Suzanne C. Wilkens

Reoperation After Combined Injury of the Index Finger: Repair Versus Immediate Amputation

PURPOSE To identify factors associated with unplanned reoperation of severely injured index fingers and to address the number of amputations after initial repair. METHODS In this retrospective study, we included all patients older than 18 years of age who had repair or immediate amputation for combined index finger injury at 2 level I trauma centers and 1 community hospital tied to a level I trauma center between January 2004 and February 2014. Twelve patients were excluded because of inadequate follow-up. Bivariate and multivariable analyses sought factors associated with unplanned reoperation after repair and immediate amputation. RESULTS Among 114 patients with combined injury, 75 were treated with repair and 39 with immediate amputation. A total of 41 patients had an unplanned reoperation, 33 after repair (44%) and 8 after immediate amputation (21%). In multivariable analysis, patients who had a reoperation for fingers other than the index finger were at risk for unplanned reoperation after repair. Women were more likely to have an unplanned reoperation than men, and patients who had a ray amputation were at risk for unplanned reoperation after immediate amputation. Six patients (18%) had amputation after initial repair. CONCLUSIONS Surgeons may counsel patients that they are twice as likely to have an unplanned reoperation after a repair for combined injury of the index finger compared with an immediate amputation. Unplanned reoperations were more common among patients with injuries involving multiple fingers. Effective shared decision making is particularly important in this setting given that 1 in 5 repaired index fingers were eventually amputated. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Hand Posturing Is a Nonverbal Indicator of Catastrophic Thinking for Finger, Hand, or Wrist Injury

Background Prior research documents that greater psychologic distress (anxiety/depression) and less effective coping strategies (catastrophic thinking, kinesophobia) are associated with greater pain intensity and greater limitations. Recognition and acknowledgment of verbal and nonverbal indicators of psychologic factors might raise opportunities for improved psychologic health. There is evidence that specific patient words and phrases indicate greater catastrophic thinking. This study tested proposed nonverbal indicators (such as flexion of the wrist during attempted finger flexion or extension of uninjured fingers as the stiff and painful finger is flexed) for their association with catastrophic thinking. Questions/purposes (1) Do patients with specific protective hand postures during physical examination have greater pain interference (limitation of activity in response to nociception), limitations, symptoms of depression, catastrophic thinking (protectiveness, preparation for the worst), and kinesophobia (fear of movement)? (2) Do greater numbers of protective hand postures correlate with worse scores on these measures? Methods Between October 2014 and September 2016, 156 adult patients with stiff or painful fingers within 2 months after sustaining a finger, hand, or wrist injury were invited to participate in this study. Six patients chose not to participate as a result of time constraints and one patient was excluded as a result of inconsistent scoring of a possible hand posture, leaving 149 patients for analysis. We asked all patients to complete a set of questionnaires and a sociodemographic survey. We used Patient Reported Outcomes Measurement Information System (PROMIS) Depression, Upper Extremity Physical Function, and Pain Interference computer adaptive test (CAT) questionnaires. We used the Abbreviated Pain Catastrophizing Scale (PCS-4) to measure catastrophic thinking in response to nociception. Finally, we used the Tampa Scale of Kinesophobia (TSK) to assess fear of movement. The occurrence of protective hand postures during the physical examination was noted by both the physician and researcher. For uncertainty or disagreement, a video of the physical examination was recorded and a group decision was made. Results Patients with one or more protective hand postures did not score higher on the PROMIS Pain Interference CAT (hand posture: 59 [56-64]; no posture: 59 [54-63]; difference of medians: 0; p = 0.273), Physical Function CAT (32 ± 8 versus 34 ± 8; mean difference: 2 [confidence interval {CI}, -0.5 to 5]; p = 0.107), nor the Depression CAT (48 [41-55] versus 48 [42-53]; difference of medians: 0; p = 0.662). However, having at least one hand posture was associated with a higher degree of catastrophic thinking (PCS scores: 13 [6-26] versus 10 [3-16]; difference of medians: 3; p = 0.0104) and a higher level of kinesophobia (TSK: 40 ± 6 versus 38 ± 6; mean difference: -2 [CI, -4 to -1]; p = 0.0420). Greater catastrophic thinking was associated with a greater number of protective hand postures on average (rho: 0.20, p = 0.0138). Conclusions Protective hand postures and (based on prior research) specific words and phrases are associated with catastrophic thinking and kinesophobia, less effective coping strategies that hinder recovery. Surgeons can learn to recognize these signs and begin to treat catastrophic thinking and kinesophobia starting with compassion, empathy, and patience and be prepared to add formal support (such as cognitive-behavioral therapy) to help facilitate recovery. Level of Evidence Level III, diagnostic study.

Symptomatic Neuroma Following Initial Amputation for Traumatic Digital Amputation

PURPOSE We tested the null hypothesis that no factors are independently associated with the development of symptomatic neuroma after traumatic digital amputation. METHODS We performed a retrospective review of 1,083 patients who underwent revision amputation for traumatic digital amputation; we excluded those undergoing replantation or revascularization. Patients who developed a painful neuroma during follow-up were identified with a minimum follow-up of 1 week and a median of 3.3 months. We calculated the rate of developing a painful neuroma as a proportion of the total number of patients and performed multivariable logistic regression analysis to identify factors independently associated with its development. RESULTS Of 1,083 patients, 71 (6.6%) developed a symptomatic neuroma. Mean time to diagnosis was 6.4 months. A total of 47 patients (66%) underwent surgery for painful neuroma. Mean time to surgical intervention was 11 months. Index finger injury and avulsion injury mechanism were significantly associated with a higher risk for symptomatic neuroma. CONCLUSIONS Approximately 1 in 15 patients will develop a symptomatic neuroma after traumatic digital amputation and more than half of these patients will undergo revision surgery for neuroma, with a mean time to operative intervention of 11 months. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.

Factors Associated With Radiographic Trapeziometacarpal Arthrosis in Patients Not Seeking Care for This Condition

Background: A common adage among hand surgeons is that the symptoms of trapeziometacarpal (TMC) arthrosis vary among patients independent of the radiographic severity. We studied factors associated with radiographic severity of TMC arthrosis, thumb pain, thumb-specific disability, pinch strength, and grip strength in patients not seeking care for TMC arthrosis. Our primary null hypothesis was that there are no factors independently associated with radiographic severity of TMC arthrosis according to the Eaton classification among patients not seeking care for TMC arthrosis. Methods: We enrolled 59 adult patients not seeking care for TMC arthrosis. We graded patients’ radiographic TMC arthrosis and asked all patients to complete a set of questionnaires: demographic survey, pain scale, TMC joint arthrosis–related symptoms and disability questionnaire (TASD), and a depression questionnaire. Metacarpophalangeal hyperextension and pinch and grip strength were measured, and the grind test and shoulder sign were performed. Results: Older age was the only factor associated with more advanced radiographic pathophysiology of TMC arthrosis. One in 5 patients not seeking care for TMC arthrosis experienced thumb pain; no factors were independently associated with having pain or limitations related to TMC arthrosis. Youth and male sex were associated with stronger pinch and grip strength. Conclusions: There are a large number of patients with relatively asymptomatic TMC arthrosis. Metacarpophalangeal hyperextension and female sex may have a relationship with symptoms, but further study is needed. Our data support the concept that TMC arthrosis does not correlate with radiographic arthrosis.

QuickDASH Score Is Associated With Treatment Choice in Patients With Trapeziometacarpal Arthrosis

Background: Trapeziometacarpal (TMC) arthrosis has a variety of treatment options, including nonoperative (eg, education, splint, injection) and operative management. Symptoms and limitations vary greatly among patients. The purpose of this study was to determine an association of symptoms and limitations, quantified using the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, with treatment choice in patients newly diagnosed with TMC arthrosis. We also addressed the association of the QuickDASH score with radiographic severity and sought factors associated with higher QuickDASH scores. Methods: As part of the routine new patient intake paperwork, all new patients completed a QuickDASH form. We included 81 new patients with newly diagnosed TMC arthrosis visiting the office of 1 of 5 orthopedic hand surgeons between March 1, 2015, and November 30, 2015. Eight patients were excluded because of incomplete QuickDASH forms. Results: Based on QuickDASH tertiles, patients with a low QuickDASH score were more likely to choose education alone than patients with intermediate and high QuickDASH scores; no patients in the lowest QuickDASH tertile chose injection or surgery. Patients who chose education alone also had a lower mean QuickDASH score than patients who chose splint or surgery. Radiographic severity and other patient-related factors were not associated with greater symptoms and limitations. Conclusions: More adaptive patients (lower QuickDASH) are less likely to choose injection or surgery, irrespective of disease severity. The psychosocial factors known to correlate with greater symptoms and limitations might lead patients to feel they have fewer options or to choose more interventional options than they would if they were more at ease. In other words, inadequate attention to psychosocial factors may increase the risk of misdiagnosis of patient preferences.

Unplanned Reoperation After Trapeziometacarpal Arthroplasty: Rate, Reasons, and Risk Factors:

Background: Trapeziometacarpal (TMC) arthritis is an expected part of ageing to which most patients adapt well. Patients who do not adapt to TMC arthritis may be offered operative treatment. The factors associated with reoperation after TMC arthroplasty are incompletely understood. The purpose of this study was to determine the rate of, the underlying reasons for, and the factors associated with unplanned reoperation after TMC arthroplasty. Methods: In this retrospective study, we included all adult patients who had TMC arthroplasty for TMC arthritis at 1 of 3 large urban area hospitals between January 2000 and December 2009. Variables were inserted into a multivariable Cox proportional hazards model to determine factors associated with unplanned reoperation, and the Kaplan-Meier curve was used to estimate and describe the probability of unplanned reoperation over time. Results: Among 458 TMC arthroplasties, 19 (4%) had an unplanned reoperation; 16 of 19 (84%) for persistent pain and two-thirds within the first year. The multivariate Cox regression analysis showed that unplanned reoperation was independently associated with younger age, surgeon inexperience, and index procedure type. Conclusions: Surgeons should be aware as well as patients should be informed that as many as 4% are offered or request a second surgery, usually for persistent pain and often within the 1-year window when additional improvement is anticipated.

Decision Aid for Trapeziometacarpal Arthritis: A Randomized Controlled Trial

PURPOSE Decision aids increase patient participation in decision making and reduce decision conflict. The goal of this study was to evaluate the effect of a decision aid prior to the appointment, upon decisional conflict measured immediately after the visit relative to usual care. We also evaluated other effects of the decision aid over time. METHODS In this randomized controlled trial, we included 90 patients seeking the care of a hand surgeon for trapeziometacarpal (TMC) arthritis for the first time. Patients were randomly assigned to receive either usual care (an informational brochure) or an interactive Web-based decision aid. At enrollment, consult duration was recorded, and patients completed the following measures: (1) Decisional Conflict Scale; (2) Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH); (3) pain intensity; (4) Physical Health Questionnaire (PHQ-2); (5) satisfaction with the visit; and (6) Consultation And Relational Empathy (CARE) scale. At 6 weeks and 6 months, patients completed: (1) pain intensity measure; (2) Decision Regret Scale; and (3) satisfaction with treatment. We also recorded changes in treatment and provider. RESULTS Patients who reviewed the interactive decision aid prior to visiting their hand surgeon had less decisional conflict at the end of the visit. Other outcomes were not affected. CONCLUSIONS Use of a decision aid prior to a first-time visit for TMC led to a measurable reduction in decision conflict. Decision aids make people seeking care for TMC arthritis more comfortable with their decision making. Future research might address the ability of decision aids to reduce surgeon-to-surgeon variation, resource utilization, and dissatisfaction with care CLINICAL RELEVANCE: Surgeons should consider the routine use of decision aids to reduce decision conflict.

A systematic review and meta-analysis of arthroscopic assisted techniques for thumb carpometacarpal joint osteoarthritis

Arthroscopic management of thumb carpometacarpal (CMC) osteoarthrosis (OA) is an approach that has unclear results. We performed a systematic review encompassing three electronic databases up to May 2016 for studies describing arthroscopic-assisted techniques for thumb CMC OA. Meta-analyses of visual analogue scores (VAS) for pain, Disabilities of the Arm, Shoulder and Hand (DASH) scores, grip strength and pinch strength before and after arthroscopy were performed for ten included non-randomized cohort studies comprising 294 patients. Based on Hedges’ g measure, we found a large effect on VAS and DASH scores, a small effect on grip strength and no effect on pinch strength. On average, VAS improved by 4.1 cm, DASH by 22 points and grip strength by 2.8 kg. Complications were reported in 4% of patients. The use of arthroscopic-assisted techniques for thumb CMC OA is still limited; however, it may be a reasonable option for patients with thumb CMC OA who do not respond to non-operative treatment.

The Incidence of Arthroplasty After Initial Arthroscopy for Trapeziometacarpal Arthrosis

Background: It remains unclear how many patients undergo secondary surgery after initial arthroscopy for trapeziometacarpal (TMC) arthrosis. We studied the factors related to secondary TMC arthroplasty after TMC arthroscopy. We also examined secondary questions of: (1) what percentage of patients underwent secondary TMC arthroplasty; and (2) how much time elapsed from initial arthroscopy to arthroplasty. Methods: In this retrospective study, we included all adult patients who were treated with arthroscopy of the TMC joint at 2 level I hospitals and affiliates. Factors were assessed for their independent association with secondary TMC arthroplasty using bivariate and multivariable analyses. Results: Fourteen of 84 (17%) thumbs underwent secondary TMC arthroplasty an average of 11 months after the initial arthroscopy. Synovectomy alone and smoking tobacco were independently associated with secondary TMC arthroplasty when compared with arthroscopic (partial) trapeziectomy with additional tendon interposition or allograft. Conclusions: This study demonstrated that 1 in 6 thumbs underwent secondary TMC arthroplasty, an average of 11 months after the initial arthroscopy. Coupling arthroscopy with partial trapeziectomy, interposition, or extension osteotomy may be a preferable strategy to isolated synovectomy. In addition, smoking tobacco is associated with inferior outcomes regardless of surgical procedure.

Is Physician Empathy Associated With Differences in Pain and Functional Limitations After a Hand Surgeon Visit

Background In prior work we demonstrated that patient-rated physician empathy was the strongest driver of patient satisfaction after a visit to an orthopaedic hand surgeon. Data from the primary care setting suggest a positive association between physician empathy and clinical outcomes, including symptoms of the common cold. It is possible that an empathic encounter could make immediate and measureable changes in a patient’s mindset, symptoms, and functional limitations. Questions/purposes (1) Comparing patients who rated their physicians as perfectly empathic with those who did not, is there a difference in pre- to postvisit change in Patient Reported Outcome Measurement Information System (PROMIS) Upper Extremity Function scores? (2) Do patients who gave their physicians perfectly empathic ratings have a greater decrease in pre- to postvisit change in Pain Intensity, PROMIS Pain Interference, and PROMIS Depression scores? Methods Between September 2015 and February 2016, based on the clinic patient flow, 134 new patients were asked to participate in this study. Eight patients were in a rush to leave the surgeon’s office, which left us with a final cohort of 126 patients. Directly before and directly after the appointment with their physician, patients were asked to complete three PROMIS Computerized Adaptive Tests (CAT; Upper Extremity Function, Pain Interference, and Depression) as well as an ordinal rating of pain intensity. After the visit, participants were asked to rate their physician using the Consultation And Relational Empathy (CARE) measure. Based on prior experience, we dichotomized the CARE score anticipating a substantial skew: 54 patients (43%) rated their physician perfectly empathic. Results Between patients who rated physicians as perfectly empathic and those who did not, there was no difference in the pre- to postvisit change in PROMIS Upper Extremity Function CAT score (perfect empathy: 0.84 ± 2.94; less than perfect empathy: -0.23 ± 3.12; mean difference: 0.23; 95% confidence interval [CI], -0.31 to 0.77; p = 0.054). There was a small decrease in Pain Intensity (perfect empathy: -0.96 ± 2.08; less than perfect empathy: -0.33 ± 1.03; mean difference: -0.60; 95% CI, -0.88 to -0.32; p = 0.028). There were no differences in PROMIS Pain Interference score (perfect empathy: -1.33 ± 2.85; less than perfect empathy: -1.37 ± 3.12; mean difference: -1.35; 95% CI, -1.88 to -0.83; p = 0.959) or PROMIS Depression scores (perfect empathy: -1.51 ± 4.02; less than perfect empathy : -1.21 ± 3.83; mean difference: -1.34; 95% CI, -2.03 to -0.65; p = 0.663). Conclusions A single visit with a surgeon rated perfectly empathic is not associated with change in upper extremity-specific limitations or coping mechanisms or a noticeable change in pain scores during the visit, as these differences were below the minimum clinically important difference. Future research should address the influence of empathy on patient-reported outcomes and physician empathy over time in contrast to a single office visit. Level of Evidence Level II, prognostic study.