Complications after hand surgery in patients with a raised International Normalized Ratio.

A multicentre database was used to compare complications in 231 patients with an elevated International Normalized Ratio with 1626 control patients with a normal International Normalized Ratio. Patients with International Normalized Ratios measured within 48 hours of hand surgery were identified. Logistic regression models were used to assess the association between anticoagulation and reoperation rates, emergency department visits and hospital readmissions for the first 30 days after operation. The group with a raised International Normalized Ratio had a significantly higher Charlson Comorbidity Score. An elevated International Normalized Ratio was associated with an odds ratio for a post-operative emergency department visit of 3.3 and an odds ratio of 4.7 for readmission. There was no statistically significant difference in early reoperations between the two groups. LEVEL OF EVIDENCE: III.

The quality of randomised controlled trials involving surgery from the hand to the elbow: a critical analysis of the literature.

AIMS: Our purpose was to determine the quality of current randomised controlled trials (RCTs) in hand surgery using standardised metrics. MATERIALS AND METHODS: Based on five-year mean impact factors, we selected the six journals that routinely publish studies of upper extremity surgery. Using a journal-specific search query, 62 RCTs met our inclusion criteria. Then three blinded reviewers used the Jadad and revised Coleman Methodology Score (RCMS) to assess the quality of the manuscripts. RESULTS: Based on the Jadad scale, 28 studies were of high quality and 34 were of low quality. Methodological deficiencies in poorly scoring trials included the absence of rate of enrolment, no power analysis, no description of withdrawal or dropout, and a failure to use validated outcomes assessments with an independent investigator. CONCLUSION: A large number of RCTs in hand, wrist, and elbow surgery were of suboptimal quality when judged against the RCMS and Jadad scales. Even with a high level of evidence, study design and execution of RCTs should be critically assessed. Methodological deficiencies may introduce bias and lead to statistically underpowered studies. Cite this article: Bone Joint J 2017;99-B:94-9.

A knotless bidirectional-barbed tendon repair is inferior to conventional 4-strand repairs in cyclic loading.

UNLABELLED: We divided 21 flexor digitorum profundus tendons in the index, middle and ring fingers in seven cadaver hands into three groups. The tendons were cut in zone 2 and repaired using a 4-strand cruciate core suture repair with one of the following three materials in each group: (1) a knotless repair with a 2-0 bidirectional-barbed suture, which has similar tensile strength as a 4-0 non-barbed suture used in the other two groups; (2) a knotted locking repair with a non-barbed 4-0 conventional suture; and (3) a non-locking repair with a non-barbed 4-0 knotless suture. The repaired fingers were cyclically loaded through a simulated active range of motion to a 5 N load. We monitored and recorded the gap sizes at regular intervals during the test. The 2-0 bidirectional-barbed suture group and non-barbed suture groups developed gaps of 2.2 mm after 10 cycles and 2.4 mm after 20 cycles, respectively. Over 1000 cycles, the mean gaps were 3.2 mm in the 4-0 conventional suture group and 9.1 mm in the 2-0 bidirectional-barbed group. The tendons in the 2-0 bidirectional-barbed group gapped earlier, with statistically significant differences compared with those in the locking repair with a non-barbed 4-0 knotless suture group. The repair strength of the barbed suture technique was inferior to the cruciate repairs using a conventional 4-0 non-barbed suture tested in this cyclic-loading model. LEVEL OF EVIDENCE: Level V.

Evaluation of pisotriquetral motion pattern using four-dimensional CT: initial clinical experience in asymptomatic wrists.

AIM: To characterise the normal motion pattern of the pisotriquetral (PT) joint during wrist extension and flexion, as well as observer performance of measurements using four-dimensional (4D)-computed tomography (CT) acquisitions and double-oblique multiplanar reconstruction (MPR) technique in asymptomatic contralateral joints of patients with unilateral wrist pain. MATERIALS AND METHODS: In this Health Insurance Portability and Accountability Act (HIPAA)-compliant institutional review board-approved study, 4D-CT was performed on the asymptomatic contralateral wrists of 10 patients (mean age: 46 years; M/F: 6/4) for comparison to the symptomatic side. Two independent observers defined the "oblique-sagittal" plane for PT joint measurements. Measurements were obtained for the anteroposterior (AP) interval and craniocaudal (CC) excursion during the extension-flexion arc of wrist motion. RESULTS: The median (interquartile range) of the AP interval was 0.65 mm (0.55-1 mm) in extension, 1.1 mm (0.8-1.82 mm) in the neutral position, and 4.65 mm (2.07-5.87 mm) in flexion. Likewise, the median of the CC excursions in asymptomatic wrists were 0 mm in extension, 0.27 mm (0-0.37 mm) in the neutral position, and 0.28 mm (0.18-0.31 mm) in flexion. The AP interval measurements obtained at wrist flexion were larger than measurements obtained at wrist extension. There was a strong consistency in AP interval difference measurements between the two observers (ICC=0.80; p<0.01); however, CC excursion difference measurements did not reach the significance threshold between the two observers (ICC=0.40; p=0.11). CONCLUSION: PT joint kinematics in asymptomatic wrists demonstrates an increase in AP interval and CC excursion during wrist flexion. MPR techniques provide good interobserver agreements for AP interval measurements. The reported intervals for asymptomatic joints can be used as a reference for asymptomatic wrists.

Comparison of digital nerve sensory recovery after repair using loupe or operating microscope magnification.

UNLABELLED: Our purpose was to determine whether there was a significant difference in sensory recovery after digital nerve repair using loupe magnification or an operating microscope. We identified patients aged 21-75 who had primary proper digital nerve repairs at least 24 months before our study. A total of 12 patients with 13 digital nerve injuries repaired with loupe magnification and nine patients with 12 digital nerve injuries repaired using the operating microscope, agreed to return for assessment by a therapist blinded to treatment. We found no significant difference in sensory recovery between the two groups as measured by static two-point discrimination, moving two-point discrimination, and Semmes-Weinstein monofilament. There were also no significant differences in average Disabilities of the Arm Shoulder and Hand or visual analogue pain scores. LEVEL OF EVIDENCE: IV.

Long-term outcomes following single-portal endoscopic carpal tunnel release.

BACKGROUND: There is limited published information about long-term outcomes and recurrence rates following single-portal endoscopic carpal tunnel release. METHODS: We reviewed symptom and function outcomes from a prospectively collected database of patients who underwent single-portal endoscopic carpal tunnel release at a minimum of 8 years follow-up. Out of 207 patients in the original database, we were able to confirm correct current contact information for 106 patients. Of these, 91 patients with 115 single-portal endoscopic carpal tunnel releases agreed to participate. All of these patients were eligible for this long-term follow-up study based on documented preoperative and 6-month postoperative Levine-Katz questionnaire scores. Patients then completed a current update of the Levine-Katz questionnaires to assess function and symptom outcomes at latest follow-up. RESULTS: The average 6-month postoperative scores were significantly lower compared with the average preoperative scores and were maintained at long-term follow-up. There were no significant differences in average change in scores at long-term follow-up compared to 6-months postoperative. CONCLUSIONS: Single-portal endoscopic carpal tunnel release is an effective surgical treatment for carpal tunnel syndrome. Low recurrence rates and maintenance of low symptom and function scores can be expected at 8 to 10 years following this technique.

Carpal tunnel volume changes of the wrist under distraction.

This study attempts to determine changes in carpal canal volume with distraction across the wrist. Uniform longitudinal distraction was maintained with two external fixators on the radial and ulnar aspects of the forearm axis of five cadaver specimens. After CT scanning, volume determinations were made at 5 mm increments beginning at the lunocapitate joint to a point 1.5 cm distal to the middle finger carpometacarpal joint. There was a statistically significant decrease of the mean total carpal canal volume from 0 to 4.54 kg of distraction, with no statistically significant decrease from 0 to 2.27 kg or 2.27 to 4.54 kg. The largest decrease occurred at 15 and 20 mm distal to the proximal edge of the transverse carpal ligament corresponding to the level of the hamate hook. Reduction in mean carpal canal volume was 10.2% and 7.5% at these distances, respectively, from 0 to 4.54 kg of distraction. Progressive distraction across the wrist causes a decrease in total carpal canal volume.