Surgical Techniques in Non-Traumatic Midcarpal Instability: Evaluating the Dorsal Capsulodesis and Three-Ligament Tenodesis Technique.

BACKGROUND: Surgical management of midcarpal instability (MCI), also referred to as carpal instability nondissociative, remains controversial due to limited evidence on different techniques. This study aimed to assess and compare differences in patient-reported pain, hand and wrist function, patient satisfaction, range of motion, and return to work in patients with non-traumatic MCI who underwent surgical treatment either through dorsal wrist capsulodesis or three-ligament tenodesis (3LT). METHODS: Patients with MCI and persisting complaints after conservative therapy treated with 3LT or dorsal capsulodesis were included. Patients with posttraumatic instability were excluded. Primary endpoints included the Patient Rated Wrist Evaluation (PRWE) and Satisfaction with Treatment Result Questionnaire at 12 months postoperative. All data were retrospectively analyzed. RESULTS: A total of 91 patients treated with dorsal capsulodesis and 21 treated with 3LT between December 2011 and December 2019 were included. At twelve months postoperative, both treatment groups reported significant improvements in pain and function scores. However, at three months postoperative, the dorsal capsulodesis group exhibited significantly better outcomes, followed by a greater return to work (72%) compared to the 3LT group (50%). However, the capsulodesis group demonstrated a decreased range of motion at three months which was restored at 12 months postoperative. No significant difference in satisfaction with treatment was observed. CONCLUSIONS: Both 3LT and dorsal capsulodesis demonstrate promising results for addressing non-traumatic MCI. However, considering the quicker recovery and faster return to work associated with dorsal capsulodesis, we recommend favoring capsulodesis over 3LT when both surgical options are deemed suitable for the patient. LEVEL OF EVIDENCE: III.

Recurrence rate and patient-reported outcomes after wedge excision of carpal boss.

The treatment of carpal boss is primarily conservative. Surgical treatment by performing a wedge excision of the bony protrusion, is possible. However, a common belief exists that carpal boss should not be operated because of the high recurrence rate. Additionally, little is known about the clinical outcomes of wedge excision and the preferred post-operative treatment. Patients with carpal boss and persisting pain who underwent wedge excision after conservative treatment were included. They received questionnaires before and three months after surgery. The primary outcomes were pain and hand function measured using patient-reported wrist evaluations (PRWE). Secondarily, recurrence, patient satisfaction and time until return to work were evaluated. These clinical outcomes were also compared between patients who received a plaster splint or a pressure dressing post-operatively. 76 patients were included. Three months after surgery, a significant improvement in PRWE was seen, for both pain and function. A re-operation rate for recurrent carpal boss of 13% was observed. After three months, 58% of patients were satisfied and 73% had returned to work. While no differences in clinical outcomes were found, patients were more satisfied after receiving a pressure dressing than a plaster splint post-operatively. The current study demonstrates encouraging early outcomes after wedge excision, and a low recurrence re-operation rate. Furthermore, a pressure dressing seems preferable post-operatively compared to a plaster splint.

Educating Future Generations of Surgeons across Borders: Novel Global Linked Hybrid Live Cadaveric Peripheral Nerve Surgical Training Course.

Background: This study aimed to evaluate a novel, multi-site, technology-facilitated education and training course in peripheral nerve surgery. The program was developed to address the training gaps in this specialized field by integrating a structured curriculum, high-fidelity cadaveric dissection, and surgical simulation with real-time expert guidance. Methods: A collaboration between the Global Nerve Foundation and Esser Masterclass facilitated the program, which was conducted across three international sites. The curriculum was developed by a panel of experienced peripheral nerve surgeons and included both text-based and multimedia resources. Participants' knowledge and skills were assessed using pre- and postcourse questionnaires. Results: A total of 73 participants from 26 countries enrolled and consented for data usage for research purposes. The professional background was diverse, including hand surgeons, plastic surgeons, orthopedic surgeons, and neurosurgeons. Participants reported significant improvements in knowledge and skills across all covered topics (p < 0.001). The course received a 100% recommendation rate, and 88% confirmed that it met their educational objectives. Conclusions: This study underscores the potential of technology-enabled, collaborative expert-led training programs in overcoming geographical and logistical barriers, setting a new standard for globally accessible, high-quality surgical training. It highlights the practical and logistical challenges of multi-site training, such as time zone differences and participant fatigue. It also provides practical insights for future medical educational endeavors, particularly those that aim to be comprehensive, international, and technologically facilitated.

Reconstruction of an early stage SLAC wrist with the 3-LT procedure: A controversial reappraisal.

OBJECTIVE: We hypothesized that the three-ligament tenodesis (3-LT) procedure is still sufficient - even in scapholunate advanced collapse (SLAC) cases - to reduce pain and improve wrist function. We compared patient-reported outcomes of scapholunate interosseus ligament (SLIL) injury patients with SLAC to SLIL injury patients treated with 3-LT, and then to patients who received proximal row carpectomy (PRC), as a control group. METHOD: We included all patients with a traumatic SLIL injury and associated SLAC components treated with 3-LT and completed Patient Reported Wrist Evaluation (PRWE) questionnaires preoperative and at 12 months follow-up. First, we compared matched patients with SLIL injury and SLIL injury with SLAC, stage 1-3, who received 3-LT. Second, we compared patients who received 3-LT, with patients who underwent PRC, while having SLAC stage 2-3. RESULTS: We compared 51 patients with SLAC to 95 with SLIL injury who had a 3-LT procedure, and 10 3-LT patients were compared to 18 patients undergoing PRC, given SLAC 2-3. In both analyses, the PRWE scores had significantly improved in all groups, however no significant differences in PRWE were found between 3-LT in SLIL injury and SLIL injury with SLAC, 6.9 points (95% CI [-14.92; 1.22], p = 0.096) and between 3-LT and PRC, given SLAC stage 2-3, 15.1 points (not enough power). CONCLUSION: There is no difference in PRWE between matched SLIL injury patients with or without degenerative changes treated with a 3-LT. Therefore, the 3-LT procedure seems to be a viable treatment option for patients with early-stage SLAC wrist. LEVEL OF EVIDENCE: Therapeutic III.

The effectiveness of acellular nerve allografts compared to autografts in animal models: A systematic review and meta-analysis.

BACKGROUND: Treatment of nerve injuries proves to be a worldwide clinical challenge. Acellular nerve allografts are suggested to be a promising alternative for bridging a nerve gap to the current gold standard, an autologous nerve graft. OBJECTIVE: To systematically review the efficacy of the acellular nerve allograft, its difference from the gold standard (the nerve autograft) and to discuss its possible indications. MATERIAL AND METHODS: PubMed, Embase and Web of Science were systematically searched until the 4th of January 2022. Original peer reviewed paper that presented 1) distinctive data; 2) a clear comparison between not immunologically processed acellular allografts and autologous nerve transfers; 3) was performed in laboratory animals of all species and sex. Meta analyses and subgroup analyses (for graft length and species) were conducted for muscle weight, sciatic function index, ankle angle, nerve conduction velocity, axon count diameter, tetanic contraction and amplitude using a Random effects model. Subgroup analyses were conducted on graft length and species. RESULTS: Fifty articles were included in this review and all were included in the meta-analyses. An acellular allograft resulted in a significantly lower muscle weight, sciatic function index, ankle angle, nerve conduction velocity, axon count and smaller diameter, tetanic contraction compared to an autologous nerve graft. No difference was found in amplitude between acellular allografts and autologous nerve transfers. Post hoc subgroup analyses of graft length showed a significant reduced muscle weight in long grafts versus small and medium length grafts. All included studies showed a large variance in methodological design. CONCLUSION: Our review shows that the included studies, investigating the use of acellular allografts, showed a large variance in methodological design and are as a consequence difficult to compare. Nevertheless, our results indicate that treating a nerve gap with an allograft results in an inferior nerve recovery compared to an autograft in seven out of eight outcomes assessed in experimental animals. In addition, based on our preliminary post hoc subgroup analyses we suggest that when an allograft is being used an allograft in short and medium (0-1cm, > 1-2cm) nerve gaps is preferred over an allograft in long (> 2cm) nerve gaps.

Anatomy of the Superficial Radial Nerve and Its Target Nerves for Targeted Muscle Reinnervation: An Anatomical Cadaver Study.

BACKGROUND: Targeted muscle reinnervation (TMR) is a surgical procedure for treating symptomatic neuroma, in which the neuroma is removed and the proximal nerve stump is coapted to a donor motor branch innervating a nearby muscle. This study aimed to identify optimal motor targets for TMR of the superficial radial nerve (SRN). METHODS: Seven cadaveric upper limbs were dissected to describe the course of the SRN in the forearm and motor nerve supply-number, length, diameter, and entry points in muscle of motor branches-for potential recipient muscles. RESULTS: The radial nerve provided three (three of six) motor branches, two (two of six) motor branches, or one (one of six) motor branch to the brachioradialis muscle, entering the muscle 21.7 ± 17.9 to 10.8 ± 15 mm proximal to the lateral epicondyle. One (one of seven), two (three of seven), three (two of seven), or four (one of seven) motor branches innervated the extensor carpi radialis longus muscle, with entry points 13.9 ± 16.2 to 26.3 ± 14.9 mm distal from the lateral epicondyle. In all specimens, the posterior interosseous nerve gave off one motor branch to the extensor carpi radialis brevis, which divided into two or three secondary branches. The distal anterior interosseus nerve was assessed as a potential recipient for TMR coaptation and had a freely transferable length of 56.4 ± 12.7 mm. CONCLUSIONS: When considering TMR for neuromas of the SRN in the distal third of the forearm and hand, the distal anterior interosseus nerve is a suitable donor target. For neuromas of the SRN in the proximal two-thirds of the forearm, the motor branches to the extensor carpi radialis longus, extensor carpi radialis brevis, and brachioradialis are potential donor targets.

Phantom Limb Pain and Painful Neuroma After Dysvascular Lower-Extremity Amputation: A Systematic Review and Meta-Analysis.

BACKGROUND: Phantom limb pain (PLP) and symptomatic neuroma can be debilitating and significantly impact the quality of life of amputees. However, the prevalence of PLP and symptomatic neuromas in patients following dysvascular lower limb amputation (LLA) has not been reliably established. This systematic review and meta-analysis evaluates the prevalence and incidence of phantom limb pain and symptomatic neuroma after dysvascular LLA. METHODS: Four databases (Embase, MEDLINE, Cochrane Central, and Web of Science) were searched on October 5th, 2022. Prospective or retrospective observational cohort studies or cross-sectional studies reporting either the prevalence or incidence of phantom limb pain and/or symptomatic neuroma following dysvascular LLA were identified. Two reviewers independently conducted the screening, data extraction, and the risk of bias assessment according to the PRISMA guidelines. To estimate the prevalence of phantom limb pain, a meta-analysis using a random effects model was performed. RESULTS: Twelve articles were included in the quantitative analysis, including 1924 amputees. A meta-analysis demonstrated that 69% of patients after dysvascular LLA experience phantom limb pain (95% CI 53-86%). The reported pain intensity on a scale from 0-10 in LLA patients ranged between 2.3 ± 1.4 and 5.5 ± .7. A single study reported an incidence of symptomatic neuroma following dysvascular LLA of 5%. CONCLUSIONS: This meta-analysis demonstrates the high prevalence of phantom limb pain after dysvascular LLA. Given the often prolonged and disabling nature of neuropathic pain and the difficulties managing it, more consideration needs to be given to strategies to prevent it at the time of amputation.

Preoperative indicators of the effectiveness of surgical release in de Quervain patients: a prospective cohort study.

BACKGROUND: A significant proportion of patients still report pain following a surgical release for de Quervain disease (DQ). This study aimed to investigate the effectiveness of a surgical release for DQ and to identify the preoperative factors associated with pain after a surgical release for DQ. METHODS: This prospective cohort study includes 707 patients who underwent a surgical release and completed the Visual Analog Scale Questionnaire (VAS, range 0-100). We used a paired t-test to analyse the effectiveness of the surgical release on pain at three months post-operatively compared to the pre-operatively measured outcome. A hierarchical multivariable linear regression model was created to investigate the contribution of the patient- and disease characteristics to post-operative pain. RESULTS: All VAS domains showed improvement after surgical release. On average, the mean VAS pain decreased by 44 points (95% CI 42; 46). Smoking (B=6.37; p<0.01), younger age (B=-0.35; p<0.01), longer duration of complaints (B=0.13; p<0.01), concomitant surgery (B=14.40; p<0.01) and higher VAS pain scores at intake (B=0.15; p<0.01) were associated with worse VAS pain scores post-operatively. Together, the variables explained 11% of the variance in mean VAS pain score at three months of follow-up. CONCLUSION: This study confirms that surgical treatment for patients with DQ significantly reduces patient-reported pain. Smoking, younger age, concomitant surgery, duration of complaints, and higher VAS pain scores at intake are associated with worse patient-reported pain three months after surgical release. However, the small effects suggest that these factors should not be considered the only important factors. LEVEL OF EVIDENCE: Therapeutic, II.

Treatment Delay in Patients Undergoing Headache Surgery (Nerve Decompression Surgery).

Background: Although headache surgery has been shown to be an effective treatment option for refractory headache disorders, it has not been included as part of the headache disorder management algorithm by non-surgical providers. This study aims to evaluate the delay in surgical management of patients with headache disorders. In addition, a cost comparison analysis between conservative and operative treatment of headache disorders was performed, and the surgical outcomes of headache surgery were reported. Methods: Among 1112 patients who were screened, 271 (56%) patients underwent headache surgery. Data regarding the onset of headache disorder and pre- and postoperative pain characteristics were prospectively collected. To perform a cost comparison analysis, direct and indirect costs associated with the conservative treatment of headache disorders were calculated. Results: The median duration between onset of headache disorder symptoms and headache surgery was 20 (8.2-32) years. The annual mean cost of conservative treatment of headache disorders was $49,463.78 ($30,933.87-$66,553.70) per patient. Over the 20-year time period before surgery, the mean cost was $989,275.65 ($618,677.31-$1,331,073.99). In comparison, the mean cost of headache surgery was $11,000. The median pain days per month decreased by 16 (0-25) (p<0.001), the median pain intensity reduced by 4 (2-7) (p<0.001), and the median pain duration decreased by 11 hours (0-22) (p<0.001). Conclusion: This study shows that patients experience symptoms of headache disorders for an average of 20 years prior to undergoing headache surgery. Surgical treatment not only significantly improves headache pain but also reduces healthcare costs and should be implemented in the management algorithm of headache disorders.

Feasibility of Ultrasound Measurements of Peripheral Sensory Nerves in Head and Neck Area in Healthy Subjects.

Background: Current diagnostic methods for nerve compression headaches consist of diagnostic nerve blocks. A less-invasive method that can possibly aid in the diagnosis is ultrasound, by measuring the cross-sectional area (CSA) of the affected nerve. However, this technique has not been validated, and articles evaluating CSA measurements in the asymptomatic population are missing in the current literature. Therefore, the aim of this study was to determine the feasibility of ultrasound measurements of peripheral extracranial nerves in the head and neck area in asymptomatic individuals. Methods: The sensory nerves of the head and neck in healthy individuals were imaged by ultrasound. The CSA was measured at anatomical determined measurement sites for each nerve. To determine the feasibility of ultrasound measurements, the interrater reliability and the intrarater reliability were determined. Results: In total, 60 healthy volunteers were included. We were able to image the nerves at nine of 11 measurement sites. The mean CSA of the frontal nerves ranged between 0.80 ± 0.42 mm2 and 1.20 ± 0.43 mm2, the mean CSA of the occipital nerves ranged between 2.90 ± 2.73 mm2 and 3.40 ± 1.91 mm2, and the mean CSA of the temporal nerves ranged between 0.92 ± 0.26 mm2 and 1.40 ± 1.11 mm2. The intrarater and interrater reliability of the CSA measurements was good (ICC: 0.75-0.78). Conclusions: Ultrasound is a feasible method to evaluate CSA measurements of peripheral extracranial nerves in the head and neck area. Further research should be done to evaluate the use of ultrasound as a diagnostic tool for nerve compression headache.

Patient-Reported Outcomes and Function After Surgical Repair of the Ulnar Collateral Ligament of the Thumb.

PURPOSE: The purpose of this study was to report prospectively collected patient-reported outcomes of patients who underwent open thumb ulnar collateral ligament (UCL) repair and to find risk factors associated with poor patient-reported outcomes. METHODS: Patients undergoing open surgical repair for a complete thumb UCL rupture were included between December 2011 and February 2021. Michigan Hand Outcomes Questionnaire (MHQ) total scores at baseline were compared to MHQ total scores at three and 12 months after surgery. Associations between the 12-month MHQ total score and several variables (i.e., sex, injury to surgery time, K-wire immobilization) were analyzed. RESULTS: Seventy-six patients were included. From baseline to three and 12 months after surgery, patients improved significantly with a mean MHQ total score of 65 (standard deviation [SD] 15) to 78 (SD 14) and 87 (SD 12), respectively. We did not find any differences in outcomes between patients who underwent surgery in the acute (<3 weeks) setting compared to a delayed setting (<6 months). CONCLUSIONS: We found that patient-reported outcomes improve significantly at three and 12 months after open surgical repair of the thumb UCL compared to baseline. We did not find an association between injury to surgery time and lower MHQ total scores. This suggests that acute repair for full-thickness UCL tears might not always be necessary. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

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.

Multiple Compression Syndromes of the Same Upper Extremity: Prevalence, Risk Factors, and Treatment Outcomes of Concomitant Treatment.

PURPOSE: Multiple nerve compression syndromes can co-occur. Little is known about this coexistence, especially about risk factors and surgical outcomes. Therefore, this study aimed to describe the prevalence of multiple nerve compression syndromes in the same arm in a surgical cohort and determine risk factors. Additionally, the surgical outcomes of concomitant treatment were studied. METHODS: The prevalence of surgically treated multiple nerve compression syndromes within one year was assessed using a review of patients' electronic records. Patient characteristics, comorbidities, and baseline scores of the Boston Carpal Tunnel Questionnaire were considered as risk factors. To determine the treatment outcomes of simultaneous treatment, patients who underwent concomitant carpal tunnel release (CTR) and cubital tunnel release (CubTR) were selected. The treatment outcomes were Boston Carpal Tunnel Questionnaire scores at intake and at 3 and 6 months after the surgery, satisfaction 6 months after the surgery, and return to work within the first year. RESULTS: A total of 7,867 patients underwent at least one nerve decompression between 2011 and 2021. Of these patients, 2.9% underwent multiple decompressions for the same upper extremity within one year. The risk factors for this were severe symptoms, younger age, and smoking. Furthermore, the treatment outcomes of concomitant CTR and CubTR did not differ from those of CubTR alone. The median time to return to work after concomitant treatment was 6 weeks. Patients who underwent CTR or CubTR alone returned to work after 4 weeks. CONCLUSIONS: Approximately 3% of the patients who underwent surgical treatment for nerve compression syndrome underwent decompression for another nerve within 1 year. Patients who report severe symptoms at intake, are younger, or smoke are at a greater risk. Patients with carpal and cubital tunnel syndrome may benefit from simultaneous decompression. The time to return to work may be less than if they underwent decompressions in separate procedures, whereas their surgical outcomes are comparable with those of CubTR alone. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

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.

Arthroscopic versus Open Distal Hemitrapeziectomy without Interposition: 2-Year Results of a Randomized Controlled Trial.

BACKGROUND: Distal hemitrapeziectomy is suggested as an alternative for total trapeziectomy for carpometacarpal thumb joint osteoarthritis, when the scaphotrapeziotrapezoidal joint is unaffected. This can be performed as an arthroscopic or open procedure, with suggested advantages for the less invasive arthroscopic technique. To determine which technique has better outcome on subjective and objective measures, the authors performed a prospective, randomized, controlled trial. METHODS: The authors randomized 90 thumbs in the open ( n = 45) and arthroscopic ( n = 45) groups and evaluated results preoperatively and at 3-, 12- and 24-month follow-up. The primary outcome was the Patient-Rated Wrist and Hand Evaluation (PRWHE) to assess pain and function. Also, the authors evaluated pinch, grip, and range of motion, together with return to work, satisfaction, and complications. RESULTS: Full follow-up was obtained in 62 thumbs (open group, n = 32; arthroscopic group, n = 30). For both groups, the PRWHE improved from preoperatively to 12- and 24-month follow-up. Also, grip power, key pinch, and tip pinch improved at final follow-up for both groups. Between groups, there were no clinically important differences between PRWHE, power of grip or pinch, and range of motion. Operation time was shorter for the open group; also, return to work was slightly shorter after open surgery. Satisfaction was comparable between groups. CONCLUSIONS: This study shows good functional improvement and pain reduction obtained with a hemitrapeziectomy. No arthroscopic benefits could be substantiated in the results. Because of shorter operation time for the open procedure, and because of equal outcomes compared to the arthroscopic technique, we prefer open hemitrapeziectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Neuropathic Donor-Site Pain following Radial Forearm Free Flap Harvest: A Multicenter Study on Incidence, Prognostic Factors, and Quality of Life.

BACKGROUND: The radial forearm free flap (RFFF) is widely used and is considered one of the workhorse flaps in oncologic head and neck reconstructions. However, the potential for significant donor-site morbidity remains a major drawback. Although various donor-site problems have been reported, the incidence of neuropathic pain and possible predicting factors remain unclear. This study aimed to identify the incidence, prognostic factors, and impact on quality of life of neuropathic pain following RFFF harvest. METHODS: In this multicenter, cross-sectional study, 167 patients who underwent an RFFF reconstruction between 2010 and 2020 were included. Baseline characteristics were collected by medical charts. All patients received questionnaires to measure patient's pain (Doleur Neuropathique 4 and visual analog scale, pain), hand function (Patient-Reported Wrist and Hand Evaluation), and quality of life (EuroQol 5D). Multiple logistic regression was used to identify prognostic factors associated with outcomes. RESULTS: A total of 114 patients (68%) completed the questionnaire. Neuropathic pain was present in 18% of all patients. Donor-site wound problems, mostly tendon exposure, occurred in 32% and was significantly correlated with neuropathic pain (p = 0.003). Neuropathic pain was significantly associated with poorer quality of life (p < 0.001) and poorer hand function (p < 0.001). CONCLUSION: Almost one-fifth of all patients deal with neuropathic pain following RFFF harvest. Neuropathic pain is significantly correlated with poorer hand function and a poorer quality of life. Therefore, future research should focus on analyzing surgical factors such as the management of wound problems and primary denervation to improve hand function and quality of life of these patients.

Comparing Patient-Reported Outcomes on Three-Ligament Tenodesis between Partial and Complete Scapholunate Ligament Injuries: A Cohort Study.

PURPOSE: Multiple studies report outcomes after 3-ligament tenodesis (3-LT) in treating traumatic scapholunate interosseous ligament injury (SLIL). However, investigators do not differentiate between patients with partial or complete SLIL injury. The relation between the extent of SLIL disruption and surgical outcomes and if this should be considered when treating a patient with SLIL injury remains unknown. We aimed to evaluate differences in patient-rated wrist evaluation (PRWE) scores, satisfaction and return to work between patients with partial or complete chronic traumatic SLIL injury treated with 3 ligament tenodesis at 12 months after surgery. METHODS: All patients with chronic SLIL injury (partial and complete) who were treated with 3-LT at our clinic and received the same postoperative management between December 2011 and December 2019 were studied. Only patients who had completed the PRWE and return to work questionnaires preoperatively and 12 months after surgery were included. Patients were allocated to the partial (classified as Geissler 2 or 3) or complete SLIL injury group (classified as Geissler 4) by retrospectively assessing wrist arthroscopy reports. RESULTS: Thirty-nine patients with partial and 90 with complete SLIL injuries were included. At 1-year follow-up, PRWE scores had significantly improved in both groups. When adjusting for clinical baseline characteristics, there was no statistically significant difference between patients with partial or complete SLIL injury. Patients with complete SLIL injury had a 70% higher return to work within the first 12 months after 3-LT; however, satisfaction with the treatment result was similar for both study groups 1 year after surgery. CONCLUSIONS: Patients with complete and partial traumatic SLIL injury report better PRWE total scores at 12 months after 3-LT, but there was no statistically significant difference between the groups in PRWE scores or satisfaction with the treatment result. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Routinely-Collected Outcomes of Proximal Row Carpectomy.

PURPOSE: To describe patient-reported pain and function 12 months after proximal row carpectomy (PRC). Secondary outcomes included return to work, grip strength, range of wrist motion, satisfaction with treatment results, and complications. METHODS: This cohort study was part of the British Society for Surgery of the Hand Studyathon 2021, using ongoing routinely-collected data of 304 eligible patients who underwent PRC (73% scapholunate advanced collapse, 11% scaphoid nonunion advanced collapse wrist; 11% Kienböck, 5% other indications) from Xpert Clinics, the Netherlands between 2012-2020. The primary outcome was the Patient Rated Wrist/Hand Evaluation total score (range, 0-100, lower scores indicate better performance). RESULTS: Of the 304 patients, the primary outcome was available in 217 patients. The total Patient Rated Wrist/Hand Evaluation score improved from 60 (95% confidence interval [CI], 57-63) to 38 (95% CI, 35-41) at 3 months, and 26 (95% CI, 23-29) at 12 months. The pain and function subscales improved by 18 (95% CI, 17-20) and 16 (95% CI, 14-18) points, respectively. At 12 months, 82% had returned to work at a median time of 12 (95% CI, 9-14) weeks following PRC. Grip strength did not improve. Wrist flexion and extension demonstrated a clinically irrelevant decrease. Satisfaction with treatment result was excellent in 27% of patients, good in 42%, fair in 20%, moderate in 6%, and poor in 5%. Complications occurred in 11% of patients, and conversion to wrist arthroplasty occurred in 2 patients. CONCLUSION: A clinically relevant improvement in patient-reported pain and function was observed at 3 months after PRC, with continued improvement to 12 months. These data can be used for shared-decision making and expectation management. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Complications and Functional Outcomes following Trigger Finger Release: A Cohort Study of 1879 Patients.

BACKGROUND: Although trigger finger release is considered a safe procedure, large cohort studies reporting consistent complication rates and functional outcomes are scarce. Further insight into outcomes of this commonly performed procedure is essential for adequate treatment evaluation and patient counseling. Therefore, the aim of this study was to assess the complication rates and functional outcomes following trigger finger release. METHODS: This is an observational multicenter cohort study of patients undergoing trigger finger release. The primary outcome included the occurrence of complications. The secondary outcome was change in hand function (Michigan Hand outcomes Questionnaire) from baseline to 3 months postoperatively. RESULTS: Complications were observed in 17.1 percent of 1879 patients. Most complications were minor, requiring hand therapy or analgesics (7.0 percent of all patients), antibiotics, or steroid injections (7.8 percent). However, 2.1 percent required surgical treatment and 0.2 percent developed complex regional pain syndrome. The Michigan Hand Outcomes Questionnaire total score improved from baseline to 3 months postoperatively with 12.7 points, although the authors found considerable variation in outcomes with less improvement in patients with better baseline scores. CONCLUSIONS: This study demonstrates that trigger finger release results in improved hand function, although complications occur in 17 percent. Most complications are minor and can be treated with nonsurgical therapy, resulting in improved hand function as well. However, additional surgical treatment is required in 2 percent of patients. In addition, the authors found that change in hand function depends on the baseline score, with less improvement in patients with better baseline scores. Future studies should investigate factors that contribute to the variability in treatment outcomes following trigger finger release. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.