Practice Of Hand Surgeons Research Articles

Anterograde Intramedullary Headless Compression Screw for Managing Extra-articular Thumb Metacarpal Base Fracture: Technique and Report.

Extra-articular base fractures of the thumb are typical in hand surgeon practice. Nonoperative methods (spica) and operative methods are available for its management. There are operative methods described, such as plate and screws, Kirschner wires, and intramedullary screws. However, there is only a retrograde technique described. This study aims to present a new technique of an anterograde intramedullary headless compression screw to manage the extra-articular thumb metacarpal base fracture. This minimally invasive method allows an early range of motion and does not cross the articular surface of the thumb. This alternative fixation method has the advantage of low damage to soft tissues and good functional outcomes.

Features of minimally invasive ligamentotomy of the thumb A1 pulley (our experience)

Objective. Stenosing tenosynovitis (Nott’s disease, "trigger finger") is one of the most common pathologies of the hand which hand surgeons and orthopedic surgeons have to deal with. A variety of conservative methods are used to treat “trigger finger", including individual splinting and corticosteroid injections. Surgical treatment consists of dissection of the A1 pulley. Traditionally, the operation starts with a small incision. However, in recent years, a number of articles have appeared that report that percutaneous ligamentotomy on II-V fingers is a safe and effective alternative to an open surgery. Due to anatomical features, some authors do not recommend performing a percutaneous ligamentotomy on the thumb, fearing the damage it can cause to the digital nerves.The purpose of this research is to show that the minimally invasive needle ligamentotomy of the thumb A1 pulley is a safe procedure and to conduct the approbation of the offered method.Material and methods. The research consisted of two parts - anatomical and clinical. In the anatomical part of the research (8 upper extremities of 4 unfixed corpses), we proposed the safe accesses in order to conduct percutaneous ligamentotomy of the thumb A1 pulley.In the clinical part of the study we tested a minimally invasive ligamentotomy and analysed the results of treatment in 109 patients with stenosing tenosynovitis of the thumb II-IV stage by Green aged from 28 to 80. All patients received minimally invasive ligamentotomy of the A1 pulley with 18g needle under local anaesthesia (120 surgeries). Average length of the operation was several minutes. All procedures were performed outpatiently. Evaluation of the results of treatment was performed using the Visual Analog Scale (VAS) and Gilberts questionnaire. The observation period was from 12 months up to 24 months.The results. In most cases both clinical and esthetical results were excellent. It was possible to eliminate the “trigger” of the finger intraoperatively for all patients. However, 6 (5.5%) patients complained about the presence of residual clicks due to incomplete dissection of the ligament at the control examination a week later. Percutaneous ligamentotomy was conducted again on all patients with successful outcomes. No recurrence of the disease was noted. 17% of patients tend to complain about pain in the A1 pulley localization during the first week after the operation.Conclusion. The empirical findings prove the efficiency and safety of percutaneous ligamentotomy of the thumb A1 pulley. One of the merits of this technique is a lower risk of postoperative complications and lower treatment expenses. This technique can be successfully used in the practice of hand surgeons in the outpatient setting that have the experience with the conduction of open operations.

Does Patient Sex Affect Ultrasound Cutoff Values for Severity Grading of Carpal Tunnel Syndrome?

A growing body of evidence supports ultrasound (US) as an alternative first-line confirmatory test for carpal tunnel syndrome (CTS). Recent studies have demonstrated a correlation of US cross-sectional area with electrodiagnostic (EDX)-determined severity; however, it is unclear whether patient sex affects the cutoff values used for determining severity. The purpose of this study was to determine if patient sex affects US graded severity when using EDX as the reference standard. A cohort of 367 women and 46 men, aged 18-90 years, from 1 orthopedic hand surgeon's practice underwent EDX and US. Distal motor latency and distal sensory latency of the median nerve were recorded. Severity was classified using a modified Bland severity scale. The US measurements of the cross-sectional area of the median nerve at the wrist crease were acquired by a fellowship-trained hand surgeon. Separate receiver operator characteristic curve analyses of the male and female groups were performed for US cutoff values. The cutoff value in both the female (F) and male (M) patients was 11 mm2 for mild (area under the curve= 0.76 F; 0.78 M), 12 mm2 for moderate (area under the curve= 0.75 F; 0.73 M), and 13 mm2 for severe (area under the curve= 0.75 F; 0.71 M) CTS. The sensitivity of the cutoffs for mild, moderate, and severe CTS in the female and male groups was 49% and 56%, 44% and 50%, and 49% and 44%, respectively. The specificity of the cutoffs for mild, moderate, and severe CTS in the female and male groups was 75% and 79%, 74% and 82%, and 83% and 78%, respectively. Patient sex does not appear to have a significant impact on the determination of CTS severity graded using US cutoff values. Ultrasound can be used to grade the severity of CTS with a 75% to 85% specificity but low sensitivity. A cutoff value of 13 mm2 can be used to classify CTS as severe. Prognostic II.

АРТРОСКОПИЧЕСКОЕ УДАЛЕНИЕ СИНОВИАЛЬНОЙ КИСТЫЗАПЯСТЬЯ: СЛУЧАЙ ИЗ ПРАКТИКИ

Synovial cysts are the most common condition in hand surgeon practice. Open surgical resection was a traditional method of treatment but it is associated with numerous complications. We describe our first patient follow up after arthroscopic wrist ganglion resection.

Prevalence of Carpal Tunnel Syndrome in a Hand Surgeon's Practice.

Purpose Additional methods of diagnosing carpal tunnel syndrome (CTS) are increasingly being investigated, such as ultrasound or diagnostic tools such as carpal tunnel syndrome 6 (CTS-6), and the sensitivity and specificity of these tests are determined by the pretest probably and thereby the prevalence of a condition. It is critical that the prevalence used in these calculations accurately reflects the population undergoing these tests for a true assessment of their quality. Orthopaedic surgeons and, specifically, upper extremity specialists are most often studying these diagnostic methods, and given referral patterns, these physicians likely have a greater prevalence of CTS in their clinics than previously published for only the general population (5%). The purpose of this study is to define the prevalence of CTS in a hand surgery practice consisting of three fellowship-trained orthopaedic hand surgeons for use in future assessing the accuracy of diagnostic tests for CTS among patients presenting to a hand surgeon for evaluation. Methods All the adult patients (≥ 18 years) who had a face-to-face encounter with an orthopaedic surgeon in this practice between January 1 and December 31, 2014 were identified. The ICD-9 code 354.0 was used to identify all patients diagnosed with CTS. The medical records of all patients with ICD-9 code were reviewed and the results of electrodiagnostic testing (EDX) documented. Results A total 56,641 patients were evaluated by the orthopaedic department from January 1 to December 31, 2014. Of these patients, 812 (1.4%) had EDX-confirmed CTS. The prevalence of EDX-confirmed CTS was 0.2% for nonhand orthopaedic specialists and 10.7% for hand specialists. Of those seen by the hand subspecialists, 66% were female, 34% were male with the right hand affected in 42%, left in 26%, and bilateral upper extremities in 32%. Conclusion Current literature demonstrates a prevalence of CTS among the general population of 5%. The authors have demonstrated a prevalence of CTS in an orthopaedic surgical practice to be 1.4% with a prevalence of only 0.2% noted among nonupper extremity orthopaedic specialists. They have determined the prevalence of EDX confirmed CTS in a tertiary referral hand practice to be 10.7%, much higher than the prevalence in the general population. Accurate identification of the prevalence of CTS within these patient groups is critical for statistical analysis of new diagnostic tools being developed to assess for CTS. Level of Evidence Level IV, cross-sectional, prognostic.

Flexor pollicis longus repair in a patient with Linburg-Comstock anomaly: A case report

Background: We present a patient with this anomaly who sustained a saw cut injury to his hand resulting in severance of the FPL and bilateral digital nerves of the thumb. Methods: A 36-year old male laborer who sustained a saw cut injury to his dominant right hand presented to the emergency department. The wound extended from the skin edge of the first web to the base of first metacarpal in the palm at Urbaniak zone 3. The FPL tendon and both digital nerves were cut. In the operating room, the wound was enlarged with Z incisions and a dissection deep into the wound was conducted. The cut end of the FPL tendon was found and secured using a different technique. Bilateral digital nerve repair was performed with interpositional grafting of the lateral antecubital cutaneous nerve bundles. Results: At the end of the rehabilitation program, the thumb recovered full range of motion, and physical examination revealed synchronous flexion movement (synkinesis) of the thumb and index finger. Conclusion: Flexor pollicis longus tendon lacerations are common in the clinical practice of hand surgeons. Making a separate proximal wrist incision is a very useful technique to reach a proximal tendon stump. Otherwise, aggressive maneuvers may cause additional damage to the tendons involved and result in unpredicted outcomes. The attempts to retrieve the tendon at the injury site resulted in failure and gave a tethering sensation to the surgeon who recalled the Linburg-Comstock anomaly.

The Influence of Microsurgical Training on the Practice of Hand Surgeons

The study aims to determine the effect of formal training on the long-term practice of microsurgery. Hand surgeons completing a 1-year hand fellowship and a 5-day microsurgery rat-model training course from a single institution over a 15-year period (1996-2011) were surveyed. Patency rates (at 24 hours), additional days spent in the laboratory, and training (orthopedic [OS] vs. plastic surgery [PS]) were correlated with the questionnaire responses regarding microsurgical confidence and practice spectrum. Data were obtained for 100% (61/61) of former fellows. PSs were 4.7 and 7.6 times more likely to perform replants and free flaps than OSs, respectively. Training patency rates and days in the laboratory were fair predictors of current practice of free flaps and replants. PSs are more likely to perform replants and free flaps than OSs. Successful completion of a microsurgical skills course can be used as a predictor of those who will ultimately practice microsurgery. Broader application of microsurgical skills labs may be a technique to increase the practice of microsurgery among all hand surgeons.

The Influence of Microsurgical Training on the Practice of Hand Surgeons: N/A - Not a Clinical Study

The Influence of Microsurgical Training on the Practice of Hand Surgeons: N/A - Not a Clinical Study

The Use of a Tablet Computer to Complete the DASH Questionnaire

To determine whether electronic self-administration of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire using a tablet computer increased completion rate compared with paper self-administration. We gave the DASH in self-administered paper form to 222 new patients in a single hand surgeon's practice. After a washout period of 5 weeks, we gave the DASH in self-administered tablet computer form to 264 new patients. A maximum of 3 questions could be omitted before the questionnaire was considered unscorable. We reviewed the submitted surveys to determine the number of scorable questionnaires and the number of omitted questions in each survey. We completed univariate analysis and regression modeling to determine the influence of survey administration type on respondent error while controlling for patient age and sex. Of the 486 total surveys, 60 (12%) were not scorable. A significantly higher proportion of the paper surveys (24%) were unscorable compared with electronic surveys (2%), with significantly more questions omitted in each paper survey (2.6 ± 4.4 questions) than in each electronic survey (0.1 ± 0.8 questions). Logistic regression analysis revealed survey administration mode to be significantly associated with DASH scorability while controlling for age and sex, with electronic survey administration being 14 times more likely than paper administration to yield a scorable DASH. In our retrospective series, electronic self-administration of the DASH decreased the number of omitted questions and yielded a higher number of scorable questionnaires. Prospective, randomized evaluation is needed to better delineate the effect of survey administration on respondent error. Administration of the DASH with a tablet computer may be beneficial for both clinical and research endeavors to increase completion rate and to gain other benefits from electronic data capture.

Otto W. Madelung and the Recognition of Madelung’s Deformity

Madelung's deformity is an uncommon congenital condition of the wrist usually seen in adolescent girls. It first was documented in the 1800s and is characterized by a shortened radius that curves ulnarly and volarly, a prominent ulna head that projects dorsally from the wrist, and a triangular arrangement of the carpal bones. It is mostly an aesthetic deformity although functional problems and pain may prompt surgeons to undertake a variety of corrective surgical procedures with varying degrees of success. This challenging condition is encountered rarely in a hand surgeon's practice. Even more obscure than the condition is the physician it is named after: Otto Wilhelm Madelung, a distinguished and successful German surgeon who lived at the turn of the century. This article provides a historical perspective on the person and the condition that is still an enigma a century later.

Occupational orthopaedics in this millennium.

Treatment of musculoskeletal pain in the workplace by early return to work and prevention is the future of occupational orthopaedics. Patients who receive workers' compensation comprise 20% of the general orthopaedist's practice, 65% of a hand surgeon's practice, and 90% of the independent medical examiner's practice. To improve the treatment outcomes for patients who receive workers' compensation, orthopaedists in this millennium will need knowledge about how individual and job risk factors can combine to result in musculoskeletal pain in the workplace. This knowledge will promote the safe return of their patients to the workplace after injury. With the prediction that more than 50% of the workforce in the United States will have experienced an occupational injury or illness, it is important for orthopaedists who are treating patients with work-related injuries to understand how management of these workplace risk prevention programs will impact their patients and practice of orthopaedics. In this millennium, orthopaedists will need to know how to talk the language, interpret the information, and understand the benefits of early return to work and prevention of injuries in the workplace. The future will be about legislated prevention and healthcare in the workplace.