State of the art review. Upper extremity revision nerve compression surgery.

Although surgical release of upper extremity nerve compression syndromes is highly effective, persistence or recurrence of symptoms and signs may occur. Thorough investigation is necessary in this situation before treatment is recommended. If the symptoms cannot be explained by other pathology than compression of the affected nerve and if conservative management has not provided improvement, reoperation may be considered. This review provides an overview of the diagnostic and surgical considerations in the revision of carpal tunnel syndrome, cubital tunnel syndrome and thoracic outlet syndrome.Level of evidence: V.

An alternative treatment for degenerative triangular fibrocartilage complex injuries with distal radioulnar joint instability: first experience with 48 patients.

Treatment of ulnar impaction syndrome combined with distal radioulnar joint instability due to irreparable degenerative triangular fibrocartilage complex injuries can be complex. We describe the outcomes of a novel technique for restoring distal radioulnar stability due to ulnar impaction syndrome using a distally based extensor carpi ulnaris tendon strip combined with ulnar shortening osteotomy in 48 patients. Patients were assessed using standardized outcome measurements. The patient-rated wrist/hand evaluation total score improved from 66 (SD 15) at intake to 40 (SD 25) at 3 months, and 28 (SD 23) at 12 months postoperatively (p < 0.001). Wrist extension and flexion improved significantly at 12 months from 53° (SD 11) to 65° (SD 8) (p < 0.001) and from 45° (SD 10) to 56° (SD 12) (p = 0.01), respectively. Adding a distally based longitudinal extensor carpi ulnaris strip to ulnar shortening osteotomy for restoring distal radioulnar joint stability seems to be an effective treatment in patients with irreparable degenerative triangular fibrocartilage complex injuries due to ulnar impaction syndrome. Level of evidence: IV.

The past, present and future of the conservative treatment of distal radius fractures.

The distal radius fracture is a common fracture with a prevalence of 17% on the emergency departments. The conservative treatment of distal radius fractures usually consists of three to six weeks of plaster immobilization. Several studies show that one week of plaster immobilization is safe for non- or minimally displaced distal radius fractures that do not need reduction. A shorter period of immobilization may lead to a better functional outcome, faster reintegration and participation in daily activities. Due to upcoming innovations such as three-dimensional printed splints for distal radius fractures, a patient specific splint can be produced which may offer more comfort. Furthermore, these three-dimensional printed splints are expected to be more environmental friendly in comparison with traditional plaster casts.

Stronger pinch strength at long-term follow-up after pyrocarbon disc interposition arthroplasty compared to trapeziectomy with ligament reconstruction and tendon interposition for CMC-1 osteoarthritis.

BACKGROUND/INTRODUCTION: In this study, we wanted to compare the pyrocarbon disc interposition arthroplasty (PDI) with trapeziectomy plus ligament reconstruction tendon interposition (LRTI). Primarily, we tested whether PDI resulted in a higher pinch strength. Secondarily, we compared the grip strength, range of motion (ROM), patient reported outcomes, satisfaction and complications. METHODS: Due to scarcity of preoperative hand measurements, we performed a descriptional cross-sectional cohort study of patients operated between 2006 and 2014, with a minimum of 5 years of follow-up. Patients were treated with PDI or LRTI. We determined key pinch strength as primary outcome, followed by tip- and tripod pinch, grip strength, palmar abduction and opposition; the Michigan Hand Outcome Questionnaire (MHQ), Patient Reported hand and Wrist evaluation (PRWHE), satisfaction and complications. Propensity score matching was used to match both study groups on demographic variables. A ratio of 2:1 was used resulting in inclusion of 62 (of 154) PDI and 31 (of 31) LRTI thumbs. RESULTS: The PDI-group patients showed stronger key and tip pinch strength than the LRTI group (p=0.027 and p=0.036 respectively). Tripod pinch, grip strength and ROM were equal for both groups. MHQ and PRWHE were comparable, with higher satisfaction for the PDI group. Eight PDI patients were converted to LRTI due to pain. CONCLUSION/DISCUSSION: This study confirmed our hypothesis that key and tip pinch strength is stronger after PDI compared to LRTI for CMC-1 joint osteoarthritis. Both techniques have comparable outcomes considering patient reported outcome (MHQ and PRWHE), ROM and complications.

Long-term follow-up of patients treated with pyrocarbon disc implant for thumb carpometacarpal osteoarthritis: the effect of disc position on outcomes measures.

Pyrocarbon disc interposition arthroplasty is an effective treatment for thumb base osteoarthritis. However, as with all implant techniques, the disc can (sub)luxate over time. The relationship between disc position, the experienced pain, and the necessity for revision surgery is not known. This study evaluated the effect of radiographic pyrocarbon disc position on the Michigan Hand Questionnaire (MHQ) outcome measurement. In addition, the correlation between disc position and other factors, including pain intensity, thumb strength, and occupation, was assessed. In this retrospective study, we included 136 patients (161 thumbs) with a mean follow-up of 6.7 years (range 3.3-11). Radiographs were scored on disc position and classified as 'well aligned' (Grade 1) up to 'luxated' (Grade 4). A database used for outcome measures included MHQ scores, pain intensity, satisfaction, thumb strength, range of motion, occupation, and hand dominance. In bivariate analyses, we assessed any association between disc position and outcome measurements. Eighty of the 136 implants (59%) were well-positioned (not displaced), 41% were (slightly) displaced (grade 2-3). No relationship existed between the degree of disc displacement and MHQ scores. Manual labor occupation was the only factor that correlated with more severe disc displacement. We could not detect any association between disc position and other outcome variables including pain intensity, thumb strength, or hand dominance. In conclusion, our study suggests that radiographic disc displacement has little clinical consequences. Future studies must assess if there is a causality between heavy mechanical stress to the CMC1 joint and luxation of the pyrocarbon disc over time.Level of evidence: IV Therapeutic-Retrospective case series.

Effect of Tendon Strip (FCR vs APL) on Outcome of CMC Thumb Joint Arthroplasty With Pyrocarbon Disk Interposition.

BACKGROUND: Pyrocarbon disk interposition for carpometacarpal (CMC) thumb joint osteoarthritis can be performed with a flexor carpi radialis (FCR) or abductor pollicis longus (APL) tendon strip. With the FCR technique, a ligament reconstruction is performed in addition to disk fixation, whereas with the APL technique the disk is simply secured in place. Our aim is to compare long-term postoperative outcomes between both techniques. METHODS: In this observational study, we included 106 patients in 2 centers operated on between 2006 and 2011. We assigned patients to the FCR group or the APL group based on the respective tendon strip used. As a primary outcome, we analyzed postoperative key pinch. In addition, we analyzed postoperative tip pinch and tripod pinch, grip strength, range of motion, thumb height maintenance, and patient-reported outcome measures (PROMs). RESULTS: The analysis showed clinically important stronger key pinch for the APL group (ß = 1.28 kg). Tip pinch and grip strength showed higher outcome for the FCR group (ß = 1.22 kg and 5.14 kg, respectively). Palmar abduction was in favor of the FCR group and opposition in favor of the APL group, but these were interpreted as not clinically relevant. Radiological thumb height maintenance and PROMs showed no clinical difference. CONCLUSIONS: Pyrocarbon disk interposition arthroplasty for CMC thumb joint osteoarthritis can be secured with an APL or FCR tendon strip. At long-term follow-up, use of an APL tendon strip results in significantly higher key pinch and better opposition. Tip pinch, grip strength, and palmar abduction were better after use of the FCR tendon strip. The choice of the tendon strip can be based on outcomes considered most important for the individual patient.

Type of Work and Preoperative Ability to Perform Work Affect Return to Usual Work Following Proximal Interphalangeal Joint Arthroplasty for Osteoarthritis.

BACKGROUND: The time until return to work (RTW) and possible factors affecting this time after proximal interphalangeal (PIP) joint arthroplasty are unknown. Therefore, we aim to evaluate the RTW after PIP joint arthroplasty for osteoarthritis and assess factors affecting the time until return to their usual work. METHODS: We used prospectively gathered data from 74 patients undergoing PIP joint arthroplasty with daily hand surgery practice routine outcome collection. Standardized RTW questionnaires were completed at 6 weeks and 3, 6, and 12 months after surgery. Return to work was defined as the first time a patient reported returning to work and performing the original work for a minimum of 50% of the original hours a week, as stated in the patient's contract. Second, we evaluated baseline factors affecting the time until RTW. RESULTS: The probability of RTW within 12 months after surgery was 88%. The median time until RTW was 8 weeks (interquartile range: 4-10). Physical occupational intensity (hazard ratio [HR]: 0.36, P = .001) and the baseline Michigan Hand Outcomes Questionnaire work scores (HR: 1.02, P = .005) were independently associated with RTW. CONCLUSION: In conclusion, patients returned to work after a median of 8 weeks following PIP arthroplasty. Patients with medium or heavy physical occupations returned to work later than patients with light physical occupations. Better patient-reported work outcomes at baseline also led to an earlier RTW. This information can be valuable for providing adequate information during the preoperative consultation.

Factors associated with conversion to surgical release after a steroid injection in patients with a trigger finger.

AIMS: The aim of this retrospective study was to evaluate the rate of conversion to surgical release after a steroid injection in patients with a trigger finger, and to analyze which patient- and trigger finger-related factors affect the outcome of an injection. METHODS: The medical records of 500 patients (754 fingers) treated for one or more trigger fingers with a steroid injection or with surgical release, between 1 January 2016 and 1 April 2020 with a follow-up of 12 months, were analyzed. Conversion to surgical release was recorded as an unsuccessful treatment after an injection. The effect of patient- and trigger finger-related characteristics on the outcome of an injection was assessed using stepwise manual backward multivariate logistic regression analysis. RESULTS: Treatment with an injection was unsuccessful in 230 fingers (37.9%). Female sex (odds ratio (OR) 1.87 (95% confidence interval (CI) 1.21 to 2.88)), Quinnell stage IV (OR 16.01 (95% CI 1.66 to 154.0)), heavy physical work (OR 1.60 (95% CI 0.96 to 2.67)), a third steroid injection (OR 2.02 (95% CI 1.06 to 3.88)), and having carpal tunnel syndrome (OR 1.59 (95% CI 0.98 to 2.59)) were associated with a higher risk of conversion to surgical release. In contrast, an older age (OR 0.98 (95% CI 0.96 to 0.99)), smoking (OR 0.39 (95% CI 0.24 to 0.64)), and polypharmacy (OR 0.39, CI 0.12 to 1.12) were associated with a lower risk of conversion. The regression model predicted 15.6% of the variance found for the outcome of the injection treatment (R2 > 0.25). CONCLUSION: Factors associated with a worse outcome following a steroid injection were identified and should be considered when choosing the treatment of a trigger finger. In women with a trigger finger, the choice of treatment should take into account whether there are also one or more patient- or trigger-related factors that increase the risk of conversion to surgery.Cite this article: Bone Joint J 2022;104-B(10):1142-1147.

Treatment of Recurrent Carpal Tunnel Syndrome with the Abductor Digiti Minimi Flap: A Case Series.

Background: Approximately 5% of patients experience recurrent symptoms after carpal tunnel release (CTR) and need revision surgery. Several surgical techniques have been described for recurrent carpal tunnel syndrome (CTS) and the abductor digiti minimi (ADM) flap is one of them. Literature concerning clinical results of the ADM flap for recurrent CTS is lacking. The aim of this study is to evaluate the outcomes of the ADM flap for recurrent CTS. Methods: We treated seven patients with the ADM flap (eight hands) between July 2016 and February 2019. Patient characteristics were assessed, and patients were asked about their symptoms (pain, sensation and paresthesia) before and after surgery. Postoperatively, we administered CTS symptoms, satisfaction with the surgery, patient-reported outcome measurements (BCTQ and QuickDASH) and whether they would undergo the same surgery again. Complications were also recorded Results: The median follow-up was 14 months. The success rate measured by CTS symptoms was 88%. Seven out of eight patients were satisfied with the results and two patients would not elect to undergo the same procedure again. Two patients reported having a weaker grip at the donor site. The median BCTQ symptom and function scores were 2.9 (1.7-3.5) and 2.6 (1.8-3.0) respectively. The median QuickDASH score was 41 (IQR 22-52). Complications reported were wound dehiscence (n = 1) and hypertrophic scar (n = 1). Conclusions: The outcomes of the ADM flap in patients with recurrent CTS were like other commonly used procedures in recurrent CTS. Level of Evidence: Level IV (Therapeutic).

Tourniquet Does Not Affect Long-term Outcomes in Minor Hand Surgery: A Randomized Controlled Trial.

Surgeons often prefer to use a tourniquet during minor procedures, such as carpal tunnel release (CTR) or trigger finger release (TFR). Besides the possible discomfort for the patient, the effect of tourniquet use on long-term results and complications is unknown. Our primary aim was to compare the patient-reported outcomes 1 year after CTR or TFR under local anesthesia with or without tourniquet. Secondary outcomes included satisfaction, sonographically estimated scar tissue thickness after CTR' and postoperative complications. Methods: Between May 2019 and May 2020, 163 patients planned for open CTR or TFR under local anesthesia were included. Before surgery, and at 3, 6, and 12 months postoperatively, Quick Disabilities of the Arm, Shoulder and Hand and Boston Carpal Tunnel questionnaires were administered, and complications were noted. At 6 months postoperatively, an ultrasound was conducted to determine the thickness of scar tissue in the region of median nerve. Results: A total of 142 patients (51 men [38%]) were included. The Quick Disabilities of the Arm, Shoulder and Hand questionnaire and Boston Carpal Tunnel Questionnaire scores improved significantly in both groups during follow-up, wherein most improvements were seen in the first 3 months. No difference in clinical outcome and scar tissue formation was found between the two groups after 12 months. The complication rate was comparable between both groups. Thirty-two (24%) patients had at least one complication, none needed surgical interventions, and no recurrent symptoms were seen. Conclusions: Our study shows similar long-term clinical outcomes, formation of scar tissue, and complication rates for patients undergoing CTR or TFR with or without a tourniquet. Tourniquet usage should be based on shared decision-making.

Patient-Reported Outcomes 1 Year After Proximal Interphalangeal Joint Arthroplasty for Osteoarthritis.

PURPOSE: Implant survival, range of motion, and complications of proximal interphalangeal joint arthroplasty have been reported often, but patient-reported outcomes are less frequently described. This study evaluated patients' experiences during the first year after proximal interphalangeal joint arthroplasty, measured with the Michigan Hand Outcomes Questionnaire (MHQ). The primary focus was the reduction of patient-reported pain after proximal interphalangeal joint implant placement and the percentage of patients who considered this reduction clinically relevant, indicated by the minimal clinically important difference (MCID). METHODS: Data were collected prospectively; 98 patients completed the MHQ before and at 3 and 12 months after surgery. Our primary outcome was the change in the pain score. An increase of 24 points or more was considered a clinically important difference. Secondary outcomes included changes in MHQ total and subscale scores and MCIDs, range of motion (ROM), patient satisfaction with the outcome of the surgery, and complications. RESULTS: The pain score improved significantly, from 42 (95% confidence interval, 38-46) at baseline to 65 (95% confidence interval, 60-69) at 12 months after surgery. The MCID was reached by 50% (n = 49) of patients. The ROM did not improve, reoperations occurred in 13% (n = 13) of patients, and swan neck deformities only occurred among surface replacement implants. CONCLUSIONS: Although most patients undergoing arthroplasty for osteoarthritis experienced significantly less pain after surgery, the pain reduction was considered clinically relevant in only 50% (n = 49) of patients. Patients with high MHQ pain scores before surgery are at risk for postoperative pain reduction that will not be clinically relevant. Likewise, the other subscales of the MHQ improved after surgery, but reached a clinically relevant improvement in only 46% (n = 45) to 63% (n = 62) of patients. This knowledge can be used during preoperative consultation to improve shared decision making. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Which Tendon Plasty Has the Best Outcome? A Comparison of Four Tendon Plasty Techniques in a Large Cohort of Patients with Symptomatic Trapeziometacarpal Osteoarthritis.

BACKGROUND: Trapeziometacarpal osteoarthritis is commonly treated with a trapeziectomy combined with a form of tendon plasty. The type of tendon plasty used is based on the surgeon's preference. The purpose of this observational study was to compare the outcomes of four different tendon plasties combined with trapeziectomy used to treat osteoarthritis of the trapeziometacarpal joint: the Weilby, Burton-Pellegrini, Zancolli, and anchovy plasty procedures. METHODS: Patients treated with a trapeziectomy followed by a tendon plasty completed patient-reported outcome measures at baseline and 12 months postoperatively. The primary outcome was the Michigan Hand Outcomes Questionnaire pain subscale. Secondary outcomes were the minimal clinically important difference of Michigan Hand Outcomes Questionnaire pain scale score, Michigan Hand Outcomes Questionnaire hand function, satisfaction, and complication rate. RESULTS: Seven hundred ninety-three patients underwent a trapeziectomy with a tendon plasty between November of 2013 and December of 2018. There was no difference in pain score after 12 months between the four tendon plasty techniques. Patients undergoing an anchovy plasty had a higher chance of reaching the minimal clinically important difference for Michigan Hand Outcomes Questionnaire pain score compared to the other techniques (OR, 2.3; 95 percent CI, 1.2 to 4.6). Overall, more than 80 percent of the patients were satisfied with the treatment outcome, independent of which technique was used. Complication rates of the different techniques were similar. CONCLUSIONS: Surgical treatment of osteoarthritis of the trapeziometacarpal joint reduced pain after 12 months, independent of which tendon plasty was used. Patients undergoing an anchovy plasty were more likely to experience a clinically relevant improvement in pain while having similar hand function, satisfaction, and complication rates. This suggests that anchovy plasty is the preferred tendon plasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Long-term outcomes after ulna shortening osteotomy: a mean follow-up of six years.

AIMS: The primary aim of this study was to describe long-term patient-reported outcomes after ulna shortening osteotomy for ulna impaction syndrome. METHODS: Overall, 89 patients treated between July 2011 and November 2017 who had previously taken part in a routine outcome evaluation up to 12 months postoperatively were sent an additional questionnaire in February 2021. The primary outcome was the Patient-Rated Wrist and Hand Evaluation (PRWHE) total score. Secondary outcomes included patient satisfaction with treatment results, complications, and subsequent treatment for ulnar-sided wrist pain. Linear mixed models were used to compare preoperative, 12 months, and late follow-up (ranging from four to nine years) PRWHE scores. RESULTS: Long-term outcomes were available in 66 patients (74%) after a mean follow-up of six years (SD 1). The mean PRWHE total score improved from 63 before surgery to 19 at late follow-up (difference in means (Δ) 44; 95% confidence interval (CI) 39 to 50; p = <0.001). Between 12 months and late follow-up, the PRWHE total score also improved (Δ 12; 95% CI 6 to 18; p = < 0.001). At late follow-up, 14/66 of patients (21%) reported a PRWHE total score of zero, whereas this was 3/51 patients (6%) at 12 months (p = 0.039). In all, 58/66 patients (88%) would undergo the same treatment again under similar circumstances. Subsequent treatment (total n = 66; surgical n = 57) for complications or recurrent symptoms were performed in 50/66 patients (76%). The most prevalent type of reoperation was hardware removal in 42/66 (64%), and nonunion occurred in 8/66 (12%). CONCLUSION: Ulna shortening osteotomy improves patient-reported pain and function that seems to sustain at late follow-up. While satisfaction levels are generally high, reoperations such as hardware removal are common. Cite this article: Bone Jt Open 2022;3(5):375-382.

Two-Corner Fusion or Four-Corner Fusion of the Wrist for Midcarpal Osteoarthritis? A Multicenter Prospective Comparative Cohort Study.

BACKGROUND: Midcarpal osteoarthritis is a debilitating wrist pain, and a mainstay treatment is midcarpal fusion. The accepted standard for midcarpal fusion is four-corner fusion, but lately, two-corner fusion (i.e., capitolunate fusion) has gained popularity. This is the first prospective, multicenter, cohort study comparing capitolunate fusion with four-corner fusion for midcarpal osteoarthritis. METHODS: Patients with scaphoid nonunion advanced collapse or scapholunate advanced collapse wrist of grade 2 to 3 undergoing capitolunate fusion or four-corner fusion between 2013 and 2019 were included. Sixty-three patients (34 with capitolunate fusion, 29 with four-corner fusion) were included. Patient demographics were similar between groups. Patient-Rated Wrist Hand Evaluation questionnaire score, visual analog scale pain score, grip strength, range of motion, and complications were measured at baseline and 3 months and 12 months postoperatively. Complications (i.e., nonunion, hardware migration, conversion to wrist arthrodesis, or arthroplasty) were determined. RESULTS: A significant difference in Patient-Rated Wrist Hand Evaluation or visual analog scale pain score at 3 and 12 months postoperatively between the capitolunate fusion and four-corner fusion groups was not found. There were no differences in grip strength between patient groups preoperatively or 12 months postoperatively. At 12 months postoperatively, capitolunate fusion patients had better flexion compared with that in the four-corner fusion group (p = 0.002); there were no differences in complications and reoperation rates between groups. CONCLUSIONS: Capitolunate fusion and four-corner fusion were comparable in terms of functional scores (i.e., Patient-Rated Wrist Hand Evaluation and visual analog scale pain scores) and complication scores. Capitolunate fusion showed favorable wrist mobility compared with four-corner fusion in treatment of midcarpal osteoarthritis. Capitolunate fusion advantages include use of less material, less need for bone-graft harvesting, and easier reduction of the lunate during fixation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

The impact of COVID-19 pandemic on hand surgery: a FESSH perspective.

COVID-19 has affected us all. The following collection of short essays highlights various aspects of the pandemic and how it has impacted hand surgery and lessons learned, from the perspective of the Federation of European Societies for Surgery of the Hand (FESSH) Executive Committee members. A range of topics were individually chosen by each of the five committee members and presented.

The association between plate location and hardware removal following ulna shortening osteotomy: a cohort study.

Hardware removal after ulna shortening osteotomy is common. We evaluated the association between plate location and hardware removal rate in 326 procedures in 321 patients with a median follow-up of 4.3 years (IQR 3.3) and corrected for confounding variables and did survival analyses. Complications were scored using the International Consortium for Health Outcome Measurement complications in Hand and Wrist Conditions tool. The 1-year and 5-year reoperation rates for hardware removal were 21% and 46% in the anterior group versus 37% and 64% in the dorsal group. Anterior plate placement was independently associated with a decreased immediate risk of hardware removal. Higher age, male sex and treatment on the dominant side were also associated with a reduced risk of hardware removal. We did not find a difference in hardware removal rates between freehand or jig-guided ulna shortening osteotomies. We noted perioperative problems in 3% of the procedures and complications in 20%.Level of evidence: III.