Faculty Bibliography

BACKGROUND:Wide-awake local anesthesia no tourniquet (WALANT) surgery offers a unique clinical and economic approach to delivering high-quality upper extremity care.Purpose:This article explores the evoluation, techniques, clinical efficancy, financial advantages, and future directions of WALANT as it establishes is growing role in value-based orthopedic care. In doing so, it outlines the value proposition of WALANT for patients, providers, and the hospital system. METHODS:The authors conducted a comprehensive PubMed search to identify studies evaluating the clinical and economic outcomes of WALANT surgery in upper extremity procedures. Eligible studies included prospective and retrospective research, as well as case studies and case series, comparing WALANT with traditional anesthesia. The studies examined focused on metrics such as functional outcomes, patient satisfaction, and cost savings for the patient and the hospital system. RESULTS:Current literature shows that hand and upper extremity surgery performed under WALANT yields similar functional outcomes and even demonstrates equal or higher patient satisfaction compared with traditional anesthesia. Regarding cost savings, WALANT's minimalist approach to procedures can lead to significant waste reduction and notable financial benefits for the patient, the provider, the hospital, and the wider healthcare system. CONCLUSIONS:WALANT surgery offers a compelling value proposition for the patient, the provider, and the healthcare system at large. Through efficient use of resources focused on minimizing waste and optimizing patient experience and outcomes, WALANT offers an opportunity for value-based surgical care. Further research into more sophisticated clinical uses and large-scale cost-savings analyses is necessary for WALANT procedures to be further validated and more broadly adopted. LEVEL OF EVIDENCE/METHODS:Level V.Key Words: wide-awake surgery, WALANT, upper extremity surgery, hand surgery.

This case is a 37-year-old man with diffuse primary synovial chondromatosis of the elbow, with associated ulnar nerve compression and flexion contracture at the elbow. An open synovectomy with removal of loose bodies and an ulnar nerve decompression with anterior subcutaneous transposition were performed. Postoperatively, the patient's elbow mobility and nerve compression symptoms improved steadily, which significantly improved his function. Primary synovial chondromatosis of the elbow is a rare disease that can result in pain, swelling, decreased range of motion, and mechanical symptoms. Treatment usually involves synovectomy and removal of loose bodies to address patients' pain and joint motion.

Since the beginning of documented medical history, amputation procedures, limb loss, and the myriad creative solutions attempted to care for these individuals have been reported. With the coalescence of multiple World Wars resulting in an ever-increasing number of individuals with limb loss and advancing medical technology, a need to innovate in this field has always been present. The complexity of the hand and upper extremity in self-care, communication, vocation, and exercise results in more demands of prostheses to mimic or replace these functions as opposed to the lower extremity, which is focused mostly on weight bearing and ambulation. As such, this need has pushed technological advances past the simpler passive or body-powered prostheses alone, now with externally powered and hybrid devices revolutionizing the way these appliances were implemented in everyday life. Despite the ever-advancing field of prosthetic technology, upper and lower extremity amputees alike still battle common challenges of pain, phantom limb sensation, and lack of prosthetic control and sensation. Targeted muscle reinnervation and regenerative peripheral nerve interface offer new surgical solutions to some of these challenges and are proving invaluable. As technology and surgical options continue to advance at an ever-rapid pace, a more thoughtful and individualized approach to the care of upper extremity limb loss is available. In this study, we review the history and evolution of upper extremity prostheses and discuss considerations in making optimal surgical and prosthetic decisions for upper extremity amputees.

The scapholunate ligament (SLL) is a critical stabilizer of the wrist joint. Disruption of the SLL leads to altered wrist kinematics, including scaphoid flexion, lunate extension, and increased stress on surrounding cartilage and ligaments, which can progress to dorsal intercalated segment instability and scapholunate advanced collapse. Despite predictable biomechanical changes, clinical outcomes vary widely because some patients develop significant functional limitations, whereas others remain asymptomatic. Nonoperative management, including immobilization, therapy, and bracing, remains the first-line treatment for partial tears or stable injuries. Surgical intervention, such as SLL repair with capsulodesis or reconstruction, is indicated for cases with persistent pain, instability, or functional deficits. Capsulodesis is a commonly used adjunct to SLL repair. Multiple surgical techniques exist for SLL repair in the acute setting and for reconstruction in the chronic setting when SLL is deemed irreparable. Although several surgical techniques are available for chronic injuries, a gold standard has not yet been established.

PURPOSE/UNASSIGNED:The anatomy of the "critical corner" in volar lunate facet fractures makes achieving fixation difficult, and standard precontoured volar locking plates may be limited in certain fracture patterns. The purpose of this review was to identify various fixation techniques for the volar lunate facet and review the outcomes data associated with each fixation method. METHODS/UNASSIGNED:A review of the literature was performed by first screening the PubMed database for relevant articles using key terms: "volar lunate facet," "critical corner," and "distal radius fractures." Two reviewers independently assessed all 87 articles for relevance. Articles were included if both reviewers agreed on their inclusion and if they described an alternative fixation method for treating volar lunate facet fractures. The reviewers then extracted as much data as possible regarding the fixation methods, including technique, sample size, follow-up period, and various outcomes such as range of motion, grip strength, return to work, and rates of union. RESULTS/UNASSIGNED:Of the 28 articles that were included, the fixation methods reviewed were categorized into direct Kirschner wire fixation, compression fixation-"spring wire fixation," tension fixation-"wire-loop fixation," and containment fixation with the use of a buttress pin in various configurations. These alternative fixation methods had high rates of union, few complications, and good to excellent clinical outcomes. CONCLUSIONS/UNASSIGNED:The limitations of using a single volar locking plate for volar lunate facet fractures have led to the development of novel fixation techniques. Although these alternative fixation methods have demonstrated promising outcomes, the existing studies have small sample sizes. CLINICAL RELEVANCE/UNASSIGNED:Distal radius fractures involving the volar lunate facet present a challenge in operative fixation due to the various anatomical features described. Each unique fracture pattern must be thoroughly evaluated to determine the most appropriate fixation method.

PURPOSE/OBJECTIVE:The purpose of this study was to conduct a systematic review evaluating the reported complications and outcomes of bone-anchored prostheses in digit and partial hand amputees. METHODS:A literature review of primary research articles on osseointegration and bone-anchored prostheses for digit and partial amputees was performed. The Medline, Embase, Scopus, and Cochrane Library databases were queried. Inclusion criteria were journal articles that evaluated osseointegration and bone-anchored prostheses in digit and partial hand amputees. The main outcome measures were reported complications and the need for revision surgery. Secondary outcomes included all reported outcome assessments. RESULTS:Fifteen articles were included with publication dates ranging from 1996 to 2022. The sample sizes ranged from single-patient case reports to a 13-patient retrospective study. Overall, 33 men and 16 women were reported with a mean age of 33.6 years (range: 12-68) and a total of 71 amputated digits. The median follow-up was 2.1 years (IQR: 1.1-6.8 years). A total of 24 complications were reported in 14 digits (19.7%). Complications included superficial infection in 6 digits (8.5%), abutment loosening or failure in 5 (7%), fixture aseptic loosening in 4 (5.6%), deep infection in 1 (1.4%), and soft tissue instability in 1 (1.4%). Sixteen revision surgeries or component changes were reported. CONCLUSIONS:Bone-anchored prostheses using osseointegrated implants in the hand are associated with favorable outcomes in the limited number of low-quality studies available for review. Superficial infections and implant-related failures were the most frequently reported complications. TYPE OF STUDY/LEVEL OF EVIDENCE/METHODS:Systematic review IV.

The diagnosis and treatment of fast-flow arteriovenous malformations with or without dynamic arteriovenous fistulae in the upper limb can be both frustrating and daunting for the hand surgeon. The clinical presentation can vary from an incidental finding to a pulsating mass, threatening the entirety of the upper extremity and precipitating cardiac failure secondary to diverging vasculature. Non-operative treatment is appropriate for the small, minimally symptomatic mass. However, considerable controversy remains regarding the management of symptomatic lesions, specifically regarding the utility of embolization or sclerotherapy and the aggressiveness of surgical resection, concepts that are dependent primarily on both the size and location of the lesion. Although classification schemes exist, which attempt to stratify the severity of the lesion encountered by the upper-extremity surgeon, they make no attempt to categorize its location based on clinical relevance. Therefore, our purpose was to review the etiology, clinical presentation, and management of arteriovenous malformations in the upper limb and to refine the present classification to include present treatment options for this uncommonly encountered pathology.

BACKGROUND:Corticosteroid injections are widely used for treating thumb carpometacarpal (CMC) arthritis, yet the accuracy of non-image-guided injections in expert hands is uncertain, with prior studies reporting intraarticular placement in about 60% of thumbs when performed by physicians with different levels of training. Despite their common use, there is a need to assess both the accuracy and the short-term clinical efficacy of these injections, particularly when performed without image guidance by fellowship-trained hand surgeons. QUESTIONS/PURPOSES:(1) What is the accuracy of thumb CMC injections performed without image guidance by fellowship-trained hand surgeons in an office setting? (2) What is the short-term efficacy of thumb CMC injections performed without image guidance? METHODS:We prospectively enrolled 33 patients with a mean ± SD age of 63 ± 12 years, 76% (25) of whom were female, with symptoms of basal joint arthritis that persisted despite conservative treatment, and we administered 1.5-mL corticosteroid injections without image guidance. We used descriptive statistics to analyze the outcomes, which included VAS, QuickDASH (Q-DASH), and Thumb Disability Examination (TDX) scores. Minimum clinically important differences (MCIDs) were defined as 0.9 points for the VAS, 18 points for Q-DASH, and 17 points for TDX. RESULTS:Of the 33 injections analyzed, 79% (26) were intraarticular. At 6 weeks, patients reported a mean improvement of 22 points in QuickDASH, 24 points in TDX, and 4 points in VAS scores. Importantly, 73% (24 of 33), 55% (18 of 33), and 82% (27 of 33) of the patients achieved the MCID in the patient-reported outcomes, respectively, suggesting that even without image guidance, corticosteroid injections can provide effective short-term relief for thumb CMC arthritis. CONCLUSION:We found that about 79% of injections were placed intraarticularly, which was comparable with the findings of previous studies using image guidance, and provided meaningful improvements in pain and function for 6 weeks. These findings suggest that for experienced fellowship-trained hand surgeons, non-image-guided injections remain a viable option. Future studies should explore long-term outcomes and the potential role of adjunctive treatments such as antiinflammatory medications and splinting to enhance patient care. LEVEL OF EVIDENCE:Level II, therapeutic study.

BACKGROUND:Corticosteroid injections are a first-line treatment of trigger finger and de Quervain's tenosynovitis. Little research has evaluated preinjection patient-reported outcomes as a predictive factor for treatment success following corticosteroid injection. We hypothesized that patients with less pretreatment impairment would demonstrate greater post-treatment improvement than patients whose function was more severely impaired. METHODS:We retrospectively reviewed prospectively collected Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) scores in patients undergoing corticosteroid injection for trigger finger or de Quervain's tenosynovitis from 2017 to 2023. Independent variables were patient baseline characteristics, comorbidities, and baseline PROMIS UE. The primary outcome was treatment success between 30 days and 12 weeks, defined as achieving the minimal clinically important difference for PROMIS UE without undergoing surgery. RESULTS:= .44). CONCLUSION/CONCLUSIONS:Corticosteroid injection provides meaningful improvement for a subset of trigger finger and de Quervain's tenosynovitis patients. Corticosteroid injection remains a first-line treatment for trigger finger and de Quervain's tenosynovitis patients, especially for those with more severe functional impairment.