Ulnar collateral ligament injuries of the thumb: phalangeal translation during valgus stress in human cadavera

BACKGROUND: The clinical diagnosis of thumb ulnar collateral ligament disruption has been based on joint angulation during valgus stress testing. This report describes a definitive method of distinguishing between complete and partial ulnar collateral ligament injuries by quantifying translation of the proximal phalanx on the metacarpal head during valgus stress testing. METHODS: Sixty-two cadaveric thumbs underwent standardized valgus stress testing under fluoroscopy with the ulnar collateral ligament intact, following an isolated release of the proper ulnar collateral ligament, and following a combined release of both the proper and the accessory ulnar collateral ligament (complete ulnar collateral ligament release). Following complete ulnar collateral ligament release, the final thirty-seven thumbs were also analyzed after the application of a valgus force sufficient to cause 45° of valgus angulation at the metacarpophalangeal joint to model more severe soft-tissue injury. Two independent reviewers measured coronal plane joint angulation (in degrees), ulnar joint line gap formation (in millimeters), and radial translation of the proximal phalanx on the metacarpal head (in millimeters) on digital fluoroscopic images that had been randomized. RESULTS: Coronal angulation across the stressed metacarpophalangeal joint progressively increased through the stages of the testing protocol: ulnar collateral ligament intact (average [and standard deviation], 20° ± 8.1°), release of the proper ulnar collateral ligament (average, 23° ± 8.3°), and complete ulnar collateral ligament release (average, 30° ± 8.9°) (p < 0.01 for each comparison). Similarly, gap formation increased from the measurement in the intact state (5.1 ± 1.3 mm), to that following proper ulnar collateral ligament release (5.7 ± 1.5 mm), to that following complete ulnar collateral ligament release (7.2 ± 1.5 mm) (p < 0.01 for each comparison). Radial translation of the proximal phalanx on the metacarpal head did not increase after isolated release of the proper ulnar collateral ligament (1.6 ± 0.8 mm vs. 1.5 ± 0.9 mm in the intact state). There was a significant increase in translation following release of the complete ulnar collateral ligament complex (3.0 ± 0.9 mm; p < 0.01) and an additional increase after forcible angulation of the joint to 45° (4.1 ± 0.9 mm; p < 0.01). Translation 2 mm greater than that in the stressed control was 100% specific for complete disruption of the ulnar collateral ligament complex. CONCLUSIONS: While transection of the proper ulnar collateral ligament leads to an increase in metacarpophalangeal joint angulation and gapping on stress fluoroscopic evaluation, only release of both the accessory and the proper ulnar collateral ligament significantly increases translation of the proximal phalanx on the metacarpal head. CLINICAL RELEVANCE: A finding of phalangeal translation on a stress fluoroscopic image distinguishes partial from complete tears of the thumb ulnar collateral ligament

Performance of simplified scoring systems for hand diagrams in carpal tunnel syndrome screening

PURPOSE: Katz et al have published a standardized scoring system of hand diagrams for carpal tunnel syndrome. The purpose of this study was to quantitatively evaluate alternative scoring of the hand diagram for detection of carpal tunnel syndrome. METHODS: In a prospective study of 1107 workers, 221 workers with hand symptoms completed hand diagrams and electrodiagnostic testing for carpal tunnel syndrome. Scoring algorithms for the hand diagrams included the Katz rating; a median nerve digit score (0–2) with a maximum of 2 symptomatic digits of thumb, index, and long; and isolated digit scores (0–1) of thumb, index, or long. Intraclass correlation coefficients quantified inter-rater reliability. Sensitivity, specificity, and logistic regression analyses evaluated scoring systems performances ability to predict abnormal median nerve conduction. RESULTS: One hundred ten (50%) subjects illustrated symptoms within the median nerve distribution. All scoring systems demonstrated substantial inter-rater reliability. “Classic” or “probable” Katz scores, median nerve digit score of 2, and positive long finger scores were significantly associated with abnormal median nerve distal sensory latency and median-ulnar difference. Abnormal distal motor latency was significantly associated with the median nerve digit score of 2 and positive long finger scores. Increasing Katz scores from “possible” to “probable” and “classic” were not associated with greater odds of electrodiagnostic abnormality. Positive long finger scores performed at least as well as the most rigorous scoring by Katz. CONCLUSIONS: Symptoms diagramed within the median nerve distribution are associated with abnormal nerve conduction among workers. The median nerve digit score and the long finger score offer increased ease of use compared to the Katz method while maintaining similar performance characteristics. The long finger appears best suited for isolated digit scoring to predict abnormal median nerve conduction in a working population

Patient-Reported Outcomes Measurement Information System physical function correlates with Toronto Extremity Salvage Score in an orthopaedic oncology population

Background: The National Institute of Health\u27s Patient-Reported Outcomes Measurement Information System (PROMIS) uses computerised-adaptive testing to reduce survey burden and improve sensitivity. PROMIS is being used across medical and surgical disciplines but has not been studied in orthopaedic oncology. Questions/purposes: The aim of the study was to compare PROMIS measures with upper extremity (UE) and lower extremity (LE) Toronto Extremity Salvage Score (TESS) by assessing the following: (1) responder burden, (2) correlation between scores and (3) floor/ceiling effects. Patients and methods: This cross-sectional trial analysed all 97 adult patients treated surgically for a bone or soft tissue tumour at a tertiary institution between November 2015 and March 2016. TESS (UE or LE) and PROMIS (Physical Function, Pain Interference and Depression) surveys were administered preoperatively. Pearson correlations between each PROMIS domain and TESS were calculated, as were floor/ceiling effects of each outcome measure. Results: (1) Completion of three PROMIS questionnaires required a mean total of 16.8 (+/- 5.8 standard deviation) questions, compared with 31 and 32 questions for the LE and UE TESS questionnaires, respectively. (2) The PROMIS Physical Function scores demonstrated a strong positive correlation with the LE TESS (r = 0.84; 95% confidence interval [CI], 0.72-0.91; p \u3c 0.001) and moderate positive correlation with the UE TESS (r = 0.64; 95% CI, 0.34-0.83; p = 0.055). The PROMIS Depression scores demonstrated a weak negative correlation with both the LE TESS (r = -0.38; 95% CI, -0.61 to -0.10; p = 0.010) and with UE TESS (r = -0.38; 95% CI, -0.67 to -0.01; p = 0.055). The PROMIS Pain Interference scores demonstrated a strong negative correlation with the LE TESS (r = -0.71; 95% CI, -0.83 to -0.52; p \u3c 0.001) and a moderate negative correlation with the UE TESS (r = -0.62; 95% CI, -0.81 to -0.30; p = 0.001). (3) The UE TESS had a range of scores from 16 to 100 with a 27% ceiling effect and no floor effect, and the LE TESS had a range from 10 to 98 with no floor or ceiling effect. There was no floor or ceiling effect for any PROMIS measures. Conclusions: In an orthopaedic oncology population, the PROMIS Physical Function and Pain Interference scores correlate with the TESS and have the benefit of reduced survey burden and ceiling effect. The PROMIS Depression scores may provide additional information regarding patient outcomes not captured by the TESS. Level of Evidence: Level III. The translational potential of this article: Patient reported outcome measures asses patients\u27 symptoms, function and health-related quality of life and are designed to capture more clinical information than can be gathered by objective medial testing alone. As reimbursements and the understanding of patient outcomes are becoming tied to performance on PROMIS measures, it is an important step to establish how PROMIS measures correlate and compare to traditional legacy measures

Long-term outcomes following a single corticosteroid injection for trigger finger

BACKGROUND: The outcomes of corticosteroid injection for trigger finger are well documented only with short-term follow-up. The purpose of this investigation was to determine the long-term effectiveness of a single injection and to examine predictors of success up to ten years after injection. METHODS: This case series analyzed 366 first-time corticosteroid injections in flexor tendon sheaths from January 2000 to December 2007 with a minimum follow-up duration of five years. Two hundred and forty patients (66%) were female, 161 patients (44%) had multiple trigger fingers, and eighty-eight patients (24%) had diabetes at the time of injection. The primary outcome of treatment failure was defined as subsequent injection or surgical trigger finger release of the affected digit. Medical records were reviewed, and any patients without documented failure or a return office visit in 2012 to 2013 were contacted by telephone regarding symptom recurrence and the need for additional treatment. Kaplan-Meier analyses with log-rank test and Cox regression analysis assessed the effect of baseline patient and disease characteristics on injection success. RESULTS: Forty-five percent of patients demonstrated long-term treatment success after a single injection. In the final regression model, the interaction of sex and the number of trigger fingers was the single predictor of treatment success. Exploring this association revealed a ten-year success rate of 56% for female patients presenting for the first time with a trigger finger compared with 35% in male patients presenting for the first time with a trigger finger, 39% in female patients with multiple trigger fingers, and 37% in male patients with multiple trigger fingers. Eighty-four percent of treatment failures occurred within the first two years following injection. Patient age, symptom type, and undifferentiated diabetes status were not predictive of treatment success. CONCLUSIONS: Female patients presenting with their first trigger finger have the highest rate of long-term treatment success after a single corticosteroid injection. Patients who continue to experience symptom relief two years after injection are likely to maintain long-term success. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence

The impact of depression and pain catastrophization on initial presentation and treatment outcomes for atraumatic hand conditions

BACKGROUND: Prior studies have suggested that patient-rated hand function is impacted by depression and pain catastrophization. We studied the impact that these comorbidities have on treatment outcomes. METHODS: Two hundred and fifty-six patients presenting to an orthopaedic hand clinic were followed in this prospective cohort investigation. Patients who were prescribed treatment for atraumatic hand/wrist conditions were eligible for inclusion. At enrollment, all patients completed the Center for Epidemiologic Studies Depression (CES-D) scale, the Pain Catastrophizing Scale (PCS), and the Michigan Hand Outcomes Questionnaire (MHQ; scale of 0 to 100, with 100 indicating the best hand performance). One month and three months after treatment, patients again completed the MHQ. Participants’ psychological comorbidity status was categorized as either affected (a CES-D score of ≥16, indicating depression, or a PCS score of ≥30, indicating catastrophization) or unaffected (a CES-D score of <16 and a PCS score of <30). Diagnoses and treatments for both the affected and unaffected groups were examined. The effect of time and patient status, and their interaction, on MHQ scores was evaluated by mixed modeling. RESULTS: Fifty patients were categorized as affected and 206 as unaffected. Diagnoses and treatments differed minimally between the two groups. At the time of enrollment, the mean MHQ score of the unaffected group (64.9; 95% confidence interval [CI], 62.5 to 67.3) was significantly higher than that of the affected group (48.1; 95% CI, 43.3 to 53.0). Both groups demonstrated similar significant absolute improvement over baseline at three months after treatment (an increase of 12.5 points [95% CI, 7.5 to 17.4] in the affected group and 12.8 points [95% CI, 10.4 to 15.3] in the unaffected group). Thus, at the time of final follow-up, the rating of hand function by the affected patients (60.6 [95% CI, 55.0 to 66.2]) was still significantly poorer than the rating by the unaffected patients (77.7 [95% CI, 75.0 to 80.5]). CONCLUSIONS: Although patients affected by depression and/or pain catastrophization reported worse self-rated hand function at baseline and at the time of follow-up, these patients showed similar absolute improvement in self-rated hand function following treatment compared with patients with unaffected status. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence

Accuracy of patient recall of hand and elbow disability on the QuickDASH questionnaire over a two-year period

BACKGROUND: Patient self-reporting questionnaires such as the QuickDASH, a shortened version of the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure, are critical to current orthopaedic outcomes research. The use of these questionnaires could introduce recall bias in retrospective, case-control, and cross-sectional studies if no preoperative data has been collected prior to study inception. The purpose of this study was to quantify recall accuracy on the QuickDASH questionnaire as a function of the duration of the recall interval. METHODS: This cross-sectional study enrolled 140 patients with nontraumatic hand and elbow diseases. Patients were stratified into groups of thirty-five based on the time since their initial office visit (three months, six months, twelve months, or twenty-four months). All patients had completed the QuickDASH as part of a standard intake form at the time of the initial office visit (actual baseline score). Patients were contacted by phone and asked to recall their upper extremity disability from the time of the initial office visit with use of the QuickDASH questionnaire. Patients also completed the QuickDASH to rate their current disability. Actual and recalled QuickDASH scores for each group were statistically compared. Kruskal-Wallis analysis was used to determine any differences in recall accuracy between the groups. Pearson correlation coefficients quantified relations between recall accuracy and patient age and current function (absolute QuickDASH scores). RESULTS: Mean differences between recalled QuickDASH scores and actual scores were all less than the QuickDASH minimal clinically important difference (MCID) of 13 points at different time points: three months (–7.1, p < 0.01), six months (0.8, p = 0.79), twelve months (–2.3, p = 0.43), and twenty-four months (–2.8, p = 0.26). There were no significant differences in recall accuracy across the four groups (p = 0.77). Recalled QuickDASH scores were highly correlated with actual baseline values (r(p) ≥ 0.74). Recall accuracy was neither correlated with patient age nor current QuickDASH scores (r(p) ≤ 0.04). CONCLUSIONS: Patients with a nontraumatic hand or elbow diagnosis are able to recall prior level of function accurately for up to two years with the QuickDASH questionnaire. Although data collected prospectively remain optimal, our data suggest that research conducted with use of recalled QuickDASH scores produces reliable assessment of disability from common upper extremity diagnoses with acceptable recall bias. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence

Outcomes of acute versus subacute scapholunate ligament repair

PURPOSE: This study investigated the long-term outcomes of direct scapholunate ligament (SLL) repairs with or without dorsal capsulodesis performed within 6 weeks (acute repair) of a SLL tear versus 6 to 12 weeks following injury (subacute repair). METHODS: A review of medical records from April 1996 to April 2012 identified 24 patients who underwent SLL repair (12 acute, 12 subacute). Patients returned to the clinic for radiographic examinations of the injured wrist, standardized physical examinations, and validated questionnaires. RESULTS: The mean follow-up times for the acute and subacute groups were 7.2 and 6.2 years, respectively. At the final examination, patients with acute surgery regained more wrist extension (acute = 55°, subacute = 47°). The total wrist flexion-extension arcs, grip strengths, pinch strengths, and patient-rated outcome scores were found to be similar between groups. The final scapholunate gap, scapholunate angle, and the prevalence of arthritis were also found to be similar between the acute and subacute groups. CONCLUSIONS: Although SLL repair is more commonly recommended for treatment of acute SLL injuries, there were no significant long-term differences between acute and subacute SLL surgeries (repair ± capsulodesis). TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III

Improvements in physical function and pain interference and changes in mental health among patients seeking musculoskeletal care

IMPORTANCE: Among patients seeking care for musculoskeletal conditions, there is mixed evidence regarding whether traditional, structure-based care is associated with improvement in patients\u27 mental health. OBJECTIVE: To determine whether improvements in physical function and pain interference are associated with meaningful improvements in anxiety and depression symptoms among patients seeking musculoskeletal care. DESIGN, SETTING, AND PARTICIPANTS: This cohort study included adult patients treated by an orthopedic department of a tertiary care US academic medical center from June 22, 2015, to February 9, 2022. Eligible participants presented between 4 and 6 times during the study period for 1 or more musculoskeletal conditions and completed Patient-Reported Outcomes Measurement Information System (PROMIS) measures as standard care at each visit. EXPOSURE: PROMIS Physical Function and Pain Interference scores. MAIN OUTCOMES AND MEASURES: Linear mixed effects models were used to determine whether improvements in PROMIS Anxiety and PROMIS Depression scores were associated with improved PROMIS Physical Function or Pain Interference scores after controlling for age, gender, race, and PROMIS Depression (for the anxiety model) or PROMIS Anxiety (for the depression model). Clinically meaningful improvement was defined as 3.0 points or more for PROMIS Anxiety and 3.2 points or more for PROMIS Depression. RESULTS: Among 11 236 patients (mean [SD] age, 57 [16] years), 7218 (64.2%) were women; 120 (1.1%) were Asian, 1288 (11.5%) were Black, and 9706 (86.4%) were White. Improvements in physical function (β = -0.14; 95% CI, -0.15 to -0.13; P \u3c .001) and pain interference (β = 0.26; 95% CI, 0.25 to 0.26; P \u3c .001) were each associated with improved anxiety symptoms. To reach a clinically meaningful improvement in anxiety symptoms, an improvement of 21 PROMIS points or more (95% CI, 20-23 points) on Physical Function or 12 points or more (95% CI, 12-12 points) on Pain Interference would be required. Improvements in physical function (β = -0.05; 95% CI, -0.06 to -0.04; P \u3c .001) and pain interference (β = 0.04; 95% CI, 0.04 to 0.05; P \u3c .001) were not associated with meaningfully improved depression symptoms. CONCLUSIONS AND RELEVANCE: In this cohort study, substantial improvements in physical function and pain interference were required for association with any clinically meaningful improvement in anxiety symptoms, and were not associated with any meaningful improvement in depression symptoms. Patients seeking musculoskeletal care clinicians providing treatment cannot assume that addressing physical health will result in improved symptoms of depression or potentially even sufficiently improved symptoms of anxiety