Michigan Hand Questionnaire Research Articles

The necessity for hand therapy interventions for patients with partial thickness isolated hand/forearm burns: A randomized controlled pilot trial

ObjectiveThe recovery of patients with partial thickness isolated hand burns managed with an epidermal skin substitute appears to be rapid and the necessity for routine hand therapy interventions in this setting is unknown. This study investigated the need for hand therapy for these patients. MethodsA randomized controlled trial was undertaken. The Treatment Group received routine hand therapy provided by a physiotherapist, including assessment, daily range of motion exercises, education and, if required, edema management and outpatient physiotherapy follow-up. Control Group participants received no hand therapy input. Outcomes included the Michigan Hand Questionnaire (baseline, 1, 2, 4 weeks and 3 months post-injury), finger total active motion, wrist range, grip strength (1, 2 and 4 weeks) and participant satisfaction (4 weeks). ResultsTwenty-nine participants were recruited over a 2.3 year period. All outcomes significantly improved over time (p ≤ 0.008). No significant between-group differences were observed for any outcome except the pain subscale of the Michigan Hand Questionnaire. Participants with deeper burns had significantly poorer outcomes for some Michigan Hand Questionnaire data. Study limitations included a small sample size, heterogeneity and some loss to follow-up. ConclusionsWhile the provision of routine hand therapy interventions for patients with partial thickness isolated hand/forearm burns that were managed with an epidermal skin substitute did not appear to be of benefit, study limitations means these results cannot be extrapolated and reinforces the need for further research. Routine hand therapy input may be of benefit for those with deeper burns.

A Functional Angle of Up to 35° at the Distal Interphalangeal Joint Can Be Achieved with Headless Compression Screw Fusion.

Arthrodesis of the distal interphalangeal (DIP) joint reliably improves symptomatic arthritis. A range of successful surgical techniques including tension band wiring, plate fixation and headless compression screws have been described and produce stable painless unions. For best functional outcome, the fusion angle should be between 10 and 61 degrees. In the past, it has been difficult to achieve more than 10 degrees of flexion with a headless compression screw. Higher fusion angles have been reported using tension band wiring techniques. However, metalwork prominence is a common problem and may require revision surgery to rectify this. Headless compression screws are reported to cause iatrogenic fractures due to the size of the screw relative to the small diameter of the phalanx. This case series achieves an angle of up to 35 degrees with a good functional outcome. Open fusion of the DIP joint with a headless cannulated compression screw, of 2.2 mm in diameter, was undertaken in fifteen digits. Patients received standard departmental follow up to radiographic union. Patients self-reported function using the Michigan Hand Questionnaire post operatively. The fusion angles achieved were assessed on postoperative radiographs. All patients went on to a stable union without any patients requiring revision surgery as a result of fracture or protrusion of metalwork. Complications were observed in two patients which included one superficial infection (n = 1) and a discomfort requiring removal of metalwork (n = 1). Functional scores measured post operatively showed favourable outcomes. In this series, successful fusions of the DIP joints, at an angle up to 35 degrees were achieved using small diameter headless compression screws, which provided benefits including early mobilization and favourable functional outcome scores.

Surgical treatment of the consequences of the computed damage of the median nerve in the proximal part of the upper limb

Aim of the study – to assess the efficacy of surgical reconstruction of the combined proximal median nerve injuries, to evaluate the efficacy of the staged orthopedic reconstruction of the thumb opposition. The retrospective analysis of the reconstruction of 14 proximal median nerve injuries was conducted. 11 men and 3 women were enrolled into the study, mean age of participants was 42,3 years. In all cases proximal median nerve injury was accompanied by either axillary (4 cases) or brachial artery (10 cases) injury. 5 patients received direct repair of the median nerve. 9 patients received autologous grafting of the median nerve with mean gap between the stumps 7,5 cm. Both motor and sensory components of recovery were evaluated with MRC Scale and Seddon Scale respectively. Each patient evaluated the recovered median nerve mediated functions with Brief Michigan Hand Questionnaire. 14 cases with poor or no recovery of thenar muscles required tendon transfer (Bunne’sl transfer) to restore thumb opposition in later terms. Mean terms of recovery of the entire muscle-complex of the anterior surface of the forearm in all 14 patients with proximal median nerve injury was 12,9 months (with no reliable dependence on method of reconstruction). Mean MRC Scale score among all 14 patients was: 3,8 points for m. flexor pollicis longus, 4,4 points for mm. flexores digitorum and 4,4 points for m. flexor carpi radialis respectively. The median nerve mediated sensation recovered to 2,8 points on Seddon scale. Not a single patient showed effective recovery of the thenar muscles. Mean Brief MHQ score was 64,2 points – satisfactory recovery. 14 patients received effective thumb opposition within next 2 months post Bunnel’s tendon transfer. Mean Brief MHQ score increased to 78,2 points – good recovery. Surgical reconstruction of proximal median nerve injuries brings satisfying recovery of the entire muscle-complex of the anterior surface of the forearm, as well as the recovery to the median nerve mediated sensory component. Poor or no recovery of the thump opposition is majorly related to the distance between the site of the lesion and thenar’s motor-endplates. Bunnel’s tendon transfer dramatically increases functional outcomes at proximal median nerve injuries.

Surgical management of the proximal injury to the nerves of the upper extremity: strategy at overcoming multiple critical gaps

Aim of the study — to evaluate the outcomes of reconstruction procedures at complete injuries of brachial plexus in subclavicular region. The retrospective analysis of the reconstruction procedures in 3 men and one woman (mean age 36,4 years) with complete injury of brachial plexus in subclavicular region was conducted. Injury to musculocutaneuos, median, ulnar and radial nerves was accompanied by axillary (2 cases) or brachial (2 cases) artery injury. One patient had no injury to musculocutaneous nerve within the injury’s structure. All patients underwent surgical reconstruction of the neural structures 4,8 months (mean term) post initial vascular surgery. The autografting was the main reconstruction procedure of the long nerves of the upper extremity at their critical gap (mean gap 10,5cm) with donor-nerves of the small (sural nerve) and large (ulnar nerve) cross sectional diameter. Both motor and sensory components of recovery were evaluated with MRC Scale and Seddon Scale respectively. Each patient evaluated the recovered median nerve mediated functions with Brief Michigan Hand Questionnaire. It was revealed that one patients showed poor recovery of the entire complex of the muscles of the upper and lower arm (MRSC 2 points or lower). Two patients showed good recovery of the biceps brachii muscle (MRCS score 5 points) on 14th and 13th month respectively. Mean MRC Scale score among three patients for the muscles of the anterior compartment of the forearm was: 3,3 points for m. flexor pollicis longus, 3,6 points for mm. flexores digitorum and 4 points for m. flexor carpi radialis respectively. Mean MRC Scale score among three patients for the muscles of the posterior compartment of the forearm was: 2,6 points for m. extensor pollicis longus, 3,3 points for m. extensor digitorum sublimis and 4 points for radial wrist extensors respectively. The median nerve mediated sensation recovered to 2,3 points on Seddon scale. Only one patient showed effective recovery of the thumb opposition. Loss of ulnar nerve mediated functions was expectable among all 4 enrolled patients, thereafter we observed no recovery of key pinch and diagonal volar grip. Three patients showed recovery of transversal volar grip only. Mean Brief MHQ score was 55,55 points – unsatisfactory recovery. The reconstruction of the ulnar nerve, thereafter recovery of the “intrinsics”, should be the priority in terms of reanimation of the basic grips and pinches of the upper extremity – one should avoid harvesting of the ulnar nerve at multiple nerve injury cases; the expectable loss of functions at the utililization of the radial nerve as a donor nerve, could be easily recompensed with the tendon transfer procedures in later terms.

Investigating Patients' Perception of Microvascular Free Toe Flap for Reconstruction of Amputated Thumbs: A Guide for Surgeons during Informed Consent.

After thumb amputations, restoration of function and aesthetic can be accomplished with microvascular free toe flaps. However, many patients in clinical practice do not choose this reconstruction despite positive reported outcomes. This study aims to determine patients' perceptions with respect to free toe flaps to improve areas of informed consent. A retrospective survey was administered to patients with thumb amputations. Participants were required to complete a questionnaire about patient demographics, the Brief Michigan Hand Questionnaire (bMHQ), the standard gamble/time trade-off questionnaires for utility scores, and a questionnaire investigating potential reasons for electing not to undergo a free toe transfer. Thirty patients were enrolled in the study wherein 53% underwent a replantation procedure, 27% a revision amputation, and 20% a delayed reconstruction. Mean normalized score on the bMHQ was recorded as 63.54. Utility questionnaires yielded mean measures of 0.8967 and 0.86 on the standard gamble and time trade-off, respectively. From 14 elements, a majority (87%) stated flap failure as a major source of concern, followed by lack of understanding of risks and benefits (80%) and prolonged hospital stay (53%). Cultural/religious beliefs, aesthetic appearance of the foot, and concerns about footwear were not reported as important reasons in 90, 80, and 79% of patients, respectively. A better understanding of patients' attitudes and beliefs with respect to free toe flaps will allow surgeons to better address their concerns during informed consent. This study emphasizes the importance to discuss about failure rates, risks, and benefits of the operation and prolonged hospital stay.

LIFE QUALITY EVALUATION USING “TIME TRADE OFF” METHOD FOR RHEUMATOID HANDS

ABSTRACTObjective:Rheumatoid arthritis is a prevalent disease in the population (range 0.5% to 1%) and involves both orthopedic and rheumatologic treatment. The Time Trade-Off (TTO) technique, which determines the number of years the patient or the professional would be allowed before a successful procedure in terms of life expectancy and value of the procedure, has been gaining ground in clinical protocols. From this standpoint, we sought to compare evaluations provided by the patients, orthopedists, and rheumatologists in determining the TTO and to correlate their responses with the clinical repercussions using previously established scores such as the Brief Michigan Hand Questionnaire and the Disease Activity Score-28 (DAS-28).Methods:A prospective study was conducted that involved 37 patients with rheumatoid arthritis, orthopedists, and rheumatologists. The TTO questionnaire was administered by an independent evaluator for evaluation using the DAS-28 and the Brief Michigan Hand Questionnaire.Results:The descriptive analysis revealed similar medians between the orthopedists, rheumatologists, and patients for single assessments. However, there was a weak correlation between the results from the patient and rheumatologist, the patient and Brief Michigan Questionnaire, and those of the orthopedic surgeon and the DAS-28.Conclusion:Similar median values demonstrated equivalent TTO among the orthopedist, rheumatologist, and patient. However, given the weak correlations between the scores, it was not possible to substitute results using a single evaluation scale. Level of Evidence II, Prognostic Studies.

Effectiveness of the graded motor imagery to improve hand function in patients with distal radius fracture: A randomized controlled trial

Study DesignSingle-blinded randomized controlled trial. IntroductionPain management is essential in the early stages of the rehabilitation of distal radius fractures (DRFx). Pain intensity at the acute stage is considered important for determining the individual recovery process, given that higher pain intensity and persistent pain duration negatively affect the function and cortical activity of pain response. Graded motor imagery (GMI) and its components are recent pain management strategies, established on a neuroscience basis. Purpose of the StudyTo investigate the effectiveness of GMI in hand function in patients with DRFx. MethodsThirty-six participants were randomly allocated to either GMI (n = 17; 52.59 [9.8] years) or control (n = 19; 47.16 [10.5] years) groups. The GMI group received imagery treatment in addition to traditional rehabilitation, and the control group received traditional rehabilitation for 8 weeks. The assessments included pain at rest and during activity using the visual analog scale, wrist and forearm active range of motion (ROM) with universal goniometer, grip strength with the hydraulic dynamometer (Jamar; Bolingbrook, IL), and upper extremity functional status using the Disability of the Arm, Shoulder and Hand Questionnaire, and the Michigan Hand Questionnaire. Assessments were performed twice at baseline and at the end of the eighth week. ResultsThe GMI group showed greater improvement in pain intensity (during rest, 2.24; activity, 6.18 points), wrist ROM (flexion, −40.59; extension, −45.59; radial deviation, −25.59; and ulnar deviation, −26.77 points) and forearm ROM (supination, −43.82 points), and functional status (Disability of the Arm, Shoulder and Hand Questionnaire, 38.00; Michigan Hand Questionnaire, −32.53 points) when compared with the control group (for all, P < .05). ConclusionThe cortical model of pathological pain suggests new strategies established on a neuroscience basis. These strategies aim to normalize the cortical proprioceptive representation and reduce pain. One of these recent strategies, GMI appears to provide beneficial effects to control pain, improve grip strength, and increase upper extremity functions in patients with DRFx.

Association of psychological distress, quality of life and costs with carpal tunnel syndrome severity: a cross-sectional analysis of the PALMS cohort

ObjectivesThe Prediciting factors for response to treatment in carpal tunnel syndrome (PALMS) study is designed to identify prognostic factors for outcome from corticosteroid injection and surgical decompression for carpal tunnel...

Treatment of dorsal fracture-dislocation of the proximal interphalangeal joint using the Ligamentotaxor device: clinical and radiographic preliminary results.

Fracture-dislocations of the proximal interphalangeal joint are complex injuries, often difficult to treat. Several treatment options have been described. Among them dynamic external fixation proved to be a safe technique leading to good results in many authors experience. The principles of this treatment are to avoid edema, prevent stiffness and tendon adhesions, promote joint remodelling and facilitate rehabilitation. The Ligamentotaxor® device is a simple and reproducible dynamic external fixation system that has been used in recent years to treat proximal interphalangeal joint fracture-dislocations, with favourable results. The aim of the present study is to evaluate our preliminary results with the Ligamentotaxor® device for treatment of these complex lesions. Four patients between December 2015 and January 2017 were treated at our institution with the Ligamentotaxor® device. Clinical and radiographic results were evaluated at mean 6 months follow-up. Clinical results were meanly good and appeared to be comparable to most recent literature. Mean range of motion was 60,5°, mean extension lag 18,5°. Mean QuickDASH and Michigan Hand Questionnaire scored 21.6 and 72 respectively. Radiographic evaluation showed fracture healing in all cases. No relevant complications were noted. The Ligamentotaxor® device is simple to implant, provides good stability and allows an immediate gentle active movement. According to present work the preliminary results are encouraging.

Mid-Term Outcomes After Open Reduction Internal Fixation of Proximal Interphalangeal Joint Dorsal Fracture-Dislocations Through a Volar, Shotgun Approach and a Review of the Literature.

Background:Proximal interphalangeal (PIP) fracture dislocations remain a complex injury pattern to treat. There are several treatment methods available aimed to restore stability, preserve range of motion, and reconstitute the articular surface. This study looked at the mid-term clinical and radiographic results of open reduction internal fixation through a shotgun approach of comminuted PIP fracture dislocations.Methods:A retrospective review was conducted of all PIP fracture dislocations treated through a volar, shotgun approach at a single institution over a 15-year period. Patients identified were contacted and asked to return to the office for clinical and radiographic evaluation. Patient reported outcomes were assessed with the Michigan hand questionnaire (MHQ) and visual analog scale (VAS) for pain.Results:5 patients returned to the office for further evaluation with average follow-up of 69 months (range, 33-133 months). 3 patients were found to have post traumatic arthritis on radiographs. 1 case had recurrent instability and one case had a deep infection, both necessitating further surgical intervention. Average PIP arc of motion was found to be 79°. Average VAS score of 0 and MHQ result of 95 (out of a possible score of 100) indicating no residual pain and excellent functionality of the affected hand.Conclusion:Open reduction internal fixation of comminuted PIP fracture dislocations utilizing the volar, shotgun approach provides excellent mid-term functional results despite the high incidence of post traumatic arthritis.

Comparative Effectiveness of Needle Aponeurotomy and Collagenase Injection for Dupuytren's Contracture: A Multicenter Study.

Although the efficacy of collagenase clostridium histolyticum (CCH) injections has been demonstrated by randomized clinical trials, the relative effectiveness of CCH remains uncertain. Our aim was to compare the outcomes of CCH with those of percutaneous needle aponeurotomy (PNA) in daily clinical practice. We analyzed data from patients undergoing PNA or CCH between 2011 and 2014 at 7 practice sites in the Netherlands. We examined the degree of improvement in contracture and adverse effects at 6-12 weeks after surgery or the last injection. Additionally, we invited patients to complete the Michigan Hand Questionnaire before and at 6-12 months follow-up. To minimize the risk of bias, we used propensity score matching. Among 130 matched patients (93% Tubiana I or II) undergoing PNA (n = 46) and CCH (n = 84), improvement in contracture was similar: 26 degrees (65% improvement from baseline) for PNA versus 31 degrees (71%) for CCH for affected metacarpophalangeal joints (P = 0.163). This was 16 degrees (50% improvement) versus 17 degrees (42%) for affected proximal interphalangeal joints (P = 0.395), respectively. No serious adverse effects occurred in either of the 2 treatment groups. Of the mild adverse effects, only skin fissures and sensory disturbances were seen in both groups. Through 1-year follow-up, patients reported similar improvements in the overall Michigan Hand Questionnaire score (PNA 5.3 points versus CCH 4.9 points; P = 0.912). In patients with mild contractures (Tubiana I or II), CCH was as effective as PNA in reducing contractures. Both treatments were safe and improved hand function to a similar extent in daily practice.

Results of the Universal 2 Prosthesis in Noninflammatory Osteoarthritic Wrists

Background/Purpose Many treatment options are available for wrist osteoarthritis, with the objective of decreasing pain and preserving function. In later stages when midcarpal and radiocarpal osteoarthritis occur, two choices remain: total wrist arthrodesis or total wrist arthroplasty. The purpose of this study is to present the short-term functional changes following total wrist arthroplasty with the Universal 2 total wrist system (Integra Life Sciences) in patients with noninflammatory wrist osteoarthritis. Patients and Methods Patients with severe noninflammatory wrist osteoarthritis were assessed preoperatively, 6 and 12 months after surgery using a range of motion, grip strength, pain, and the disabilities of the arm, shoulder, and hand (DASH) score. The additional assessment was performed after 1 year for a range of motion using a biaxial electrogoniometer, grip strength, DASH, and the Michigan hand questionnaire. Results All range of motion directions and grip strength did not change from preoperative values. The DASH score improved from 53 preoperatively to 14 during latest follow-up. Median patients' satisfaction score decreased with approximately 20 points during the last follow-up. Conclusion The relatively good DASH score combined with the partly maintained wrist range of motion indicates that reconstruction with the Universal 2 total wrist prosthesis should be considered in patients with end-stage noninflammatory wrist osteoarthritis. Level of Evidence Level IV, therapeutic study.

Functional Outcomes of Thumb Trapeziometacarpal Arthrodesis With a Locked Plate Versus Ligament Reconstruction and Tendon Interposition

To compare standardized functional and patient-reported early outcomes following trapeziometacarpal arthrodesis (TMA) using a locking cage plate construct with trapezial excision, ligament reconstruction, and tendon interposition (LRTI). This prospective cohort enrolled 50 consecutive patients with trapeziometacarpal osteoarthritis undergoing TMA or LRTI. Demographic data, objective measurements, Sollerman function testing, and patient-reported outcomes were collected before surgery and at various time intervals up to 12 months after surgery. The study was powered to detect a minimally clinically important difference on the Michigan Hand Questionnaire between groups at 12 months. To account for selection bias, we performed between-group statistical analysis of the magnitude of change from preoperative to postoperative data. All complications were recorded. There were no significant differences in the amount of change in grip or pinch strength, patient-reported outcomes, or functional hand testing between TMA and LRTI. The TMA group had significantly increased thumb tip opposition distance. The TMA group was complicated by a 26% overall nonunion rate of which 8% were symptomatic. The LRTI group (Wagner incision) had a significantly increased incidence of superficial branch of the radial nerve paresthesia. The incidence of complications was similar between operative groups, but revision surgery was more common after TMA. Compared with LRTI, TMA failed to demonstrate superior improvement in strength, standardized functional performance, or patient-reported function and is associated with an increased likelihood of revision surgery in the first 12 months. Trapeziometacarpal arthrodesis with a locking plate and screw construct does not ensure union, although most radiographic nonunions were asymptomatic. Wagner incisions are associated with a significantly increased incidence of superficial branch of the radial nerve paresthesia compared with dorsal trapeziometacarpal exposure. Therapeutic II.

Seven-Year Outcomes of the Silicone Arthroplasty in Rheumatoid Arthritis Prospective Cohort Study.

Rheumatoid arthritis (RA) causes destruction of the metacarpophalangeal (MCP) joints, leading to hand deformities, pain, and loss of function. This study prospectively assessed long-term functional and health-related quality-of-life outcomes in RA patients with severe deformity at the MCP joints. RA patients between ages 18 to 80 years with severe deformity at the MCP joints were referred to 1 of the 3 study sites. Subjects who elected to undergo silicone metacarpophalangeal joint arthroplasty (SMPA) while continuing with medical management were followed in the SMPA cohort. Subjects who elected to continue with medical management alone without surgery were followed in the non-SMPA cohort. Objective measurements included grip and pinch strength as well as arc of motion, ulnar drift, and extensor lag of the MCP joints. Patient-reported outcomes included the Michigan Hand Questionnaire (MHQ) and the Arthritis Impact Measurement Scales questionnaire. Radiographs of SMPA implants were assessed and graded as intact, deformed, or fractured. MHQ scores showed large improvements post-SMPA, and baseline-adjusted expected outcomes in the SMPA group were significantly better at year 7 in function, aesthetics, satisfaction, and overall score compared to non-SMPA. SMPA subjects did not improve in grip or pinch strength, but achieved significant improvement and maintained the improvement long term in ulnar drift and extensor lag. Benefits of the SMPA procedure are maintained over 7 years with low rates of implant fracture or deformity. Non-SMPA patients remained stable in their hand function over the 7-year study duration.

Effect of low appendicular lean mass, grip strength, and gait speed on the functional outcome after surgery for distal radius fractures.

Loss of skeletal muscle mass and consequent loss in muscle function associate with aging, and this condition negatively impacts the activities of daily living and increases elderly individuals' frailty to falls. Thus, patients with low appendicular lean mass would show different functional recovery compared to those without this condition after surgery for distal radius fracture (DRF). This study compares the functional outcomes after surgery for DRF in patients with or without low appendicular lean mass plus slowness or weakness. A total of 157 patients older than 50years of age with a DRF treated via volar plate fixation were enrolled in this prospective study. A definition of low appendicular lean mass with slowness or weakness was based on the consensus of the Asian Working Group for Sarcopenia. The researchers compared functional assessments (wrist range of motion and Michigan Hand Questionnaire [MHQ]) and radiographic assessments (radial inclination, volar tilt, ulnar variance, and articular congruity) 12months after surgery between patients with and without low appendicular lean mass plus slowness or weakness. Multivariable regression analyses were performed to determine whether appendicular lean mass, grip strength, gait speed, patient demographic, or injury characteristics accounted for the functional outcomes. Patients with low appendicular lean mass plus slowness or weakness showed a significantly lower recovery of MHQ score than those in the control group throughout 12months. There was no significant difference in the range of motion between the groups. The radiologic outcomes showed no significant difference between groups in terms of volar tilt, radial inclination, or ulnar variance. According to multivariable regression analysis, the poor recovery of MHQ score was associated with an increase in age, weak grip strength, and lower appendicular lean mass, and these three factors accounted for 37% of the variation in the MHQ scores. Patients with low appendicular lean mass plus slowness or weakness are at risk for poor functional recovery after surgery for DRF, even when they have similar radiologic outcomes.

Hand exercises for patients with rheumatoid arthritis: an extended follow-up of the SARAH randomised controlled trial

ObjectivesThe Stretching And strengthening for Rheumatoid Arthritis of the Hand (SARAH) randomised controlled trial evaluated the effectiveness of a hand exercise programme and demonstrated it was clinically effective and cost-effective...

Dynamic assessment of the wrist after total wrist arthroplasty.

Our aim was to assess the outcome in patients with total wrist arthroplasty performed for end stage wrist osteoarthritis. We analysed the ranges of motion of operated and un-operated wrists using a flexible electrogoniometer during the Sollerman hand function test. We assessed grip strength with a digital dynamometer and completed patient reported outcome scores more than one year post-operatively. We reviewed 12 patients with a mean age of 64 (range 48-82) years. The flexion-extension arc was 72% and radioulnar deviation arc was 53% of the un-operated side but the total range of motion (area of circumduction) was 43% of the un-operated side and only 20% of the circumduction in age and gender-matched normal volunteers. Peak grip strength was 68% of the un-operated side. The patients reported good outcome with mean Michigan Hand Questionnaire (MHQ) scores of 56 (range 25-84) and mean Patient Evaluation Measure (PEM) scores of 39 (range 20-68). Patients completed the activities of Sollerman hand function test in twice the time (6 min) as required for a normal volunteer (2.8 min). The circumduction ellipses were narrow and central with limited radio-ulnar deviation and small mean areas of motion during activities of daily living.

Outcomes and Disability After Massive Proximal Upper Extremity Reconstruction in a Resource-Limited Setting.

At Ganga Hospital in Coimbatore, India, a unique approach is applied to treat massive upper limb injuries. However, long-term outcomes of complex reconstruction performed in the resource-limited setting are not known. This hinders understanding of outcomes and disability from these injuries and prevents systematically addressing care delivery around upper extremity trauma in the developing world. This project aims to analyze the details of the unique Ganga Hospital reconstruction experience and use patient-reported outcome measures for the first time in this patient population to evaluate post-injury recovery and disability . Forty-six patients were evaluated 6months or more after massive proximal upper extremity reconstruction at Ganga Hospital. Patients completed functional tests, Jebsen-Taylor test (JTT), and patient-reported outcomes (PROs)-Michigan Hand Questionnaire (MHQ), Disability of Arm, Shoulder, and Hand questionnaire (DASH), and Short-Form 36 (SF-36). Correlations between metrics were assessed with Pearson's correlation coefficients. Linear regression modeling evaluated associations between severity, reconstruction, and outcomes. MHQ and DASH results correlated with functional test performance, JTT performance, and SF-36 scores (Pearson's coefficients all ≥0.33, p≤0.05). In this cohort, mean MHQ score was 79±15 and mean DASH score was 13±15, which are not significantly different than scores for long-term outcomes after other complex upper extremity procedures. The following factors predicted PROs and functional performance after reconstruction: extent of soft tissue reconstruction, multi-segmental ulna fractures, median nerve injury, and ability for patients to return to work and maintain their job after injury. Complex proximal upper extremity salvage can be performed in the resource-limited setting with excellent long-term functional and patient-reported outcomes. PRO questionnaires are useful for reporting outcomes that correlate to functional and sensory testing and may be used to assess post-traumatic disability.

Locking Plate Arthrodesis Compares Favorably with LRTI for Thumb Trapeziometacarpal Arthrosis: Early Outcomes from a Longitudinal Cohort Study.

Trapeziometacarpal arthrodesis (TMA) has been complicated by nonunion and hardware failure. We hypothesized that modification of the TMA technique with a locking cage plate construct would afford reliable bony union while producing greater hand function than trapeziectomy with ligament reconstruction and tendon interposition (LRTI) at early follow-up. We enrolled 36 consecutive patients with trapeziometacapal osteoarthritis (14 TMA patients (15 thumbs), 22 LRTI patients (22 thumbs)). The study was powered to detect a minimal clinically important difference on the QuickDASH questionnaire between groups. Secondary outcomes included Michigan Hand Questionnaire (MHQ), VAS-pain, and EQ-5D-3L scores. Patients were examined to evaluate thumb motion and strength. TMA patients were evaluated clinically and radiographically for union. Mean follow-up was 15.6months, and the mean age was 59.2years. Union was achieved in 14/15 (93%) of TMA thumbs. Improvement in QuickDASH scores was similar after TMA and LRTI (49 to 28 and 50 to 18, respectively). Postoperative patient-rated upper extremity function, health status, and pain were similar between groups. Pinch strength was significantly greater after TMA (5.9 vs 4.7 kg). No differences in thumb or wrist range of motion were observed postoperatively with the exception of greater total metacarpophalangeal joint motion after TMA. Complications after TMA included nonunion (7%), development of symptomatic scaphotrapezotrapezoidal (STT) arthrosis (7%), symptomatic hardware (7%), and superficial branch of the radial nerve (SBRN) paresthesia (7%). Complications after LRTI included subsidence (5%), MP hyperextension deformity (5%), and SBRN paresthesias (5%). At early follow-up, patient-rated function was similar among patients undergoing TMA and LRTI. TMA produced 25% greater pinch strength compared with LRTI. Despite historical concerns regarding global loss of ROM with arthrodesis, motion was similar between groups. Our observed TMA nonunion rate of 7% is low relative to historically reported nonunion rates (7-16%). Locking cage plate technology affords rigid fixation for TMA with promising early results noting reliable bony union while minimizing complications.

The Effect of Carpal Tunnel Release on Typing Performance

To describe the effect of carpal tunnel release (CTR) on typing performance. We prospectively studied 27 patients undergoing open CTR. Patient demographics and clinical characteristics including nerve conduction studies, electromyography results, and duration of symptoms were collected. Before surgery and at 8 time points after surgery, ranging from 1 to 12 weeks, typing performance for an approximately 500-character paragraph was assessed via an on-line platform. The Michigan Hand Questionnaire (MHQ) and the Boston Carpal Tunnel Questionnaire functional component (BCTQ-F) and symptom severity component (BCTQ-S) component were completed before surgery and at 1, 3, 6, and 12 weeks after surgery. We used repeated-measures analyses of variance and follow-up dependent-samples ttests to analyze change in typing performance across sessions, and linear regressions to assess relationships between typing performance and demographic and outcome measures. We compared typing speed with the MHQ, BCTQ-F, and BCTQ-S using the Pearson correlation test. Average typing speed decreased significantly from 49.7 ± 2.7 words per minute (wpm) before surgery to 45.2 ± 3.1 wpm at 8 to 10 days after surgery. Mean typing speed for the group exceeded the preoperative value between weeks 2 and 3, with continued improvement to 53.5 ± 3.5 wpm at 12 weeks after surgery. No clinical or demographic variables were associated with the rate of recovery or the magnitude of improvement after CTR. The MHQ, BCTQ-F, and BCTQ-S each demonstrated significant improvement from preoperative values over the 12-week period. The MHQ and BCTQ-F scores correlated well with typing speed. On average, typing speed returned to preoperative levels between 2 and 3 weeks after CTR and typing speed showed improvement beyond preoperative levels after surgery. The MHQ and BCTQ-F correlate well with typing speed after CTR. Prognostic IV.