Purpose Preoperative management of biological disease modifying antirheumatic drugs (bDMARDs) in patients with rheumatoid arthritis (RA) undergoing hand surgery is a subject of ongoing debate. While consensus supports continuation of corticosteroids and conventional synthetic DMARDs, no definitive guidelines exist for bDMARDs. This study aimed to characterize the degree of perioperative medication management variability among patients with RA undergoing hand surgery and to examine whether continuation of bDMARD therapy is associated with an increased risk of postoperative surgical site infection. Methods A retrospective chart review was conducted at a single academic institution of patients with RA who underwent hand surgery between June 2015 and May 2020. Perioperative medication continuation rates were calculated for corticosteroids, conventional synthetic DMARDs, and bDMARDs. Results Of 171 patients included, 157 (92%) were on pharmacological therapy at the time of surgery. Continuation rates were 82% for corticosteroids, 73% for conventional synthetic DMARDs, and 70% for bDMARDs. Six patients (3.5%) developed a surgical site infection within 30 days. Conclusions Perioperative bDMARD management in patients with RA undergoing hand surgery is variable and lacks standardization. Prospective, multicenter studies are needed to establish evidence-based guidelines for this population. Study type Retrospective cohort study. Type of study/level of evidence Therapeutic III.
Purpose Accurate classification of brachial plexus birth injury (BPBI) is critical for predicting outcomes and guiding early intervention. In 1987, Narakas introduced the first widely adopted system. Over time, misquotations and reinterpretations have obscured the work, conflating group definitions, exaggerating recovery rates, and misrepresenting prognosis. Methods This manuscript revisits Narakas’ original classification, traces misquotations, and clarifies their impact on management. We aim to provide the original publication as a reliable reference for contemporary care of BPBI. Results Group 1 involves Sunderland grade 1−2 injuries to C5 and/or C6, with 93% achieving full spontaneous recovery. Group 2 includes Sunderland grade 2−3 injuries to C5−6 and grade 1−2 to C7. Groups 1 and 2 present similarly, with slightly weaker elbow extension in group 2. The key differentiator is slower recovery of the upper trunk, not C7 involvement. Only 22% fully recovered. Group 3 involves Sunderland grades 4−5 for C5−C6, grade 3 for C7, and grades 1−2 for C8−T1. Five percent achieved a full recovery, and 15% had a satisfactory outcome. Group 4 involves Sunderland grade 5 injuries to C5−C7 with avulsion of C8. No patients achieved full or good shoulder recovery, 35% had fair elbow recovery, and hand/wrist recovery was poor. Conclusions BPBI is complex, with extensive sequelae if mismanaged. Narakas’ work provides critical guidance for prognosis and treatment. Misquotations have propagated inaccurate expectations and hindered care. Reprinting and disseminating the original classification and associated group outcomes clarifies prognosis, informs clinical decisions, and supports improved care. Our table and commentary provide an accessible reference to optimize BPBI care. Level of evidence IV.
Purpose Use of non-tobacco nicotine products (NTNP), including e-cigarettes, nicotine pouches, and oral nicotine devices, has risen sharply, yet their impact on postoperative outcomes across elective soft tissue hand surgeries remains poorly defined. Although nicotine from combustible tobacco impairs wound healing, whether NTNP exposure confers similar risk is unknown. The purpose of this study was to evaluate the association between preoperative NTNP use and postoperative complication rates following elective soft tissue hand surgery. Methods A retrospective cohort study using the TriNetX Research Network identified adults (≥18 years) undergoing elective soft tissue hand surgery from 2004 to 2024. Patients with non-tobacco-specified nicotine dependence diagnoses documented within 1 year before surgery were compared with patients without any documented nicotine dependence. Propensity score matching (1:1) was performed based on demographics and comorbidities. Postoperative complications at 1, 3, and 6 months included deep, superficial, and unspecified surgical site infection, wound dehiscence, and deep vein thrombosis/pulmonary embolism. Odds ratios with 95 percent confidence intervals were calculated, with P < .05 considered statistically significant. Results After matching, 36,811 patients were included per cohort. NTNP use was associated with significantly increased rates of unspecified surgical site infection, deep vein thrombosis/pulmonary embolism, and wound dehiscence at all assessed postoperative time points. Deep and superficial surgical site infection rates did not differ significantly. Effect sizes were consistent across all intervals. Conclusions NTNP use within 1 year is independently associated with higher risks of wound dehiscence, thromboembolic events, and unspecified postoperative infection after soft tissue hand surgery. These findings suggest that nicotine exposure, regardless of delivery method, adversely affects postoperative healing and should be addressed through preoperative screening and cessation counseling. Type of study/level of evidence Retrospective cohort study III.
Purpose Although many studies have focused on long-term postoperative outcomes for endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR), few have focused on results in the very early postoperative period of days 3–14. This period is particularly important in some cases as a patient’s ability to function well with little pain early after surgery can be critical in regaining function, meeting family responsibilities, and returning to work. We hypothesized that ECTR patients would have improved function and less pain within the very early time postoperative period and return to work earlier compared to OCTR patients. Methods A prospective, multicenter study was performed over 2 years. Three fellowship-trained hand surgeons participated. Postoperative care and activity instructions were standardized for all three participating surgeons for both OCTR and ECTR. Results Patients undergoing carpal tunnel release via both OCTR and ECTR experienced progressive improvement in pain and function with the surgically treated hand, with significantly better outcomes seen in the endoscopic cohort. Decreased pain based on the Numeric Rating Scale and the Patient-Rated Wrist and Hand Evaluation Pain scale were found at postoperative day (POD) 3, 7, and 14 for the ECTR group compared to the OCTR group. Higher Single Assessment Numeric Evaluation and better Patient-Rated Wrist and Hand Evaluation function scores indicating earlier return of function were seen after endoscopic release. Finally, there was a significant difference (P < .5) in the number of patients who returned to work on POD 3 and POD 7 favoring the ECTR approach. Conclusions ECTR is associated with benefits in pain and function in the very early postoperative period favoring endoscopic intervention at PODs 3, 7, and 14, with earlier rates of return to work on PODs 3 and 7 in favor of the endoscopic group. Type of study/level of evidence Therapeutic IIc.
Purpose Dupuytren contracture (DC) is a common benign fibroproliferative hand disorder, causing progressive flexion contractures of the finger joints. DC is a chronic condition with no definitive cure, and treatment is primarily surgical, although percutaneous options also exist. We assessed the safety of DC treatments by analyzing national compensation claims. Methods This retrospective registry study included all compensation claims related to the treatment of DC submitted to the Finnish Patient Insurance Center between 2010 and 2023. The number of filed and compensated claims, the types of treatment injuries claimed, and the proportion of avoidable injuries were analyzed. The national incidence of claimed treatment injuries was calculated using annual procedure volumes. Injury avoidability was assessed retrospectively by expert review. Results During the 14-year study period, 54 compensation claims were filed following treatment for DC, corresponding to an incidence of 4.0 claimed injuries per 1,000 operations. The most frequently reported injuries were nerve injuries, tendon injuries, infections, and recurrent contractures. Of the 54 claims, 20 resulted in compensation, most commonly for nerve injuries, tendon injuries, amputations, and infections. Based on the retrospective assessment, 29.6% of the cases were considered avoidable. Conclusions The number of claims and compensated treatment injuries was low in relation to the total number of procedures performed. Type of study/level of evidence Therapeutic IV.
Purpose Fifth metacarpal neck fractures (5MCNFs) comprise up to 18.4% of all hand fractures. Clinical decision making is influenced by radiographic parameters, specifically apex dorsal angulation. Although sagittal computed tomography (CT) and lateral radiographs provide the truest views of the sagittal metacarpal, routine CT is not feasible, and metacarpal overlap on lateral radiograph presents a challenge for reliable measurement. Thus, oblique hand radiographs may be a valuable alternative, providing an isolated view of the fifth metacarpal. This study assesses whether oblique hand radiographs are a reliable and valid method of measuring 5MCNF angulation. Methods A retrospective cohort of patients aged ≥18 years treated nonsurgically for 5MCNFs were recruited from three centers in Calgary. All patients had healed malunions. Radiographs and CT scans were obtained at one clinical visit at least 1-year postinjury. Three physicians measured fracture angulation on oblique hand radiographs and sagittal CT. Results In total, 24 patients with malunited 5MCNFs were identified. The average patient age was 40.3 ± 13.3 years and patients were seen on average 2.97 ± 1.70 years postinjury. All patients were treated nonsurgically, and 91.7% were immobilized in a cast or a splint. The average apex dorsal angulation measurement was 42.6° ± 8.55° on oblique hand radiograph and 42.6° ± 8.86° on sagittal CT (P = .825). The interrater intraclass correlation coefficient was 0.795 (95% CI, 0.353–1.000) on oblique hand radiograph and 0.784 (95% CI, 0.414–1.000) on sagittal CT. The mean absolute interobserver difference in angulation measurement was 4.09° ± 2.90° on oblique hand radiograph and 4.66° ± 2.51° on sagittal CT. The intermodal intraclass correlation coefficients was 0.877 (95% CI, 0.659–1.000). The mean absolute angular error was 3.15° ± 1.82°. Bland–Altman analysis demonstrated no proportional bias. Conclusions Oblique hand radiographs demonstrate good reliability and high validity as a modality for the measurement of 5MCNF angulation. This study provides radiographic guidance for the assessment of 5MCNFs. Type of study/level of evidence Retrospective reliability study III.
Purpose Trigger finger is typically managed with corticosteroid injections followed by surgical release if injections fail. Office-based ultrasound-guided percutaneous A1 pulley release (USGPR) has emerged as a contemporary alternative that provides definitive surgical treatment in office settings, potentially eliminating both the recurrence risk of injections and the facility costs of traditional surgery. However, USGPR device costs and cost-effectiveness remain uncertain. Prior cost-effectiveness analyses do not include USGPR as a comparator and use reimbursement data from 2016 and earlier that may not reflect contemporary payment structures. This study evaluated the cost-effectiveness of contemporary trigger finger treatment strategies, including office-based USGPR, from a Medicare payer perspective using current 2025 reimbursement data and determined device cost thresholds at which USGPR becomes cost-effective. Methods A decision-tree cost-effectiveness analysis was performed over a 1-year time horizon comparing five strategies: up to one, two, or three corticosteroid injections followed by facility-based open A1 pulley release if needed; immediate facility-based open release; and immediate office-based USGPR. Costs were derived from 2025 Medicare reimbursement data. Effectiveness was expressed as quality-adjusted life-years. Deterministic, threshold, and probabilistic sensitivity analyses were performed. Results The three-injection strategy was most cost-effective, with expected costs of $513 and net monetary benefit of $39,687 at a willingness-to-pay threshold of $50,000 per quality-adjusted life-year. Probabilistic sensitivity analysis demonstrated this strategy remained cost-effective in 100% of 10,000 simulations. At the base case device cost of $800, office-based USGPR was most expensive at $1,577. However, threshold analyses demonstrated that USGPR would become cost-effective at device costs below $232 relative to the three-injection strategy and below $519 relative to immediate facility-based open release. Conclusions Offering up to three corticosteroid injections before surgical release represents the most cost-effective contemporary strategy for trigger finger management from a current Medicare payer perspective. At current device costs, office-based USGPR is not cost-effective, but substantial opportunity exists for this technique to become cost competitive as device costs decline. Type of study/level of evidence Economic and Decision Analysis II.
Purpose Replacement of the distal radioulnar joint (DRUJ) using a semiconstrained implant arthroplasty (Aptis) has demonstrated the capacity to restore function. The aim of this study was to investigate medium-term outcomes and navigate the effect of increasing experience with this implant, and compare the results with other follow-up studies. Methods We retrospectively investigated 36 DRUJ implant arthroplasties in 34 patients operated on between 2010 and 2021 for complications and revision surgeries. The average follow-up time was 4.4 years. In 15 patients with available data and surviving implant over time, we compared pre- and postoperative pain level and total active motion, as well as weight-bearing ability. Results Overall pain reduction was significant. Active range of motion and weight bearing ability was stable over time. We observed no infection. Revision surgery was necessary in 27% of cases, and the overall survival rate of the implant was 91% with a mean follow-up of 53 months. Conclusion We conclude that implant arthroplasty of the DRUJ reduces pain and preserves function. An extremely precise surgical technique is mandatory to avoid complications. Type of study/level of evidence Prognosis/IIb.
Purpose Tendon transfers and nerve transfers are two techniques available for reconstruction of elbow extension, grip, pinch, and release after spinal cord injury. This systematic review was aimed at assessing and comparing the strength outcomes of tendon and nerve transfers for functional reconstruction of the upper extremity to better guide surgical discussion. Methods This review was registered with PROSPERO ID: CRD42024595503 and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Embase, Scopus, and MEDLINE were queried for citations that presented strength outcomes for patients having undergone tendon and/or nerve transfers to restore upper-extremity function after a spinal cord injury. Weighted averages were used to report patient demographic data. A pooled estimate of strength outcomes was completed for the brachialis-to-anterior interosseous nerve transfer using a random-effects model. Results Five hundred and ninety-four citations were screened for 51 included studies with a total of 959 patients who were, on average, 31.8 years old (range, 5−76). For elbow extension reconstruction, strength of M3 or greater was reported in 68% of patients who underwent nerve transfers, 79% of patients who underwent a biceps-to-triceps tendon transfer, and 70% of patients who underwent a deltoid-to-triceps transfer. The pooled proportion of patients achieving M3 or better strength after a brachialis-to-anterior interosseous nerve transfer was 0.5 (0.31−0.7), with better outcomes in younger patients. For the supinator-to-posterior interosseous nerve transfer, 78% of patients reported achieving M3 strength or better. Conclusions There is no gold standard for the functional reconstruction of the upper extremity after a spinal cord injury. The choice of procedure(s) remains patient-specific. Several options are available to surgeons treating tetraplegia, and patients have achieved considerable strength recovery from both nerve and tendon transfers. Current evidence demonstrates poor outcomes after brachialis-to-anterior interosseous nerve transfers. More homogeneous follow-up protocols are needed for strength measurement and patient-reported outcome measures for both nerve and tendon transfers. Type of study/level of evidence Therapeutic III.
Purpose Patients with end-stage renal disease (ESRD) have high rates of pathologies, which may necessitate finger amputation, such as infection or vascular insufficiency. Still, little work has examined its significance in upper-extremity amputation. This study aimed to explore ESRD as a predictor of postoperative sequelae in the setting of finger amputation. Methods A retrospective cohort study was performed using the TriNetX database to identify patients with finger amputation through the phalanx, metacarpal, or distal to the carpometacarpal with or without preexisting ESRD or dependence on dialysis. Propensity score matching was used to control for risk factors such as diabetes, atherosclerosis, peripheral vascular disease hypertension, among others. Outcomes included return to operating room or death within 1-year, subsequent ray amputation, proximal upper-extremity amputation, and other common sequelae of finger amputation. Results After propensity score matching, 1,619 patients without and 1,619 patients with ESRD or dialysis dependence before index finger amputation were in each cohort. More patients with ESRD returned to the operating room within 1 year for debridement or secondary closure of dehisced wound (334 [20.63%] vs 217 [13.40%]). Furthermore, 338 (20.88%) non-ESRD amputees and 536 (33.11%) ESRD amputees underwent repeat or subsequent ray amputation. Similarly, patients with ESRD demonstrated higher rates of proximal upper extremity amputation (ie, at the hand, wrist, or forearm) following index surgery: 296 (18.28%) patients without ESRD versus 481 (29.71%) patients with ESRD. ESRD amputees also developed significantly higher rates of chronic osteomyelitis (290 [17.91%] vs 219 [13.53%], P < .001) as well as death within 1 year (375 [23.16%] vs 121 [7.47%], P < .001). Conclusions Patients with ESRD experience higher rates of subsequent proximal upper extremity amputation, subsequent ray amputation, chronic osteomyelitis, return to the operating room, and death. Further work expositing the pathophysiological mechanism of these associations may assist hand surgeons in preoperative optimization of these patients. Type of study/level of evidence Prognostic IIb.
Purpose The biomechanics of surgically treated metacarpal base fractures are poorly described. We hypothesized that intramedullary threaded nail (IMTN) fixation and dorsal plate and screw (DPS) fixation would perform similarly in multiple fracture locations approaching the metacarpal base. Methods Sixty-four metacarpals from eight matched pair cadaveric hands were stripped. Matched pairs were randomly divided into four cohorts based on fracture distance from the metacarpal base. Transverse osteotomies were created at 50%, 35%, 25%, and 15% of the total metacarpal length, measured from the metacarpal base. The 50% cohort served as a control. For each cohort, paired metacarpals were randomized to either DPS or IMTN fixation groups. All specimens were cyclically loaded in 3-point bending for 2,000 cycles at 70 N, 2,000 cycles at 120 N, and then loaded to failure. Bending stiffness, cycles to failure, and peak load to failure (LTF) were collected. Results Peak bending stiffness and peak LTF were not significantly different in the 15%, 25%, or 35% groups compared to the 50% control for both IMTN and DPS fixation. Direct comparison of IMTN and DPS fixation at each osteotomy level yielded no significant differences in LTF or bending stiffness. There was a nonsignificant trend toward higher LTF and bending stiffness with DPS fixation in more proximal fractures. Conclusions Peak LTF and bending stiffness were not significantly different for IMTN or DPS fixation in fractures located as proximally as 15% from the metacarpal base. Furthermore, both IMTN and DPS fixation had no significant differences in peak bending stiffness and LTF for metacarpal fractures as proximal as 15% from the base compared to a 50% control. Clinical relevance When managing proximal metacarpal fractures surgeons can expect no significant difference in stiffness or LTF using either DPS or IMTN fixation with values comparable to those seen when treating a midshaft metacarpal fracture.
Purpose To determine whether early radiographic trajectory data can predict the timing of stability in conservatively managed distal radius fractures (DRFs) and to identify which clinical and radiographic features most influence stabilization timing. Methods This retrospective cohort study analyzed data from 1,585 adult patients with conservatively managed DRFs collected from a single-institution fracture registry (2020−2024). Radiographic stability was classified according to predefined parameters of radial height, volar tilt, radial inclination, and ulnar variance at weekly follow-ups. An explainable machine learning model incorporating demographics, fracture characteristics, comorbidities, and early radiographic changes was developed to predict stability at various weeks. Predictive performance was evaluated using area under the receiver operating characteristic curve, calibration plots, Brier scores, decision curve analysis, and SHapley Additive exPlanations. Results Among 1,585 patients, 40% of fractures achieved radiographic stability by week 3. Baseline radiographic measurements did not differ across stability groups, but first-week displacement differed significantly across all parameters. A combined model incorporating early radiographic changes substantially outperformed a baseline-only model. Decision curve analysis demonstrated a superior net benefit compared with routine imaging strategies. SHapley Additive exPlanations analysis identified early changes in volar tilt as the single most influential predictor, followed by changes in radial inclination, patient age, and dorsal comminution. Conclusions Early radiographic trajectory, particularly first-week changes in volar tilt, predicts the timing of stability far more accurately than baseline features alone. A substantial proportion of conservatively managed DRFs stabilize earlier than conventional protocols assume, suggesting that a trajectory-guided approach could safely reduce late follow-up imaging and immobilization duration in selected patients. Prospective validation is needed before clinical implementation. Clinical relevance First-week radiographic displacement, particularly changes in volar tilt, may be more informative than traditional baseline instability criteria for guiding follow-up frequency and immobilization duration in conservatively managed DRFs. Level of evidence Prognostic/III.
Intra-articular fractures of the upper extremities often involve small, thin osteochondral fragments that are difficult to fix. This report describes a surgical technique using absorbable polydioxanone sutures for the fixation of these fragments and shares our clinical experience. This simple method uses polydioxanone, which is available in every operating room as the fixation material. In our clinical series, including fractures of the radial head, metacarpal head, and capitellum, all patients achieved bone union and joint congruity restoration without major complications. Even in pediatric patients, this approach provides stable fixation with a lower risk of physeal injury. Although the initial tensile strength of polydioxanone is lower than that of rigid internal fixation, increasing the number of sutures or optimizing the suture configuration can further enhance fixation strength. The absorbable suture fixation technique is a valuable and cost effective option for managing small, thin osteochondral fragments to maintain articular congruity until bone union is achieved.
Purpose Factors influencing the results of radial nerve to triceps to axillary nerve transfers remain poorly defined. Therefore, the goal of this study is to compare radial to axillary nerve transfer outcomes by age, and to determine if age is a reliable predictor of outcome. Methods A single center retrospective cohort study was conducted between 2015 and 2025. Exclusions included patients younger than 18 years, less than 1 year follow-up, or lack of MRC strength documented after surgery. Patients were subanalyzed by age: 18–39 years, 40–59 years, and ≥60 years. The primary outcome was recovery of M4 strength or greater. Subgroup analysis was performed to compare demographic, intraoperative variables, and postoperative outcomes. Results Fifty-three patients (n = 20 aged 18–39 years, n = 16 aged 40–59 years, n = 17 aged ≥60 years) were included with a median follow-up time of 16.7 months. There were no differences in lesion location, BMI, smoking status, or preoperative MRC grade between groups. Younger patients were more likely to sustain high-energy injuries (85% in patients aged 18–39 years, 43.8% in patients aged 40–59 years, 17.6% in patients aged ≥60 years, P = .001). 62.3 % of the cohort underwent end-to-end nerve transfer (75% in patients aged 18–39 years, 68.8% in patients aged 40–59 years, 47.1% in patients aged ≥60 years, P = .214). Postoperative clinical improvement was demonstrated in every age group. Overall, 77.4% of patients had a preoperative deltoid M0 strength and 66.0% of patients achieved at least M4 strength after surgery (75% in patients aged 18–39 years, 68.8% in patients aged 40–59 years, 52.9% in patients aged ≥60 years, P = .304). After surgery, there was no difference between groups for donor site morbidity, reoperation rate, or wound complications. Conclusions Meaningful M4–M5 recovery was achieved across all age cohorts, with a nonsignificant trend toward lower recovery rates in older patients (P = .746). Although not significant (P = .260), ETE trended toward being more common in younger patients versus ETS in older patients, likely reflecting injury severity. Patients that had therapeutic stimulation were 2.75 times more likely to reach M4–M5 compared to those that did not. Type of study/level of evidence Prognostic III.
Purpose This study assesses the impact of opioid-related disorders (ORDs) on healthcare utilization in patients following distal radius fractures (DRF) repair surgery—one of the most common fracture surgeries performed. The study hypothesis was that patients with ORD would experience higher rates of emergency department (ED) admissions, hospitalizations, and physical therapy (PT) evaluations compared to patients without ORD (NORD). Methods The TriNetX US Collaborative Database was queried to identify patients who underwent DRF repair between the ages of 18 and 49 years. The ORD cohort was propensity matched in a 1:1 ratio to NORD patients based on age, sex, race, ethnicity, and other comorbidities to limit confounder influence of results. Postoperative rates of healthcare resource utilization outcomes, including hospital readmissions, ED visits, and PT utilization, were compared within 90 days of surgery and prescriptions were compared between 30 days and 1 year postoperatively. Results A total of 789 patients were included in each cohort after propensity matching. Within 90 days postoperatively, a significantly greater percentage of ORD patients were admitted to the ED (21.8% vs 11.2% of NORD; P < .0001), hospitalized (13.6% vs 8.5% of NORD; P = .0013), and evaluated by PT (18.8% vs 12.0% of NORD; P = .0002). There was no significant difference in outpatient visits between groups (P = .9534). Within 30 days and 1 year postoperatively, patients in the ORD group received significantly more opioid prescriptions per patient (8.3 ± 17.4) compared to NORD patients (4.7 ± 8.8) (P = .002). Conclusions ORD patients received significantly more opioid prescriptions and were more likely to be admitted to the ED, be hospitalized, or be evaluated by PT after DRF repair compared to those without ORD. Surgeons and healthcare teams should prepare for greater support of patients with ORD and consider deliberate strategies to minimize perioperative complications, while optimizing opioid stewardship. Level of evidence Level 3 (retrospective cohort study).
Purpose Thumb carpometacarpal osteoarthritis is a common condition in older adults and may severely impair hand function and quality of life. When conservative treatment fails, trapeziometacarpal arthroplasty is a widely accepted surgical option, with well-documented clinical and functional outcomes. However, the subjective perioperative experience of patients remains poorly explored, despite its growing importance in value-based health care. Methods This retrospective, multicenter observational study included patients who underwent primary implant trapeziometacarpal arthroplasty between November 2007 and December 2023 in two tertiary centers. A self-administered questionnaire specifically designed to assess perioperative experience was sent to all eligible patients. Demographic data, radiographic characteristics, patient satisfaction, perioperative discomfort, postoperative pain resolution, and time to “forgetting the thumb” were analyzed descriptively. Results A total of 119 prostheses in 95 patients were analyzed, corresponding to a 42.6% response rate (95/223 eligible patients), with a mean follow-up of 6.4 ± 4.7 years. Overall satisfaction was high, with 83.2% of patients reporting being satisfied or very satisfied. Locoregional anesthesia was identified as the most unpleasant perioperative element by 22.7% of patients. Postoperative pain resolved rapidly in most cases, and 33.7% of patients reported “forgetting their thumb” within 4 months after surgery. Despite postoperative pain being frequently cited as unpleasant, only 2.5% of patients expressed a desire for improved analgesic protocols. Conclusions Trapeziometacarpal arthroplasty is associated with high patient satisfaction and rapid perceived recovery. Beyond functional outcomes, perioperative experience particularly anesthesia-related discomfort and preoperative information plays a critical role in patient satisfaction. Integrating patient-reported experience into outcome assessment may help optimize perioperative care pathways. Type of study/level of evidence Prognosis IV.
Purpose Penetrating upper-extremity trauma (PUET) presents complex challenges due to the risk of injury to neighboring structures. With many patients requiring surgery, data on the efficacy of selective nonsurgical management (SNSM) questions its role as first-line treatment. Investigation is especially needed within Federally Qualified Health Centers (FQHCs) to enhance care for individuals who often encounter barriers to care. This study descriptively characterizes practice patterns and outcomes associated with operative and nonsurgical management of PUET within an FQHC serving a predominantly underinsured, urban population. Methods A retrospective study identified patients within an FQHC who were evaluated for PUET between 2019 and 2024. Data collected includes mechanism, location, and severity of the injury, timing of operative interventions (if any), and postdischarge outcomes. Descriptive analyses identified factors associated with the likelihood of operative intervention. Results Ninety-nine patients met inclusion criteria; 16 (16.2%) underwent operative intervention and 83 (83.8%) were managed with SNSM. The cohort had a median age of 39 years and predominantly comprised men. Gunshot wounds were the most common mechanism, and the hand was the most frequently injured site. Operative patients had significantly higher rates of fracture and tendon disruption compared to SNSM patients. Infections were more frequent in operative patients. Follow-up completion differed substantially between groups, with operative patients attending hand clinic at higher rates than SNSM patients. Conclusions This descriptive study characterizes how PUET is managed within an FQHC, contributing to the limited literature examining upper-extremity surgery care in resource-limited, safety-net settings. For hand surgeons practicing in these environments, these findings support a selective rather than routine operative approach for hemodynamically stable patients, using physical examination and plain radiographs as primary decision tools. Clinical relevance SNSM can be considered a safe and appropriate approach for hemodynamically stable PUET patients without fracture or tendon injury, reducing surgical burden and supporting efficient care in FQHCs.
Purpose:The ulnar nerve at the wrist is vulnerable to injury at Guyon's canal, yet its branching pattern, bifurcation location, and the positional relationship between its motor and sensory branches have not been characterized in any Vietnamese or Southeast Asian cadaveric cohort. This study aimed to describe these morphological parameters and determine whether forearm length predicts key landmark distances. Methods:Thirty fresh forearm-wrist specimens from 15 cadavers (mean age, 75.5 years; 53.3% men) were dissected (February-August 2022). Bifurcation location relative to Guyon's canal, terminal branching pattern, motor-to-sensory positional relationship (ulnar vs radial), and ulnar-median communicating branches were documented. Distances from the bifurcation point to the pisiform bone, medial epicondyle, and dorsal cutaneous branch origin were measured. Unpaired t tests, paired t tests, Pearson's correlation, and Bonferroni correction were applied. Results:Bifurcation occurred proximal to Guyon's canal in 86.7% of specimens; terminal bifurcation predominated (93.3%). No ulnar-median communicating branches were identified. The deep (motor) branch was consistently ulnar to the superficial (sensory) branch in all 30 specimens (100%). Mean bifurcation-to-pisiform distance was 2.03 cm; bifurcation-to-medial epicondyle, 25.96 cm; and bifurcation-to-dorsal cutaneous branch, 8.38 cm. The latter correlated with forearm length and was greater in men. No measurements differed between limb sides. Conclusions:The ulnar nerve at the wrist follows consistent morphological patterns in this Vietnamese cadaveric cohort. The motor branch was ulnar to the sensory branch in all 30 specimens examined. The bifurcation-to-pisiform and bifurcation-to-medial epicondyle distances are stable across sex and side; the distance to the dorsal cutaneous branch scales with forearm length, which may assist patient-specific preoperative planning. Clinical relevance:The consistent ulnar position of the motor branch in all 30 specimens examined provides a reliable landmark for Guyon's canal surgery, ulnar nerve repair, and nerve transfer at the wrist. Preoperative forearm length measurement may assist patient-specific estimation of the dorsal cutaneous branch origin.
Purpose Early identification of vascular compromise following digit replantation and revascularization, and prompt restoration of blood flow is considered critical for successful salvage. This study aimed to assess the duration of secondary ischemia in replanted and revascularized digits with postoperative arterial insufficiency that were reoperated on and to determine whether there is a correlation between secondary ischemia time and digit survival. Methods We identified replanted and revascularized digits reoperated for isolated arterial thrombosis during their primary admission at the National Unit for Replantation Surgery in Norway from 2010 to 2024. Ischemia onset was defined as a decrease in surface skin temperature of 1 °C per hour or 1.5 °C over 2 hours. Data on the onset of ischemia, time to reestablishment of arterial circulation, and survival were extracted from the unit’s internal quality registry. Well-known predictors for survival following digit replantation were also assessed to control for confounding variables. We conducted binary logistic regression and compared the means of secondary ischemia time between the survival and nonsurvival groups with a t test. Results A total of 59 digits with vascular compromise were reoperated for isolated arterial thrombosis. Logistic regression did not identify secondary ischemia time as a predictor for survival. The average secondary ischemia time for salvaged digits compared with nonsalvaged digits was not different. The survival and nonsurvival groups were similar regarding confounding variables. Conclusions Digit replantations that undergo postoperative ischemia due to arterial occlusion may tolerate longer secondary ischemia times than previously assumed. Our study did not demonstrate secondary ischemia due to arterial thrombosis as a critical predictor for salvage. Evidence of a critical secondary ischemia threshold is still lacking. Clinical relevance This study may support a more nuanced urgency in re-exploration decisions after digit replantations with postoperative arterial insufficiencies. Delayed recognition of arterial insufficiency can still result in successful salvage.
Purpose To determine whether the distance between conduit anchoring sutures and the neurorrhaphy influences local strain distribution at a primary nerve repair site in a cadaveric model. Methods Median and ulnar nerves were harvested from cadaver limbs. Nerves were split between conduit-assisted repair at conduit lengths of 2, 4, and 6 mm, corresponding to anchor points of 1, 2, and 3 mm. All other nerves were allocated to standard primary repair. All nerves were loaded to failure at a loading rate of 20 mm/min. Strain was analyzed at the repair site and proximal and distal sites with two-dimensional digital image correlation. Results The 6-mm conduit-assisted group demonstrated significantly lower strain at the repair site when compared with the 2- and 4-mm conduit-assisted groups. The 2- and 4-mm conduit-assisted groups had significantly higher strain at the repair site when compared to their respective proximal and distal sites. The 6-mm conduit-assisted repair group had a similar strain distribution when the repair site was compared to proximal and distal strain sites. Conclusions The 6-mm conduit-assisted repair with anchor points positioned approximately 3 mm from the coaptation demonstrated lower repair site strain than shorter constructs, with no significant difference in strain at the repair site when compared to proximal and distal sites. Clinical relevance Conduit-assisted nerve repair requires sufficient anchor-point positioning to function as a strain-shielding device. When using conduit-assisted nerve repair, shorter anchor points may not adequately offload the repair and may compromise the intended coaptation site, giving surgeons insight into optimal anchor-point positions for procedural planning.
