Long-Term Quality of Life after Free Flap Upper Extremity Reconstruction for Traumatic Injuries

Background Microsurgical reconstruction of upper extremity injuries is often challenging, and the resulting impact on the quality of life (QoL) may be significant. However, there is a lack of knowledge on long-term patient-reported QoL. Methods In a retrospective long-term follow-up study, all consecutive patients with an upper extremity injury who had undergone a free flap reconstruction were identified and categorized into three groups based on the type of injury. Patient-reported upper extremity function and QoL were assessed using three validated questionnaires: the 36-item Short Form Health Survey (SF-36), the Disabilities of the Arm, Shoulder, and Ha

An anatomical study on the effectiveness of Arthrex Mini TightRope((R)) ligament reconstruction in an unstable trapeziometacarpal joint

Item does not contain fulltextINTRODUCTION: Laxity in the trapeziometacarpal (TMC) joint is a debilitating condition usually affecting a young population. It can be treated operatively with ligament reconstruction. The purpose of this study was to determine the effectiveness of the Arthrex Mini TightRope((R)) in reinforcing the stabilizing ligaments in an unstable TMC joint without decreasing the range of motion of the thumb. This method was compared with the "gold standard" published by Eaton and Littler in 1973. MATERIALS AND METHODS: Six fresh frozen arms from five cadavers were included. TMC joint laxity was measured on stress view radiographs as the ratio of the radial subluxation (RS) of the first metacarpal in relation to the trapezium, by the first metacarpal articular width (AW) (as described by Wolf in 2009). Measurements of the pre- and post-operative range of motion (ROM) were performed and compared. RESULTS: Both the Arthrex Mini TightRope((R)) and the Eaton-Littler stabilization improved the stability of the TMC joint. The pre-operative laxity value (ratio RS/AW) of 0.27 was significantly (P = 0.02) improved by each of the surgical interventions (Eaton-Littler RS/AW = 0.05 and Tightrope RS/AW = 0.09). The pre- and post-operative range of motion was not significantly different by each of the surgical interventions. There were no significant differences between the two stabilizing methods regarding laxity or range of motion. CONCLUSION: The Arthrex Mini TightRope((R)) provided a good stabilization method for the TMC joint in this anatomical model without compromising the range of motion

Ligament reconstruction in thumb carpometacarpal joint instability: A systematic review

Summary: In thumb carpometacarpal (CMC) instability, laxity of the ligaments surrounding the joint leads to pain and weakness in grip and pinch strength, which predisposes the patient to developing CMC joint arthritis. Recent advancements in joint anatomy and kinematics have led to the development of various surgical reconstructive procedures. This systematic review outlines the available ligament reconstruction techniques and their efficacy in treating nontraumatic and nonarthritic CMC instability. Additionally, we aimed to provide evidence which specific ligament reconstruction technique demonstrates the best results. Four databases (Embase, MEDLINE, Web of Science, and Cochrane Central) were searched for studies that reported on surgical techniques and their clinical outcomes in patients with nontraumatic and nonarthritic CMC instability. Twelve studies were analyzed for qualitative review, including nine different surgical ligament reconstruction techniques involving two hundred and thirty thumbs. All but one of the reported techniques improved postoperative pain scores and showed substantial improvement in pinch and grip strength. Complication rates varied between 0% and 25%. The included studies showed that ligament reconstruction effectively alleviated the patients’ complaints regarding pain and instability, resulting in overall high patient satisfaction. Nevertheless, drawing definitive conclusions regarding the superiority of any ligament reconstruction technique remains challenging owing to the limited availability of homogeneous data in the current literature

A systematic review and meta-analysis on the use of fibrin glue in peripheral nerve repair: Can we just glue it?

BACKGROUND: Within the field of peripheral nerve surgery, the use of fibrin glue as an alternative to conventional microsurgical suture repair is becoming increasingly popular. Advantages of fibrin glue for nerve reconstruction include technical ease of use, less tissue manipulation, and shorter operation times. Although fibrin glue seems a promising alternative to conventional microsurgical repair, further insight into the outcomes of nerve recovery is essential. OBJECTIVE: To summarize the current literature on the use of fibrin glue for peripheral nerve repair and compare these results with outcomes following conventional suture repair. METHODS: A systematic search in Embase, MEDLINE, Web of Science, Cochrane, and Google Scholar databases was performed. The search included animal, cadaveric, and human studies assessing outcomes following peripheral nerve repair using fibrin glue. Data on outcomes were subdivided into functional outcomes, electrophysiology, histopathology, biomechanical outcomes, and operation times. We calculated standardized mean differences and combined these in a random effects model to estimate the overall effect. RESULTS: From a total of 2057 references, 37 animal, two cadaveric, and four human studies were included. Fibrin glue repairs resulted in similar functional and electrophysiology outcomes and shorter operation times than suture repairs. However, fibrin glue alone resulted in lower strength and more dehiscence. No dehiscence was reported when fibrin glue was combined with one or two sutures. Yet, we also found that methodological details were poorly reported in animal studies, resulting in an unclear risk of bias. This should be taken into consideration when interpreting the results. CONCLUSION: The results indicate that nerve regeneration may be similar in fibrin glue repairs and suture repairs. Combining fibrin glue with one or two positional sutures allows for a precise realignment of the nerve fibers and seems to provide sufficient strength to prevent dehiscence

The prevalence, incidence, and progression of radiographic thumb base osteoarthritis in a population-based cohort: the Rotterdam Study

OBJECTIVE: To describe the prevalence, incidence, and progression of radiographic thumb carpometacarpal (CMC-1) and trapezioscaphoid (TS) radiographic osteoarthritis (ROA) in the general Dutch population aged ≥55y. DESIGN: Data were from the first and second cohort of the Rotterdam Study (1990-2005, 4-12 years follow-up, age 55+). Participants underwent bilateral radiographs at baseline (N = 7792) and follow-up (N = 3804), read for Kellgren-Lawrence (K-L) grade. ROA was defined on the joint level as K-L grade ≥2. The prevalence was assessed at baseline, incidence at follow-up in those free of ROA at baseline, and progression in those with ROA. Differences based on sex and age were evaluated using logistic regression models. RESULTS: At baseline, 1977 (25.3%) had CMC-1 ROA and 1133 (14.5%) TS ROA. The prevalence was higher in females for CMC-1 (aOR = 1.98 95%CI [1.77-2.21]) and TS ROA (aOR = 2.00 [1.74-2.29]) and increased for every year of age (CMC-1 ROA 1.08 [1.07-1.08]) (TS ROA 1.06 [1.05-1.07]). Most (437/512; 85.4%) incident cases of CMC-1 ROA (2994 at risk) were mild (K-L = 2), whereas most (145/167; 86,8%) incident cases of TS ROA (3311 at risk) were moderate to severe (K-L = 3/4). CMC-1 ROA progression was mostly (88/100; 88.0%) seen in the K-L 2 group at baseline, whereas that was (4/17; 23.5%) for TS ROA. CONCLUSION: CMC-1 ROA and TS ROA are prevalent in the general Dutch population. While incident CMC-1 ROA was primarily mild, incident TS ROA was more often moderate to severe. CMC-1 ROA was a strong predictor for incident TS ROA

Two-, Three-, or Four-Corner Arthrodesis for Midcarpal Osteoarthritis: A Systematic Review and Meta-Analysis

Purpose: Several limited midcarpal arthrodeses have been used in the treatment of midcarpal osteoarthritis as part of scapholunate advanced collapse and scaphoid nonunion advanced collapse. There is no consensus on whether two-carpal arthrodesis (2CA), three-carpal arthrodesis (3CA), bicolumnar arthrodesis, or four-carpal arthrodesis (FCA) results in the best outcomes. The objective of this study was to determine whether there is a difference in outcomes in patients undergoing FCA, 3CA, 2CA, or bicolumnar arthrodesis for midcarpal osteoarthritis. Methods: A systematic review and meta-analysis were performed in multiple databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting the four surgical techniques were included. The primary outcomes were postoperative visual analog scale pain score, the Disabilities of the Arm, Shoulder, and Hand score, and the Mayo Wrist Score. The secondary outcomes were active range of motion, grip strength, and reported complications. Results: Of 2,270 eligible studies, 80 articles were selected, including a total of 2,166 wrists. The visual analog scale pain scores for both the 2CA and FCA groups reached an adequate pain reduction based on the Patient Acceptable Symptom Scale. The Disabilities of the Arm, Shoulder, and Hand score was also comparable between these two groups. The 2CA group also showed a significantly better active range of motion than the FCA group for both flexion-extension and radioulnar deviation arc. The incidence of nonunion was 6.9% in the FCA group compared with 10.0% in the 2CA group. Conclusions: Although the 2CA procedure has a theoretical advantage over the FCA method, the analysis of data showed that generally, these techniques have similar outcomes and complications. Therefore, both (2CA and FCA) are good options for midcarpal osteoarthritis in scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists. Type of study/level of evidence: Therapeutic IV

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

Prevalence of Complications and Association With Patient-Reported Outcomes After Trapeziectomy With a Weilby Sling: A Cohort Study.

PURPOSE: The primary aim of this study was to report complications during the first year after trapeziectomy with Weilby sling using a standardized tool designed by the International Consortium for Health Outcome Measures. The secondary aim was to determine the association of complications and patient-reported outcomes 12 months after surgery. METHODS: We included patients who underwent trapeziectomy with Weilby sling between November 2013 and December 2018. All complications during the first year were scored using the International Consortium for Health Outcomes Measurement Complications in Hand and Wrist conditions (ICHAW) tool. Pain and hand function were measured before surgery and 12 months after surgery using the Michigan Hand Outcomes Questionnaire (MHQ). Minimally Important Change thresholds of 18.6 for MHQ pain and 9.4 for MHQ function were used to determine clinical importance. RESULTS: Of 531 patients after trapeziectomy with Weilby sling, 65% had an uneventful recovery, 16% experienced ICHAW Grade 1 deviations only, and 19% experienced Grade 2 or 3 deviations, including requiring antibiotics, corticosteroid injections, or additional surgery. On average, patients improved in pain and hand function, even in the presence of ICHAW events. Although all ICHAW grades were associated with poorer patient-reported outcomes 12 months after surgery, Grade 2 and 3 exceeded the Minimally Important Change threshold for pain and/or function. CONCLUSIONS: In 531 patients, 65% had an uneventful recovery, 16% experienced ICHAW Grade 1 deviations only, and 19% experienced grade 2 or 3 deviations. We recommend describing Grade 1 as "adverse protocol deviations" and grade 2 and 3 as complications, because of clinically relevant poorer patient-reported outcomes 12 months after surgery. The ICHAW is a promising tool to evaluate systematically and compare complications in hand surgery, although we recommend further evaluation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV

Are Patient Expectations and Illness Perception Associated with Patient-reported Outcomes from Surgical Decompression in de Quervain's Tenosynovitis?

BACKGROUND: Psychological factors such as depression, pain catastrophizing, kinesiophobia, pain anxiety, and more negative illness perceptions are associated with worse pain and function in patients at the start of treatment for de Quervain's tenosynovitis. Longitudinal studies have found symptoms of depression and pain catastrophizing at baseline were associated with worse pain after treatment. It is important to study patients opting for surgery for their condition because patients should choose surgical treatment based on their values rather than misconceptions. Psychological factors associated with worse patient-reported outcomes from surgery for de Quervain's tenosynovitis should be identified and addressed preoperatively so surgeons can correct any misunderstandings about the condition. QUESTION/PURPOSE: What preoperative psychosocial factors (depression, anxiety, pain catastrophizing, illness perception, and patient expectations) are associated with pain and function 3 months after surgical treatment of de Quervain's tenosynovitis after controlling for demographic characteristics? METHODS: This was a prospective cohort study of 164 patients who underwent surgery for de Quervain's tenosynovitis between September 2017 and October 2018 performed by 20 hand surgeons at 18 centers. Our database included 326 patients who underwent surgery for de Quervain's tenosynovitis during the study period. Of these, 62% (201 of 326) completed all baseline questionnaires and 50% (164 of 326) also completed patient-reported outcomes at 3 months postoperatively. We found no difference between those included and those not analyzed in terms of age, sex, duration of symptoms, smoking status, and workload. The mean ± SD age of the patients was 52 ± 14 years, 86% (141 of 164) were women, and the mean duration of symptoms was 13 ± 19 months. Patients completed the Patient-Rated Wrist Evaluation (PRWE), the VAS for pain and function, the Patient Health Questionnaire for symptoms of anxiety and depression, the Pain Catastrophizing Scale, the Credibility/Expectations Questionnaire, and the Brief Illness Perceptions questionnaire at baseline. Patients also completed the PRWE and VAS for pain and function at 3 months postoperatively. We used a hierarchical multivariable linear regression model to investigate the relative contribution of patient demographics and psychosocial factors to the pain and functional outcome at 3 months postoperatively. RESULTS: After adjusting for demographic characteristics, psychosocial factors, and baseline PRWE score, we found that only the patient's expectations of treatment and how long their illness would last were associated with the total PRWE score at 3 months postoperatively. More positive patient expectations of treatment were associated with better patient-reported pain and function at 3 months postoperatively (ß = -2.0; p < 0.01), while more negative patient perceptions of how long their condition would last were associated with worse patient-reported pain and function (timeline ß = 2.7; p < 0.01). The final model accounted for 31% of the variance in the patient-reported outcome at 3 months postoperatively. CONCLUSION: Patient expectations and illness perceptions are associated with patient-reported pain and functional outcomes after surgical decompression for de Quervain's tenosynovitis. Addressing misconceptions about de Quervain's tenosynovitis in terms of the consequences for patients and how long their symptoms will last should allow patients to make informed decisions about the treatment that best matches their values. Prospective studies are needed to investigate whether addressing patient expectations and illness perceptions, with decision aids for example, can improve patient-reported pain and function postoperatively in those patients who still choose surgery for de Quervain's tenosynovitis. LEVEL OF EVIDENCE: Level III, therapeutic study