, and 147 cases in 2015). The location of infection in the IVDU group was more likely to be in a typical injection site (forearm, P < 0.001; wrist, P = 0.002), and IVDU patients had 33% more hospital admissions and stayed in the hospital longer (3 days versus 0.59; P < 0.001). These patients also were more likely to have a computed tomography scan (P < 0.001) and have Methicillin-resistant Staphylococcus aureus (MRSA) or Methicillin-sensitive Staphylococcus aureus (MSSA) (P = 0.009). CONCLUSIONS: Over a 10-year period, the number of IVDU-related upper extremity infections more than doubled, with more severe infections that underwent advanced imaging and intensive treatment.

The Prevalence of Triangular Fibrocartilage Complex Signal Abnormalities on Magnetic Resonance Imaging Relative to Clinical Suspicion of Pathology.

PURPOSE: To determine the prevalence of triangular fibrocartilage complex (TFCC) signal changes in patients undergoing magnetic resonance imaging (MRI) of the wrist and its relationship to a clinical suspicion of TFCC pathology. The secondary purpose was to study factors that are associated with TFCC signal changes. METHODS: In this retrospective study, we looked for any TFCC signal changes in the reports of MRI findings performed during a 3-year period in 1,134 patients. Demographic characteristics, the categorized indications for MRI, and symptoms at the time of the MRI were also retrieved from the medical records. Patients were divided into 6 groups, based on age, to calculate the proportions of TFCC signal changes in the entire cohort and as an incidental finding among patients without a clinical suspicion of TFCC pathology within each age group. RESULTS: A total of 321 patients (28%) had incidental TFCC signal changes. The prevalence among 18- to 30 year-olds was 19%, and increased to 64% in patients older than 70 years. Multivariable logistic regression analysis demonstrated that an increase in age is significantly associated with having TFCC signal changes on MRI in patients who have a low clinical suspicion of TFCC pathology. The rate of incidental TFCC signal changes steadily increases with age. CONCLUSIONS: The TFCC signal abnormalities on MRI are more common with increasing age in patients with low clinical suspicion of TFCC pathology. At age 70, more than half of all patients will have TFCC signal changes, and more than 90% are present in patients with a low clinical suspicion of TFCC pathology. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Mallet Fractures of the Thumb Compared With Mallet Fractures of the Fingers.

BACKGROUND: The purpose of this study was to look for differences in mechanism, radiographic findings, and treatment between mallet fractures of the thumb and mallet fractures of the index through small fingers. METHODS: This retrospective study included 24 mallet fractures of the thumb and 392 mallet fractures of other digits. We compared demographics, injury factors (side, dominant hand, time between injury and first visit, and injury mechanism), subluxation, fragment size, treatment, and time from injury to final evaluation between the 2 groups. RESULTS: Mallet fractures of the thumb presented for treatment sooner after injury (2.9 vs 13 days on average), had less fragment displacement (27% vs 33%), and less articular involvement (39% vs 46% on average). None of the mallet fractures of the thumb had radiographic evidence of subluxation, whereas 25% of mallet fractures of other fingers had initial or later subluxation. CONCLUSIONS: Mallet fractures of the thumb are not likely to subluxate.

Recognizing the elbow prosthesis on conventional radiographs.

The objective of this study was to make an overview that can be useful in determining which type and brand of prosthesis a patient has when visiting the emergency department or outpatient clinic with a periprosthetic fracture, dislocation, or implant failure. The commonly used prostheses in Europe are opted for this list. The radiographs used for this list are obtained either from the company or from our own patients. This list contains the Coonrad/Morrey total elbow prosthesis, the Nexel total elbow prosthesis, the GSB III Elbow Prosthesis, the iBP Total Elbow System, the Discovery Elbow System, the NESimplavit Elbow System, the Latitude Elbow prosthesis, the Solar Elbow, and the Souter-Strathclyde total elbow. The characteristics of each prosthesis are described.

Prevalence of and Factors Associated With Major Depression in Patients With Upper Extremity Conditions.

PURPOSE: To determine the prevalence of an estimated diagnosis of major depression in patients with upper extremity conditions and factors that help identify patients who might benefit from psychological treatment. METHODS: In this observational cross-sectional study, 190 patients completed questionnaires measuring symptoms of depression with the Patient Health Questionnaire, upper extremity disability with the Patient-Reported Outcomes Measurement Information System Upper Extremity, pain interference with the Patient-Reported Outcomes Measurement Information System Pain Interference, and health anxiety with the Short Health Anxiety Inventory. RESULTS: The estimated prevalence of an estimated diagnosis of major depression (Patient Health Questionnaire 9 ≥ 10) among this group of patients was 12%. Having multiple pain conditions, a history of depression, and greater limitation from pain for daily activities were independently associated with an estimated diagnosis of major depression. CONCLUSIONS: The finding that 1 in 8 patients presenting to a hand surgeon have untreated or undertreated symptoms of depression sufficient to qualify for an estimated diagnosis of major depression emphasizes the importance of assessing for depression at all levels of care.

Negative Ulnar Variance and Kienböck Disease.

PURPOSE: To test the primary null hypothesis that there is no difference in mean ulnar variance (UV) scaled to the length of the capitates between 166 wrists with Kienböck disease and an equal number of matched controls and to test the secondary null hypothesis that mean scaled UV does not vary based on age, sex, or race in both Kienböck and control wrists. METHODS: Ulnar variance was measured on posteroanterior radiographs of the wrist as the distance between a line through the midpoint between the volar and the dorsal edges of the ulnar margin of the radius and a line tangential to the most distal aspect of the carpal surface of the head of the ulna, both perpendicular to the longitudinal axis of the radius. Measurement of UV was scaled to the length of the capitate, resulting in a UV to capitate height (UV:CH) ratio. RESULTS: We found a significant difference in mean UV:CH ratio between patients with Kienböck disease and a control group matched by age, sex, race, and limb. The prevalence of negative UV was high in both patients with Kienböck disease and matched controls. There were no differences in mean UV:CH ratio with respect to age, sex, or race among patients with Kienböck disease or matched controls. CONCLUSIONS: The precise role of ulna minus in the development of Kienböck disease remains uncertain and unanswered, given that many patients with Kienböck disease have neutral or positive UV. In addition, a large proportion of the normal population has negative UV, whereas Kienböck disease is rare.

The Relationship Between Catastrophic Thinking and Hand Diagram Areas.

PURPOSE: To evaluate the relationship between the total area marked on pain and numbness diagrams and psychosocial factors (depression, pain catastrophic thinking, and health anxiety). METHODS: A total of 155 patients marked painful and numb areas on separate hand diagrams. Patients also completed demographic, condition-related, and psychosocial (Pain Catastrophizing Scale, Patient-Reported Outcomes Measurement Information System Depression Computer Adaptive Test, and Short Health Anxiety Inventory) questionnaires. Bivariate and multivariable analyses were used to determine factors associated with total area marked on the pain and numbness diagrams. RESULTS: The total area marked on the pain diagram correlated with catastrophic thinking, symptoms of depression, and health anxiety. In multivariable analysis, catastrophic thinking was the sole predictor of marked pain area, accounting for 10% of variance in the hand pain diagram. The total area marked on the numbness diagram correlated with the interval between onset and visit, diagnosis, catastrophic thinking, and symptoms of depression. In multivariable analysis, the interval between onset and visit, a diagnosis of carpal tunnel syndrome, and catastrophic thinking were independently associated with total area marked on the hand numbness diagram. CONCLUSIONS: Catastrophic thinking was independently associated with larger pain and numbness areas on a hand diagram. This suggests that larger symptom markings on hand diagrams may indicate less effective coping strategies. Hand diagrams might be used as a basis for discussion of coping strategies and illness behavior in patients with upper extremity conditions. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.