Publications by authors named "Jonathan Lans"

66 Publications

An experienced surgeon's take on scapho-lunate diastasis with distal radius fracture: What does this mean? Does this influence functional outcome?

Injury 2022 Jul 6. Epub 2022 Jul 6.

Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114, USA.

Radiographic evidence of scapho-lunate diastasis associated with a displaced distal radius fracture has been well recognized yet the clinical significance remains in question. If left untreated, will this progress to both radiographic and clinical changes consistent with intercarpal arthritis? Using the accumulated data of over 400 surgically treated distal radius fractures in the ICUC database, 16 cases of untreated scapho-lunate diastasis were followed on an average of 8 years without evidence of progressive functional or radiographic deterioration. In 50% of these cases, incidental findings of similar scapho-lunate diastasis was noted in the opposite uninjured wrist.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.injury.2022.07.015DOI Listing
July 2022

The Performance of Diagnostic Tests for Identifying Periprosthetic Joint Infection After Failed Partial Knee Arthroplasty.

J Arthroplasty 2022 Jun 30. Epub 2022 Jun 30.

Department of Orthopaedic Surgery, Massachusetts General Hospital/Newton-Wellesley Hospital, Harvard Medical School, Boston, Massachusetts.

Background: Indications for unicompartmental knee arthroplasty (UKA) and patello-femoral arthroplasty are expanding. Despite the lower published infection rates for UKA and patello-femoral arthroplasty than total knee arthroplasty, periprosthetic joint infection (PJI) remains a devastating complication and diagnostic thresholds for commonly utilized tests have not been investigated recently. Thus, this study evaluated if diagnostic thresholds for PJI in patients who had a failed partial knee arthroplasty (PKA) align more closely with previously reported thresholds specific to UKA or the 2018 International Consensus Meeting on Musculoskeletal Infection.

Methods: We identified 109 knees in 100 patients that underwent PKA with eventual conversion to total knee arthroplasty within a single healthcare system from 2000 to 2021. Synovial fluid nucleated cell count and synovial polymorphonuclear percentage in addition to preoperative serum erythrocyte sedimentation rate, serum C-reactive protein, and serum white blood cell count were compared with Student's t-tests between septic and aseptic cases. Receiver operating characteristic curves and Youden's index were used to assess diagnostic performance and the optimal cutoff point of each test.

Results: Synovial nucleated cell count, synovial polymorphonuclear percentage, and serum C-reactive protein demonstrated excellent discrimination for diagnosing PJI with an area under the curve of 0.97 and lower cutoff values than the previously determined UKA specific criteria. Serum erythrocyte sedimentation rateESR demonstrated good ability with an area under the curve of 0.89.

Conclusion: Serum and synovial fluid diagnostic thresholds for PJI in PKAs align more closely with the thresholds established by the 2018 International Consensus Meeting as compared to previously proposed thresholds specific to UKA.

Level Of Evidence: Level III, retrospective comparative study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2022.06.021DOI Listing
June 2022

Factors Related to Neuropathic Pain following Lower Extremity Amputation.

Plast Reconstr Surg 2022 08 27;150(2):446-455. Epub 2022 Jul 27.

From the Department of Orthopaedic Surgery, Hand and Upper Extremity, Foot and Ankle, and Orthopaedic Oncology Services, the Harvard Medical School Orthopedic Trauma Initiative, and the Division of Plastic Surgery, Hand Surgery, and Peripheral Nerve Surgery, Massachusetts General Hospital, Harvard Medical School.

Background: Lower extremity amputations are common, and postoperative neuropathic pain (phantom limb pain or symptomatic neuroma) is frequently reported. The use of active treatment of the nerve end has been shown to reduce pain but requires additional resources and should therefore be performed primarily in high-risk patients. The aim of this study was to identify the factors associated with the development of neuropathic pain following above-the-knee amputation, knee disarticulation, or below-the-knee amputation.

Methods: Retrospectively, 1565 patients with an average follow-up of 4.3 years who underwent a primary above-the-knee amputation, knee disarticulation, or below-the-knee amputation were identified. Amputation levels for above-the-knee amputations and knee disarticulations were combined as proximal amputation level, with below-the-knee amputations being performed in 61 percent of patients. The primary outcome was neuropathic pain (i.e., phantom limb pain or symptomatic neuroma) based on medical chart review. Multivariable logistic regression was performed to identify independent factors associated with neuropathic pain.

Results: Postoperative neuropathic pain was present in 584 patients (37 percent), with phantom limb pain occurring in 34 percent of patients and symptomatic neuromas occurring in 3.8 percent of patients. Proximal amputation level, normal creatinine levels, and a history of psychiatric disease were associated with neuropathic pain. Diabetes, hypothyroidism, and older age were associated with lower odds of developing neuropathic pain.

Conclusions: Neuropathic pain following lower extremity amputation is common. Factors influencing nerve regeneration, either increasing (proximal amputations and younger age) or decreasing (diabetes, hypothyroidism, and chronic kidney disease) it, play a role in the development of postamputation neuropathic pain.

Clinical Question/level Of Evidence: Risk, III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PRS.0000000000009334DOI Listing
August 2022

Forearm Plate Fixation: Should Plates Be Removed?

Arch Bone Jt Surg 2022 Feb;10(2):153-159

Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, USA.

Background: Refracture after both bone forearm fracture fixation may vary with or without plate removal. We tested the null hypothesis that there is no difference in the rate of refracture in patients who have undergone open reduction and internal fixation of a diaphyseal forearm bone who have retained implants versus removed implants. We also studied factors associated with plate removal.

Methods: We retrospectively identified 645 adult patients with a total of 925 primary fractures that underwent primary plate fixation of an ulnar or radial shaft fracture between 2002 and 2015 at a single institutional system. Patients with nonunion, pathological fracture or infection were excluded. Independent factors associated with refracture and plate removal were identified using multivariable analysis.

Results: Refractures occurred in 6.3% of the fractures that had forearm implant removal, compared to 2.1% of the fractures with retained plates. Refractures were independently associated with plate removal (OR: 3.7, 95% CI: 1.2-11.7, ) and was more frequent in the radius (OR: 2.4, 95% CI: 1.0-5.8, ). A refracture after implant removal occurred within 3 months after removal. Ulnar plates were removed more often compared to radial plates (OR: 2.6, 95% CI: 1.4-4.7, ) as were plates used for type A fractures compared to type C fractures (OR: 3.2, 95% CI: 1.1-9.2, ).

Conclusion: The rate of refracture is higher after plate removal compared to patients who did not have plates removed. Although uncommon, refractures of the radius tend to be more common than a refracture of the ulna. If the implant is symptomatic on the ulnar side, it may be preferable to remove the ulnar implant and retain the radius implant rather than remove both plates when possible. Furthermore, limiting strenuous activity for three months after implant removal is a consideration.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.22038/ABJS.2021.45901.2255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9117894PMC
February 2022

Quantitative Analysis of the Volar Ulnar Corner of the Distal Radius: A Reference For Intraoperative Distal Radius Fracture Reduction.

J Hand Surg Am 2022 May 28. Epub 2022 May 28.

Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA. Electronic address:

Purpose: The reduction of distal radius fractures using volar locking plate fixation can be performed by securing the plate to the distal fragments and then levering the plate to the radial shaft. Oblique placement of the plate on the radial shaft may lead to malreduction. The aim of this study was to evaluate parameters that can be used for the assessment of intraoperative distal radius fracture reduction using "distal-first" volar plate fixation, especially the geometry of the ulnar corner. The prevalence of Tolat distal radioulnar joint (DRUJ) types was determined, and the angles of the volar corner were quantitatively described.

Methods: Three hundred seventy-five adult patients with a conventional wrist radiograph in their medical chart were identified. From this cohort, 50 radiographs of each Tolat DRUJ type were quantitatively analyzed using 4 angles. The probability density of each angle was described using Kernel density estimation graphs. A multivariable analysis was used to study the association between the 4 angles and Tolat DRUJ types and other patient factors.

Results: One hundred fifty-one patients (40%) had a wrist with type 1 DRUJ, 147 (39%) had a wrist with type 2 DRUJ, and 77 (21%) had a wrist with type 3 DRUJ. The measurements of the distal ulnar corner, volar ulnar corner, and DRUJ angulation were significantly different among each Tolat DRUJ type. The median lunate facet inclination, relative to the axis of the radial shaft, measured 14° (interquartile range, 12°-16°) across all the Tolat DRUJ types.

Conclusions: The prevalence of Tolat type 1, 2, and 3 DRUJ was 40%, 39%, and 21%, respectively. The angles of the volar ulnar corner varied with each DRUJ type.

Clinical Relevance: Because the lunate facet inclination was relatively consistent among all the Tolat DRUJ types, this angle may be useful as a reference for "distal-first" distal radius volar plating.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jhsa.2022.03.017DOI Listing
May 2022

Patient-Reported Outcomes After Surgical Treatment of Early Osteoarthritis of the First Carpometacarpal Joint.

Hand (N Y) 2022 May 13:15589447221093669. Epub 2022 May 13.

Harvard Medical School, Boston, MA, USA.

Background: The goals of this study are to describe the reoperation rates in patients who underwent Wilson osteotomy compared with patients who underwent carpometacarpal (CMC) arthroplasty for early-stage arthritis and to evaluate the factors influencing the patient-reported outcomes.

Methods: Retrospectively, 52 patients who underwent surgery for stage I/II osteoarthritis of the thumb carpometacarpal were identified, consisting of 17 (33%) patients who underwent Wilson osteotomy and 35 (67%) who underwent carpometacarpal arthroplasty. A total of 28 (55%) patients completed the outcome questionnaires, consisting of 11 (39%) patients who underwent Wilson osteotomy and 17 (61%) patients who underwent carpometacarpal arthroplasty. We performed a multivariable linear regression model to identify factors associated with the Numeric Rating Scale (NRS) pain intensity at final follow-up.

Results: Among the patients who underwent CMC arthroplasty, 2 had a reoperation. Among the patients who underwent Wilson osteotomy, 3 had a reoperation. Among the patients who completed the outcome questionnaires, the median quick Disabilities of the Arm, Shoulder and Hand score was 10 and the median NRS Pain Intensity score was 0. In multivariable analysis, the postoperative Patient-Reported Outcomes Measurement Information System Pain Interference (PROMIS PI) was independently associated with higher postoperative NRS pain scores.

Conclusion: In younger patients with stage I/II CMC osteoarthritis, Wilson osteotomy may be a reasonable alternative to CMC arthroplasty. Outcomes were similar between both groups at mid-term follow-up, with only a slightly higher pain score in the osteotomy group. In patients with stage I/II carpometacarpal osteoarthritis, the PROMIS PI is the main factor indicating successful outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/15589447221093669DOI Listing
May 2022

Prolonged Opioid Use following Hand Surgery: A Systematic Review and Proposed Criteria.

Plast Reconstr Surg Glob Open 2022 Apr 8;10(4):e4235. Epub 2022 Apr 8.

Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Mass.

Prolonged opioid use after surgery has been a contributing factor to the ongoing opioid epidemic. The purpose of this systematic review is to analyze the definitions of prolonged opioid use in prior literature and propose appropriate criteria to define postoperative prolonged opioid use in hand surgery.

Methods: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines 130 studies were included for review. The primary outcome was the timepoint used to define prolonged opioid use following surgery. The proportion of patients with prolonged use and risk factors for prolonged use were also collected for each study. Included studies were categorized based on their surgical specialty.

Results: The most common timepoint used to define prolonged opioid use was 3 months (n = 86, 67.2% of eligible definitions), ranging from 1 to 24 months. Although 11 of 12 specialties had a mean timepoint between 2.5 and 4.17 months, Spine surgery was the only outlier with a mean of 6.90 months. No correlation was found between the definition's timepoint and the rates of prolonged opioid use.

Conclusions: Although a vast majority of the literature reports similar timepoints to define prolonged postoperative opioid use, these studies often do not account for the type of procedures being performed. We propose that the definitions of postoperative prolonged opioid use should be tailored to the level and duration of pain for specific procedures. We present criteria to define prolonged opioid use in hand surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/GOX.0000000000004235DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8994078PMC
April 2022

The Significance of Race/Ethnicity and Income in Predicting Preoperative Patient-Reported Outcome Measures in Primary Total Joint Arthroplasty.

J Arthroplasty 2022 07 18;37(7S):S428-S433. Epub 2022 Feb 18.

Department of Orthopaedic Surgery, Massachusetts General Hospital/Newton-Wellesley Hospital, Harvard Medical School, Boston, Massachusetts.

Background: Utilization of total joint arthroplasty (TJA) by minorities is disproportionately low compared to Whites. Contributing factors include poorer outcomes, lower expectations, and decreased access to care. This study aimed to evaluate if race and income were predictive of preoperative patient-reported outcome measures (PROMs) and the likelihood of achieving the minimal clinically important difference (MCID) following TJA.

Methods: We retrospectively reviewed 1,371 patients who underwent primary TJA between January 2018 and March 2021 in a single healthcare system. Preoperative and postoperative PROM scores were collected for Patient-Reported Outcomes Measurement Information System (PROMIS) Mental Health, PROMIS Physical Function (PF10a), and either Knee injury and Osteoarthritis Outcome Score (KOOS) or Hip disability and Osteoarthritis Outcome Score (HOOS). Demographic and comorbidity data were included as explanatory variables. Multivariable regression was used to analyze the association between predictive variables and PROM scores.

Results: Mean preoperative PROM scores were lower for non-Whites compared to Whites. Increased median household income was associated with higher preoperative PROM scores. Non-White race was associated with lower PROMIS Mental Health and KOOS, but not PF10a or HOOS scores. Only non-White race was associated with a decreased likelihood of achieving MCID for PF10a. Neither race nor income was predictive of achieving MCID for KOOS and HOOS.

Conclusion: Non-White race/ethnicity and lower income were associated with lower preoperative PROMs prior to primary TJA. Continued research is necessary to identify the causes of this discrepancy and correct this disparity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2022.02.041DOI Listing
July 2022

Reoperation Following Zone II Flexor Tendon Repair.

Hand (N Y) 2022 Feb 26:15589447211043220. Epub 2022 Feb 26.

Massachusetts General Hospital, Boston, USA.

Background: The goal of zone II flexor tendon surgery is to perform a repair with sufficient strength to withstand the forces encountered during rehabilitation. Postoperative rerupture and adhesion formation may lead to reoperation. This study aimed to determine the factors associated with reoperation after primary zone II flexor tendon repair.

Methods: In this retrospective case series, a total of 252 fingers in 201 patients underwent zone II flexor tendon repair. A medical record review was performed to collect data regarding patient demographics, injury and treatment characteristics and postoperative complications including reoperation. Reoperation was defined as any unplanned surgical procedure performed after initial flexor tendon repair.

Results: There were 49 fingers (19%) in 42 patients that underwent reoperation at a median of 5.5 (interquartile range: 2.8-7.9) months. Older age, workers' compensation, and a Kessler-type repair of the flexor digitorum profundus were independently associated with reoperation.

Conclusions: In vitro studies suggest that Kessler-type repairs are inferior compared with other suture configurations. Our study demonstrates a clinical correlation to these biomechanical studies. Our results suggest that Kessler-type repairs are inferior compared with non-Kessler-type repairs, due to postoperative complications requiring secondary surgeries.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/15589447211043220DOI Listing
February 2022

Long-Term Opioid Use Following Surgery for Symptomatic Neuroma.

J Reconstr Microsurg 2022 Feb 16;38(2):137-143. Epub 2021 Jul 16.

Division of Plastic Surgery, Hand Surgery, and Peripheral Nerve Surgery, Massachusetts General Hospital, Harvard Medical School, Boston.

Background:  Identifying patients at risk for prolonged opioid use following surgery for symptomatic neuroma would be beneficial for perioperative management. The aim of this study is to identify the factors associated with postoperative opioid use of >4 weeks in patients undergoing neuroma surgery.

Methods:  After retrospective identification, 77 patients who underwent surgery for symptomatic neuroma of the upper or lower extremity were enrolled. Patients completed the Patient-Reported Outcomes Measurement Information System (PROMIS) depression, Numeric Rating Scale (NRS) pain score, and a custom medication questionnaire at a median of 9.7 years (range: 2.5-16.8 years) following surgery. Neuroma excision followed by nerve implantation ( = 39, 51%), nerve reconstruction/repair ( = 18, 23%), and excision alone ( = 16, 21%) were the most common surgical treatments.

Results:  Overall, 27% ( = 21) of patients reported opioid use of more than 4 weeks postoperatively. Twenty-three patients (30%) reported preoperative opioid use of which 11 (48%) did not report opioid use for >4 weeks, postoperatively. In multivariable logistic regression, preoperative opioid use was independently associated with opioid use of >4 weeks, postoperatively (odds ratio [OR] = 4.4, 95% confidence interval [CI]: 1.36-14.3,  = 0.013).

Conclusion:  Neuroma surgery reduces opioid use in many patients but patients who are taking opioids preoperatively are at risk for longer opioid use. Almost one-third of patients reported opioid use longer than 4 weeks, postoperatively.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0041-1731640DOI Listing
February 2022

Soft-tissue coverage for wound complications following total elbow arthroplasty.

Clin Shoulder Elb 2021 Dec 1;24(4):245-252. Epub 2021 Dec 1.

Orthopedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

Background: In patients with total elbow arthroplasty (TEA), the soft-tissue around the elbow can be vulnerable to soft-tissue complications. This study aims to assess the outcomes after soft-tissue reconstruction following TEA.

Methods: We retrospectively included nine adult patients who underwent soft-tissue reconstruction following TEA. Demographic data and disease characteristics were collected through medical chart reviews. Additionally, we contacted all four patients that were alive at the time of the study by phone to assess any current elbow complications. Local tissue rearrangement was used for soft-tissue reconstruction in six patients, and a pedicle flap was used in three patients. The median follow-up period was 1.3 years (range, 6 months-14.7 years).

Results: Seven patients (78%) underwent reoperation. Four patients (44%) had a reoperation for soft-tissue complications, including dehiscence or nonhealing of infected wounds. Five patients (56%) had a reoperation for implant-related complications, including three infections and two peri-prosthetic fractures. At the final follow-ups, six patients (67%) achieved successful wound healing and two patients had continued wound healing issues, while two patients had an antibiotic spacer in situ and one patient underwent an above-the-elbow amputation.

Conclusions: This study reports a complication rate of 78% for soft-tissue reconstructions after TEA. Successful soft-tissue healing was achieved in 67% of patients, but at the cost of multiple surgeries. Early definitive soft-tissue reconstruction could prove to be preferable to minor interventions such as irrigation, debridement, and local tissue advancement, or smaller soft-tissue reconstructions using local tissue rearrangement or a pedicled flap at a later stage.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5397/cise.2021.00409DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8651597PMC
December 2021

A Correlation between Upper Extremity Compressive Neuropathy and Nerve Compression Headache.

Plast Reconstr Surg 2021 Dec;148(6):1308-1315

From the Division of Plastic and Reconstructive Surgery and the Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School.

Background: Compressive neuropathies of the head/neck that trigger headaches and entrapment neuropathies of the extremities have traditionally been perceived as separate clinical entities. Given significant overlap in clinical presentation, treatment, and anatomical abnormality, the authors aimed to elucidate the relationship between nerve compression headaches and carpal tunnel syndrome, and other upper extremity compression neuropathies.

Methods: One hundred thirty-seven patients with nerve compression headaches who underwent surgical nerve deactivation were included. A retrospective chart review was conducted and the prevalence of carpal tunnel syndrome, thoracic outlet syndrome, and cubital tunnel syndrome was recorded. Patients with carpal tunnel syndrome, cubital tunnel syndrome, and thoracic outlet syndrome who had a history of surgery and/or positive imaging findings in addition to confirmed diagnosis were included. Patients with subjective report of carpal tunnel syndrome/thoracic outlet syndrome/cubital tunnel syndrome were excluded. Prevalence was compared to general population data.

Results: The cumulative prevalence of upper extremity neuropathies in patients undergoing surgery for nerve compression headaches was 16.7 percent. The prevalence of carpal tunnel syndrome was 10.2 percent, which is 1.8- to 3.8-fold more common than in the general population. Thoracic outlet syndrome prevalence was 3.6 percent, with no available general population data for comparison. Cubital tunnel syndrome prevalence was comparable between groups.

Conclusions: The degree of overlap between nerve compression syndromes of the head/neck and upper extremity suggests that peripheral nerve surgeons should be aware of this correlation and screen affected patients comprehensively. Similar patient presentation, treatment, and anatomical basis of nerve compression make either amenable to treatment by nerve surgeons, and treatment of both entities should be an integral part of a formal peripheral nerve surgery curriculum.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PRS.0000000000008574DOI Listing
December 2021

Factors Associated with Reoperation after Pyrocarbon Proximal Interphalangeal Joint Arthroplasty for the Arthritic Joint: A Retrospective Cohort Study.

J Hand Microsurg 2021 Jul 9;13(3):132-137. Epub 2020 Apr 9.

Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States.

 The rate of reoperation after pyrocarbon proximal interphalangeal (PIP) joint arthroplasty ranges from 5.9 to 37% and complications such as radiographic loosening, deformity, dislocation, and stiffness are common. Because of the limited amount of knowledge around these problems, we evaluated factors associated with reoperation after pyrocarbon PIP arthroplasty.  We retrospectively included all adult patients that underwent primary PIP pyrocarbon implant arthroplasty between 2002 and 2016 at one institutional system. A total of 45 patients, with a mean age of 55 (standard deviation: 14), underwent 66 PIP arthroplasties. To address for within individual correlations, we only included fingers treated at patients' initial surgery ( = 54) in our statistical analysis. These patients were predominantly diagnosed with noninflammatory arthritis 73% ( = 33). Arthroplasty was performed upon 10 index, 22 middle, 20 ring, and 2 small fingers.  The reoperation rate after pyrocarbon PIP arthroplasty was 30% over a median follow-up of 25 months (interquartile range: 8.7-54). Indications for reoperation consisted of subluxation ( = 6), stiffness ( = 5), swan-neck deformity ( = 3), and soft tissue complications ( = 2). Younger age ( = 0.025), male sex ( = 0.017), and noninflammatory arthritis ( = 0.038) were associated with a higher reoperation rate.  In this study, our reoperation rate after pyrocarbon PIP arthroplasty was 30%. This study suggested that younger patients, males, and patients with noninflammatory arthritis are at higher risk of reoperation. We recommend considering these factors when selecting candidates for pyrocarbon arthroplasty. Future studies should focus on prospectively researching these factors in comparison with other implants.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0040-1709088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8440050PMC
July 2021

A Quantitative Analysis of Subchondral Bone Density Around Osteochondritis Dissecans Lesions of the Capitellum.

J Hand Surg Am 2022 Aug 25;47(8):790.e1-790.e11. Epub 2021 Aug 25.

Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA.

Purpose: In capitellar osteochondritis dissecans (OCD), unstable lesions generally demonstrate signs of subchondral sclerosis. We postulate that OCD lesions have abnormal subchondral bone density. We aimed to quantify the subchondral bone thickness around OCD lesions using conventional computed tomography (CT) imaging.

Methods: This retrospective study included 15 patients with capitellar OCD (OCD group) and 12 patients with an unaffected radio-capitellar joint (control group). We constructed 3-dimensional humerus models using CT data and quantified the bone density with colored contour mapping to determine the subchondral bone thickness. We measured the thickness relative to the condylar height at the centroid and lateral, medial, superior, and inferior edge points of the OCD lesion, and compared the findings between the groups. We then correlated the CT measurements with the magnetic resonance imaging measurements.

Results: Subchondral bone thickness at the centroid and lateral, medial, superior, and inferior edges in the OCD group was significantly higher than that in the control group. Correlation analyses revealed that the magnetic resonance imaging measurements highly correlated with the CT subchondral bone measurements.

Conclusions: We found that there is a zone of increased subchondral bone thickness around OCD lesions that should be considered during drilling, microfracture, or other reconstruction methods. We observed a high correlation with low errors between the measurements taken from conventional CT images and the measurements from magnetic resonance imaging, suggesting that both modalities are useful in clinical decision making.

Type Of Study/level Of Evidence: Diagnostic IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jhsa.2021.06.020DOI Listing
August 2022

Joint-sparing versus nonjoint-sparing reconstruction of the radius following oncologic resection: A systematic review.

J Surg Oncol 2021 Dec 25;124(8):1523-1535. Epub 2021 Aug 25.

Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Background And Objectives: Reconstructions of the distal radius are uncommon procedures. This systematic review compares joints-sparing (JS) versus nonjoint-sparing (NJS) reconstructions following oncologic resection of the distal radius.

Methods: A search was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Collected outcomes included patient-reported outcome measures (PROMs), range of motion and grip strength, and complication and reoperation rates.

Results: A total of 52 nonrandomized cohort studies (n = 715) were included. PROMs were comparable between the cohorts, while the range of flexion-extension was greater in JS reconstructions (78.1° vs. 25.6°) and the range of pronation-supination was greater in NJS reconstructions (133.6° vs. 109.8°). Relative grip strength was greater following JS reconstruction (65.0% vs. 56.4%). About one in sixteen of the JS reconstructions were eventually revised to an NJS construct.

Conclusions: This systematic review demonstrates that JS reconstructive techniques can offer satisfying results in patients treated for oncologic distal radius defects. However, about 6% of JS reconstructions are eventually revised to a NJS construct. Further investigation is warranted to identify factors that affect or predict these findings, to aid in future in treatment selection and reduce the common need for reoperations following these procedures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jso.26660DOI Listing
December 2021

Surface osteosarcoma: Predictors of outcomes.

J Surg Oncol 2021 Sep 27;124(4):646-654. Epub 2021 May 27.

Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Background And Objectives: The subtypes of surface osteosarcomas include well-differentiated, low-grade parosteal osteosarcoma (POS), intermediate-grade periosteal osteosarcoma (PerOS), high-grade surface osteosarcoma (HGSO), and high-grade, dedifferentiated POS (dPOS). We aimed to determine disease progression, defined as local recurrence and metastatic disease, and overall (OS) and disease-specific survival (DSS). We identify outcome predictive factors and report functional results.

Methods: This retrospective study evaluated patients with primary surface osteosarcoma at our hospital from 1992 to 2019. Fifty-one patients had a median follow-up of 6.1 years (range: 0.1-25.2). Histologic subtypes included 32 POS, 11 PerOS, 4 HGSO, and 3 dPOS. Bone and soft tissue margins were classified using the American Joint Committee on Cancer residual tumor classification (Rx = Not evaluable; R0 = negative margin; R1 = microscopic positive margin; and R2 = macroscopic positive margin) and the modified R classification (mRx = not evaluable; mR0 = negative margin >1 mm; mR1 = negative margin ≤1 mm; mR1-dir: Positive microscopic margin locally; mR2a: Positive macroscopic margin locally; mR2b: positive macroscopic margin distally; and mR2C: positive macroscopic margin locally and distally). Forty-one patients had functional outcomes.

Results: Three POS patients developed recurrence: two had R0 margins and one an intralesional resection. Five patients developed lung metastases (POS: 3, dPOS: 2). Four patients died. The only significant disease progression predictor was age. OS at 10 years was 97%. 48 patients had negative bone margins (R0 or mR0 and mR1) and 47 patients had negative soft-tissue margins (R0 or mR0 and mR1). The average MSTS score was 88.43 (range: 34.29-100).

Conclusions: We advocate surgery for POS and believe R0 (mR0 and mR1 resections) or planned R1 (mR1-dir) to preserve function are acceptable. We favor chemotherapy and surgery for PerOS, though a chemotherapeutic response is highly variable. High-grade tumors are the most infrequent subtype, but HGSO and dPOS seem to portend a poorer prognosis. Good function can be obtained.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jso.26531DOI Listing
September 2021

Patient Reported Outcomes of Long Head Biceps Tenodesis after Spontaneous Rupture.

Arch Bone Jt Surg 2021 Mar;9(2):195-202

Hand and Upper Extremity Service, Department of Orthopedic Surgery, Massachusetts General Hospital, MA, USA.

Background: The aim of this study was to evaluate the factors influencing patient reported outcome measures (PROM) of biceps tenodesis after the rupture of proximal long head of the biceps tendon.

Methods: Retrospective chart review was conducted to identify patients with complete proximal rupture of the long head of the biceps that underwent biceps tenodesis between 2002-2017. This yielded 42 patients, of which 23 (55%) completed the PROMIS Pain Interference, PROMIS Upper Extremity, Quick DASH, and a custom biceps tear questionnaire, at a median of 8.5 years (IQR:5.2-12) post-operatively. The median age of the respondents was 57 years (IQR: 43-61). The majority of patients (n=12, 52%) underwent tenodesis using suture anchor fixation, while the remaining underwent tenodesis with interference screw technique (n=6, 26%), key hole technique (n=1, 4.3%), or tunnel technique (n=1, 4.3%). A bivariate analysis was performed to evaluate factors influencing the PROMs.

Results: Six patients (27%) reported persistent biceps cramping at a median of 8.2 years post-operatively, negatively impacting PROMs, and this was associated with older age. Six patients (27%) had post-operative complications, including infection, pain, stiffness, and re-rupture, of which four patients (17%) underwent reoperation. Patients with activity/sports-induced injury or those that underwent tenodesis using a suture anchor technique demonstrated better PROMs.

Conclusion: Post-operative biceps cramping persists in almost one-third of patients and significantly impacts PROMs. Patient activity level and the use of suture anchor technique for tenodesis were independent predictors of improved biceps tenodesis outcome scores.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.22038/abjs.2020.48669.2414DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8121026PMC
March 2021

Evaluation of the Proximal Ulna Dorsal Angulation for Ulnar Component Sizing in Elbow Prosthetic Reconstruction After Distal Humeral Resection of Tumor.

J Am Acad Orthop Surg Glob Res Rev 2020 05;4(5):e2000062

From the Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Dr. Yeung, Dr. Lans, Dr. Kuechle, Wright, and Dr. Lozano-Calderón), and the Division of Musculoskeletal Radiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Dr. Chang).

Introduction: Elbow prosthetic reconstruction after distal humeral tumor resection is challenging. We identify the value of the proximal ulna dorsal angulation (PUDA) as an easily-measured radiographic parameter that can help inform ulnar component sizing in the Solar Elbow System (SES) and the Modular Universal Tumor and Revision System (MUTARS), two modular prosthetic systems that are commonly used after tumor resection in this anatomic location. We hypothesized that a larger PUDA measurement would require smaller ulnar stems.

Methods: Demographic data and PUDA measurements were retrospectively reviewed for 514 patients. Multivariate regression was used to determine the effects of patient demographic data on the PUDA. PUDA measurements were collected by three independent reviewers on lateral elbow radiographs. MUTARS and SES templating software was then used to validate the relationship between the PUDA and ulnar stem sizing.

Results: Regression analysis showed no substantial contribution of demographic variables to the PUDA measurement (adjusted R2 = 0.02, F(6, 508) = 2.704, P = 0.01). The MUTARS implant fit 97% of elbows with a PUDA <5° and 91.6% of elbows with PUDA ≥5° (P = 0.26). The largest SES combination fit 100% of elbows with a PUDA ≤10° versus 93% of elbows with a PUDA >10° (P = 0.029). Elbows accommodating the largest SES combination had a smaller median PUDA (5.4° versus 11.7°, P = 0.034); elbows accommodating the MUTARS implant had a smaller median PUDA (5.4° versus 5.8°, P = 0.34).

Discussion: The PUDA is a valuable and easily used preoperative planning tool for prosthetic elbow reconstruction after tumor resection. The proximal ulna dorsal angulation can be easily measured to predict ulnar component fit and reduce intraoperative complications. In patients with a PUDA ≥5°, ulnar component stem fit for current systems may be more challenging.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5435/JAAOSGlobal-D-20-00062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7434037PMC
May 2020

Corrigendum to 'Soft tissue sarcoma of the hand: Is unplanned excision a problem? [Eur J Surg Oncol 45/7 (2019) 1281-1287].

Eur J Surg Oncol 2021 May 5;47(5):1232. Epub 2021 Mar 5.

Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Wang 435, 15 Parkman Street, Boston, MA, 02114, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ejso.2021.02.022DOI Listing
May 2021

Long-term patient-reported outcome measures following limb salvage with complex reconstruction or amputation in the treatment of upper extremity sarcoma.

J Surg Oncol 2021 Apr 2;123(5):1328-1335. Epub 2021 Mar 2.

Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Background And Objectives: This study compares long-term patient-reported outcomes between patients that underwent limb-salvage surgery with complex reconstruction by free or pedicled flap (LS) or amputation. Additionally, the need for revision surgery is compared.

Methods: A total of 43 patients were studied at a median follow-up of 9.54 years. Sixteen patients completed questionnaires regarding functional outcome and mental wellbeing. Functional outcomes were measured by using the Toronto Extremity Salvage Score (TESS), QuickDASH, and PROMIS Upper Extremity instruments. Mental wellbeing was assessed using the PROMIS Anxiety and Depression instruments. Revision surgery was assessed for the entire follow-up.

Results: The median TESS scores were 96.0 versus 71.7 (p = 0.034) and the PROMIS Upper Extremity scores were 50.1 versus 40.3 (p = 0.039) for the LS and amputation cohorts, respectively. No significant difference was found regarding symptoms of anxiety (52.7 vs. 53.8; p = 0.587) or depression (52.0 vs. 50.5; p = 0.745). Of the patients in the LS cohort 51.6% required at least one reoperation compared to 8.33% in the amputation cohort.

Conclusions: LS surgery maintains functional benefits over amputation after almost a decade of follow-up. Still, mental wellbeing seems to be comparable between these patients, whereas LS procedures are associated with a sixfold increased need for reoperations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jso.26426DOI Listing
April 2021

Osteoarticular allograft reconstruction after distal radius tumor resection: Reoperation and patient reported outcomes.

J Surg Oncol 2021 Apr 9;123(5):1304-1315. Epub 2021 Feb 9.

Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Background: The aims of this study are to evaluate the rate of wrist joint preservation, allograft retention, factors associated with reoperation and to report the patient reported outcomes after osteoarticular allograft reconstruction of the distal radius.

Methods: Retrospective chart review identified 33 patients who underwent distal radius resection followed by osteoarticular allograft reconstruction, including 27 giant cell tumors and 6 primary malignancies. Ten patients with a preserved wrist joint completed the QuickDASH, PROMIS-CA physical function, and Toronto extremity salvage score (TESS) at a median of 13 years postoperatively.

Results: The allograft retention rate was 89%, and an allograft fracture predisposed to conversion to wrist arthrodesis. The reoperation rate was 55% and 36% underwent wrist arthrodesis at a median of 4.2 years following index surgery. The use of locking plate fixation was associated with lower reoperation and allograft fracture rates. Patients reported a median QuickDASH of 10.2 (range: 0-52.3), a mean PROMIS physical function of 57.8 (range: 38.9-64.5) and the median TESS was 95.5 (range: 67.0-98.4).

Conclusion: Osteoarticular allograft reconstruction results in acceptable long-term patient reported outcomes, despite a high revision rate. Allograft fixation with locking plates seems to reduce the number of reoperations and allograft fractures, along with reduction in wrist arthrodesis rates.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jso.26405DOI Listing
April 2021

An Economic Analysis of Direct Costs of Distal Radius Fixation and the Implications of a Disposable Distal Radius Kit.

J Orthop Trauma 2021 09;35(9):e346-e351

Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA.

Objective: To assess the direct costs of distal radius fracture volar plate (VP) fixation and to create a model to examine the effect of these cost drivers.

Materials And Methods: Retrospectively, 744 distal radius fractures treated with open reduction and internal fixation (ORIF) were identified. The outcomes assessed included (1) the direct costs related to distal radius ORIF and (2) if a VP alone was amenable. Costs were represented as a cost ratio relative to the average cost of distal radius ORIF, where the average value is set as 1.0. Simulation models were run with all cost drivers (sex, age, open fracture, intra-articular fracture, and ancillary fixation) and with only ancillary fixation as a cost driver.

Results: The cost ratio ranged from 0.61 to 1.81 and ancillary fixation was associated with increased implant costs in multivariable analysis. In the simulations, the cost ratio ranged from 0.96 to 1.23 when all cost drivers were included and from 0.99 to 1.20 if only ancillary fixation was included as a cost driver, a reduction of the range by 22.2%. Older patients, females, closed fractures, and extra-articular fractures were more amenable to VP fixation alone.

Conclusions: Eighty-three percent of the surgically treated distal radius fractures were treated with VP fixation alone. A disposable kit could help limit cost variance per case by roughly 22%, as only ancillary fixation varies these costs. Closed fractures and extra-articular fractures in older patients or female patients are more amenable to VP fixation alone.

Level Of Evidence: Economic Level III. See Instructions for Authors for a complete description of levels of evidence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BOT.0000000000002049DOI Listing
September 2021

Factors associated with 30-day soft tissue complications following upper extremity sarcoma surgery.

J Surg Oncol 2021 Feb 17;123(2):521-531. Epub 2020 Dec 17.

Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.

Background And Objectives: The incidence of soft tissue complications following sarcoma surgery in the upper extremity is reportedly high. Therefore, this study assessed the National Surgical Quality Improvement Program (NSQIP) database to identify independent risk factors, while also reporting the incidence of soft tissue complications in the first 30 days after surgery.

Methods: A total of 620 patients that underwent surgical treatment for upper extremity sarcoma were included from the NSQIP database. Soft tissue complications were defined as surgical site infection, wound dehiscence, or soft-tissue related reoperations. Clinically relevant patient and treatment characteristics were selected and analyzed.

Results: The 30-day soft tissue complication rate was 4.7%. In the multivariable analysis, higher body mass index (p = .047) and longer operative times (p = .002) were independently associated with soft tissue complications.

Conclusions: Higher body mass index and longer operative times are risk factors for soft tissue complications following upper extremity sarcoma surgery. The soft-tissue complication rate following resection of upper extremity tumors is low in this national cohort, possibly due to the relatively small tumor size and low prevalence of radiotherapy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jso.26311DOI Listing
February 2021

Complications and Factors Associated with Reoperation following Total Wrist Fusion.

J Wrist Surg 2020 Dec 21;9(6):498-508. Epub 2020 Aug 21.

Department of Orthopaedic Surgery, Hand and Upper Extremity Service, General Hospital, Harvard Medical School, Boston, Massachusetts.

 Total wrist fusion can be elected to relieve pain in patients with osteoarthritis and rheumatoid arthritis. This study aimed to investigate the overall complications and the factors associated with reoperation and soft tissue complication after total wrist fusion.  We retrospectively identified adult patients who underwent total wrist fusion using Current Procedural Terminology (CPT) codes, International Classification of Diseases, Ninth and Tenth Revision (ICD-9 and ICD-10) and verified these by medical chart review. We included patients (  = 215) who were treated at a single institutional system from January 1, 2002 to January 1, 2019. The mean age was 53.3 ± 15.0 years and the median follow-up was 6.1 years (interquartile range [IQR] =1.7-9.0). The most common indications for wrist fusion included inflammatory arthritis (  = 66, 31%), degenerative arthritis (  = 59, 27%), and posttraumatic arthritis (  = 47, 22%). All wrist fusions were performed using a dorsal fusion plate or dorsal spanning plate, either with a local autograft (  = 167, 78%), iliac crest autograft (  = 2, 1.0%), allograft (  = 7, 3.3%), a combination of both (  = 16, 7.4%), or without a graft (  = 23, 11%). We performed a multivariable logistic regression to evaluate factors associated with reoperation. In addition, we performed a similar analysis to identify the factors associated with soft tissue complication after total wrist fusion.  Forty-one (19%) patients underwent reoperation at a median of 6.9 months (IQR = 3.9-18). The indications included symptomatic implants (  = 12, 27%), implant failures (  = 8, 20%), infections (  = 7, 17%), and nonunions (  = 6, 15%). In multivariable analysis, total wrist fusion of the dominant hand (odds ratio [OR]: 2.2, 95% confidence interval [CI]: 1.1-4.7,  = 0.033) was associated with a higher reoperation rate. Soft tissue complications occurred in 20 patients (9.3%) consisting of hematomas (  = 8, 3.7%), observed blistering (  = 5, 2.3%), and observed wound dehiscence (  = 4, 1.9%). In multivariable analysis, smoking (OR: 2.5, CI: 0.95-6.4,  = 0.010) was independently associated with soft tissue complication after total wrist fusion. Seventy-two (33%) patients had a postoperative complication including symptomatic hardware (  = 16, 7.4%), implant failure (  = 11, 5.1%), infection (  = 11, 5.1%), nonunion (  = 8, 3.7%), and carpal tunnel syndrome (  = 4, 1.9%).  Roughly one-third (33%) of the patients undergoing total wrist fusion experience a postoperative complication and 19% of the patients underwent a reoperation. Total wrist fusion of the dominant hand results in higher reoperation rates. The risk of a soft tissue complication after total wrist fusion is increased in smokers.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0040-1714683DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7708030PMC
December 2020

Degenerative changes in the elbow joint after radial head excision for fracture: quantitative 3-dimensional analysis of bone density, stress distribution, and bone morphology.

J Shoulder Elbow Surg 2021 May 2;30(5):e199-e211. Epub 2020 Nov 2.

Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

Hypothesis And Background: Some investigators speculate that excision may lead to elbow arthritis and associated problems; however, evidence supporting this theory is limited. It is hypothesized that radial head excision causes bone density changes as a result of asymmetrical stress distributions, consequently leading to osteophyte formation. In this study, we sought to quantitatively compare the 3-dimensional (3D) bone density and stress distributions between operative and nonoperative elbows in patients who underwent radial head excision. Furthermore, we aimed to quantify the bone morphologic changes using 3D models in the same cohort.

Methods: After retrospective identification, this study enrolled 6 patients who had undergone radial head excision for radial head fractures. We created 3D bone models using computed tomography data obtained from the injured and uninjured elbows. Humerus and ulna models were divided into anatomic regions, and the bone density of each region was assessed and described by its percentage of high-density volume (%HDV). We also constructed finite element models and measured the stress values in each region. Furthermore, we compared the bone morphology by superimposing the operative elbow onto the mirror image of the nonoperative elbow.

Results: The mean interval from radial head excision to examination was 8.4 ± 3.3 years. The %HDV on the operative side was higher than that of the nonoperative side at the anterolateral trochlea (77.5% ± 6.5% vs. 64.6% ± 4.0%, P = .028) and posterolateral trochlea (70.7% ± 7.8% vs. 63.1% ± 3.8%, P = .034) regions of the distal humerus. Reciprocal changes were observed in the proximal ulna, as %HDV was higher in the lateral coronoid (52.6% ± 9.6% vs. 34.2% ± 6.6%, P = .007). The stress distributions paralleled the bone density measurements. The operative elbows demonstrated an enlarged capitellum and a widened and deepened trochlea with osteophyte formation compared with the nonoperative side.

Discussion And Conclusion: In elbows treated with radial head excision, we identified asymmetrical bone density and stress alterations on the lateral side of the ulnohumeral joint and bone morphologic changes across the joint. These data support the theory that radial head excision contributes to ulnohumeral arthritis over the long term.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2020.09.035DOI Listing
May 2021

Risk Factors for Neuropathic Pain Following Major Upper Extremity Amputation.

J Reconstr Microsurg 2021 Jun 14;37(5):413-420. Epub 2020 Oct 14.

Division of Plastic Surgery, Hand Surgery, and Peripheral Nerve Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Background:  Active treatment (targeted muscle reinnervation [TMR] or regenerative peripheral nerve interfaces [RPNIs]) of the amputated nerve ends has gained momentum to mitigate neuropathic pain following amputation. Therefore, the aim of this study is to determine the predictors for the development of neuropathic pain after major upper extremity amputation.

Methods:  Retrospectively, 142 adult patients who underwent 148 amputations of the upper extremity between 2000 and 2019 were identified through medical chart review. All upper extremity amputations proximal to the metacarpophalangeal joints were included. Patients with a follow-up of less than 6 months and those who underwent TMR or RPNI at the time of amputation were excluded. Neuropathic pain was defined as phantom limb pain or a symptomatic neuroma reported in the medical charts at 6 months postoperatively. Most common indications for amputation were oncology ( = 53, 37%) and trauma ( = 45, 32%), with transhumeral amputations ( = 44, 30%) and shoulder amputations ( = 37, 25%) being the most prevalent.

Results:  Neuropathic pain occurred in 42% of patients, of which 48 (32%) had phantom limb pain, 8 (5.4%) had a symptomatic neuroma, and 6 (4.1%) had a combination of both. In multivariable analysis, traumatic amputations (odds ratio [OR]: 4.1,  = 0.015), transhumeral amputations (OR: 3.9,  = 0.024), and forequarter amputations (OR: 8.4,  = 0.003) were independently associated with the development of neuropathic pain.

Conclusion:  In patients with an upper extremity amputation proximal to the elbow or for trauma, there is an increased risk of developing neuropathic pain. In these patients, primary TMR/RPNI should be considered and this warrants a multidisciplinary approach involving general trauma surgeons, orthopaedic surgeons, plastic surgeons, and vascular surgeons.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0040-1718547DOI Listing
June 2021

Bone resorption of the greater tuberosity after open reduction and internal fixation of complex proximal humeral fractures: fragment characteristics and intraoperative risk factors.

J Shoulder Elbow Surg 2021 Jul 7;30(7):1626-1635. Epub 2020 Oct 7.

Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

Hypothesis And Background: In complex proximal humeral fractures, bone resorption of the greater tuberosity is sometimes observed after open reduction and internal fixation (ORIF). However, this has not been well characterized, and risk factors for resorption are not completely understood. We aimed (1) to identify the risk factors associated with bone resorption of the greater tuberosity and (2) to quantify the geometric and bone density characteristics associated with bone resorption using 3-dimensional computed tomography models in complex proximal humeral fractures treated with ORIF.

Methods: We identified a retrospective cohort of 136 patients who underwent ORIF of 3- or 4-part proximal humeral fractures; greater tuberosity resorption developed after ORIF in 30 of these patients. We collected demographic, fracture-related, and surgery-related characteristics and performed multivariable logistic regression analysis to identify factors independently associated with the development of greater tuberosity resorption. Furthermore, we identified 30 age- and sex-matched patients by use of propensity score matching to perform quantitative fragment-specific analysis using 3-dimensional computed tomography models. After the fragment of the greater tuberosity was identified, the number of fragments, the relative fragment volume to the humeral head, and the relative bone density to the coracoid process were calculated. Measurements were compared between matched case-control groups.

Results: We found that an unreduced greater tuberosity (odds ratio [OR], 10.9; P < .001), inadequate medial support at the calcar (OR, 15.0; P < .001), and the use of an intramedullary fibular strut (OR, 4.5; P = .018) were independently associated with a higher risk of bone resorption. Quantitative fragment-specific analysis showed that greater tuberosities with a larger number of fragments (5 ± 2 vs. 3 ± 2, P = .021), smaller fragments (9.9% ± 3.8% vs. 18.6% ± 4.7%, P < .001), and fragments with a lower bone density (66.4% ± 14.3% vs. 88.0% ± 18.4%, P = .001) had higher rates of resorption.

Discussion And Conclusion: An unreduced greater tuberosity or inadequate medial support increases the risk of greater tuberosity resorption, as do a larger number of fracture fragments, smaller fragments, and lower bone density. Additionally, fibular strut grafting is an independent risk factor for tuberosity resorption. Further study is needed, but alternatives to strut grafting such as femoral head allograft may warrant serious consideration.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2020.09.014DOI Listing
July 2021

Soft-tissue Sarcoma of the Hand: Patient Characteristics, Treatment, and Oncologic Outcomes.

J Am Acad Orthop Surg 2021 Mar;29(6):e297-e307

From the Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Yawkey Center, Boston, MA (Dr. Lans and Dr. Chen), the Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Ms. Yue and Dr. Lozano Calderon), the Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands (Dr. Castelein), and the Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Yawkey Center, Boston, MA (Dr. Suster and Dr. Nielsen).

Introduction: The aim of this study was to describe patient characteristics, treatment, and oncologic outcomes of soft-tissue sarcomas (STSs) of the hand.

Methods: Sixty-nine STSs of the hand in adult patients treated at a tertiary referral center were retrospectively included. We describe patient and tumor characteristics along with oncologic outcomes.

Results: Epithelioid sarcoma (23%) was the most common histologic subtype, followed by synovial sarcoma (15%). Of all tumors, 17 (25%) were grade I, 22 (32%) were grade II, and 30 (44%) were grade III. The 5-year disease-free survival for epithelioid sarcomas was 75% with a disease survival of 100%, along with a metastatic rate of 15%. Of the patients with a synovial sarcoma, 40% developed metastases, and the 5-year disease-free survival was 68% and the 5-year disease survival was 73%.

Conclusion: Hand STSs are aggressive tumors with a high metastatic potential. Even with adequate oncologic treatment, long-term clinical follow-up (10 years) in these tumors is advised. The treating surgical oncologist should not be deceived by their smaller size.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5435/JAAOS-D-20-00434DOI Listing
March 2021

Bone density measurements from CT scans may predict the healing capacity of scaphoid waist fractures.

Bone Joint J 2020 Sep;102-B(9):1200-1209

Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Aims: We quantitatively compared the 3D bone density distributions on CT scans performed on scaphoid waist fractures subacutely that went on to union or nonunion, and assessed whether 2D CT evaluations correlate with 3D bone density evaluations.

Methods: We constructed 3D models from 17 scaphoid waist fracture CTs performed between four to 18 weeks after fracture that did not unite (nonunion group), 17 age-matched scaphoid waist fracture CTs that healed (union group), and 17 age-matched control CTs without injury (control group). We measured the 3D bone density for the distal and proximal fragments relative to the triquetrum bone density and compared findings among the three groups. We then performed bone density measurements using 2D CT and evaluated the correlation with 3D bone densities. We identified the optimal cutoff with diagnostic values of the 2D method to predict nonunion with receiver operating characteristic (ROC) curves.

Results: In the nonunion group, both the distal (100.2%) and proximal (126.6%) fragments had a significantly higher bone density compared to the union (distal: 85.7%; proximal: 108.3%) or control groups (distal: 91.6%; proximal: 109.1%) using the 3D bone density measurement, which were statistically significant for all comparisons. 2D measurements were highly correlated to 3D bone density measurements (Spearman's correlation coefficient (R) = 0.85 to 0.95). Using 2D measurements, ROC curve analysis revealed the optimal cutoffs of 90.8% and 116.3% for distal and proximal fragments. This led to a sensitivity of 1.00 if either cutoff is met and a specificity of 0.82 when both cutoffs are met.

Conclusion: Using 3D modelling software, nonunions were found to exhibit bone density increases in both the distal and proximal fragments in CTs performed between four to 18 weeks after fracture during the course of treatment. 2D bone density measurements using standard CT scans correlate well with 3D models. In patients with scaphoid fractures, CT bone density measurements may be useful in predicting the likelihood of nonunion. Cite this article: 2020;102-B(9):1200-1209.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1302/0301-620X.102B9.BJJ-2020-0169.R2DOI Listing
September 2020

Angioleiomyoma of the Hand: A Case Series and Review of the Literature.

Arch Bone Jt Surg 2020 May;8(3):373-377

Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

Background: Angioleiomyomas are rare tumors arising from vascular tissue that can occasionally present in the hand. Reports of angioleiomyomas in this location are highly limited. Here, we describe the presentation and outcomes of a series of cases of angioleiomyomas.

Methods: A retrospective case review of five patients with angioleiomyomas arising in the hand was performed. Patients were identified via International Classification of Diseases, Ninth and Tenth Revision (ICD-9 and ICD-10) diagnosis codes and were reviewed through the electronic medical record for demographic information, tumor characteristics, management, and outcomes. A literature review was also conducted of angioleiomyomas.

Results: Five patients were diagnosed with angioleiomyoma at our institution between 1992 and 2015. Patients presented with a painful, slow-growing hand mass in all cases. The majority of patients were male and of middle-age. All of the patients were successfully treated with marginal excision and had full return to functional status without recurrence.

Conclusion: Angioleiomyomas are rare tumors that can arise in the hand and should be included in the differential diagnosis of a patient presenting with a painful hand mass. They can be successfully treated with marginal excision.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.22038/ABJS.2019.14129DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358226PMC
May 2020
-->