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Seven aspects of the management of acute scaphoid fractures are open to debate: Diagnosis of true fractures among suspected fractures, assessment of fracture displacement, cast immobilization strategies, the role of surgical fixation, proximal pole fractures, assessment of union, and the underlying objective of treatment. We reviewed current evidence, and our varied interpretations of it, to highlight areas of uncertainty where more evidence might be helpful.

Background: Postcongenital heart surgery pulmonary regurgitation requires subsequent pulmonary valve replacement. We sought to compare the outcomes of pulmonary valve replacement after using bioprosthetic valves, porcine versus pericardial bioprosthesis. Method: Retrospective single-center study of consecutive pulmonary valve replacement in patients with pulmonary regurgitation following initial congenital cardiac surgery. From 2004 to 2016, 82 adult patients (53 males, 29 females) underwent pulmonary valve replacement at a mean age of 28.7 ± 8 years (range 18-52 years) with a mean time to pulmonary valve replacement of 24 ± 7 years (range 13-43 years). Porcine bioprosthetic valves (group 1, n = 32) and pericardial valves (group 2, n = 50) were used. Cardiac magnetic resonance imaging was performed (n = 54) at a mean of 18 ± 13 months before and 24 ± 21 months after pulmonary valve replacement. Results: No significant difference was seen between the groups except that the mean follow-up was longer for group 1 (5.02 ± 2.06 vs 4.08 ± 3.21 years). In-hospital mortality was 1.1%. Follow-up completeness was 100% with no late death. Mean right ventricular end-systolic and end-diastolic volumes reduced significantly in both the groups ( P < .001), whereas right ventricular ejection fraction remained unchanged (group 1, P = .129; group 2, P = .675) . Only the left ventricular end-diastolic volume increased in both the groups, but the increase was significant for group 2 only (group 1, P = .070; group 2, P = .015), whereas the left ventricular end-systolic and ejection fraction remained unchanged in both the groups. There was no reoperation for pulmonary valve replacement. Freedom from intervention was 93.8% (group 1) and 100% (group 2) at eight years after pulmonary valve replacement ( P = .407). Conclusion: Midterm outcomes of pulmonary valve replacement in our adult cohort were satisfactory. Both types of bioprosthetic valves performed comparably for eight years and were a good option in adults.

Background: Measurement of wrist range of motion (ROM) is important to all aspects of treatment and rehabilitation of upper extremity conditions. Recently, gyroscopes have been used to measure ROM and may be more precise than manual evaluations. The purpose of this study was to evaluate the use of the iPhone gyroscope application and compare it with use of a goniometer, specifically evaluating its accuracy and ease of use. Methods: A cross-sectional study evaluated adult Caucasian participants, with no evidence of wrist pathology. Wrist ROM measurements in 306 wrists using the 2 methods were compared. Demographic information was collected including age, sex, and occupation. Analysis included mixed models and Bland-Altman plots. Results: Wrist motion was similar between the 2 methods. Technical difficulties were encountered with gyroscope use. Age was an independent predictor of ROM. Conclusions: Correct measurement of ROM is critical to guide, compare, and evaluate treatment and rehabilitation of the upper extremity. Inaccurate measurements could mislead the surgeon and harm patient adherence with therapy or surgeon instruction. An application used by the patient could improve adherence but needs to be reliable and easy to use. Evaluation is necessary before utilization of such an application. This study supports revision of the application on the iPhone to improve ease of use.

Objective: Pulp and nail asymmetry is commonly seen in thumb duplication condition, particularly when both digits are significantly hypoplastic. Conventional or modified Bilhaut-Cloquet procedure can help to restore the symmetry but very often results in a major dorsal scar leading to cosmetic imperfection. The authors introduced a neurovascular island flap for pulp and nail augmentation, and combined with a dorsally based skin flap approach, to improve the aesthetic result in thumb duplication reconstruction. Materials and Methods: Eight patients, including 1 Wassel type II, 1 Wassel type III, and 6 Wassel type IV, were operated on between 2002 and 2010. The contralateral thumbs are all normal. All patients had significant hypoplasia and asymmetry of the pulp and nail of the planned retained digit. The average age of operation was 12 months (range, 8-15 months). A dorsally based skin flap centered on the site of bifurcation was raised for exposure and dissection of the abnormal structures. A neurovascular island flap, including part of the pulp tissue, nail bed, with or without the associated phalangeal bone, was raised from the planned ablated digit based on its single neurovascular bundle. After the standard procedure of ablation, ligament, and musculature reconstruction, with or without realignment osteotomy, the island flap was transferred to the proper digit with meticulous repair of the nail bed, nail fold, and pulp tissue using fine sutures under magnification with operating microscope. All patients were followed up with to monitor the aesthetic, functional, and radiological outcome. The average follow-up was 80 months (range, 25-120 months). An aesthetic scoring system was proposed to assess the cosmetic results of the thumb duplication reconstruction. Results: All flaps survived, with transient intraoperative ischemia of the transferred pulp in 1 case. The major portion of the surgical scar lied toward the volar aspect of the thumb, leaving the cosmetic dorsal aspect relatively intact. Pulp and nail fold symmetry was improved in all cases. The nail width discrepancy reduced from 25.2% preoperatively to 4.6% at final follow-up. The hypoplastic appearance of the pulp was improved in all cases. The pulp circumference was comparable with the contralateral normal thumb, with average pulp circumference discrepancy of 6.8% (range, 1.7%-13.0%) at final follow-up. Nail ridges were moderate in 2 early cases, minimal in 3 cases, and inconspicuous in 3 cases. Surgical scar was not obvious in all but 1 case. The proposed aesthetic scoring system was able to assess and highlight the cosmetic aspect of the outcome and correlated well with the parents’ satisfaction. Conclusions: In selected cases of thumb duplication with significant pulp hypoplasia and nail asymmetry, the neurovascular pulp and nail island flap is a safe and effective mean to restore symmetry for better aesthetic improvement.

Background/Purposes The outcome of tendon repair depends on the strength, which allows early active mobilization to achieve better function without rupture. The aims of this study are to assess quantitatively the biomechanical properties and relationship between the number of tendon weaving and suture method using Pulvertaft technique. Results We found that the load to failure was increased with increasing number of weaves and sutures. From 1-weave to 4-weave single suture samples, the peak load to failure was 9.5 N, 19.7 N, 37.5 N, and 42.6 N, respectively. Based on previous studies, wrist and finger tendons should withstand 1–8N on passive mobilization. Conclusion On active mobilization, finger tendon repair need to provide 34 N for immediate mobilization. Therefore, irrespective of number of sutures, both 3- and 4-weave repairs could allow early mobilization biomechanically.

Background: Thumb base arthritis is a common condition. Arthroscopic or arthroscopic assisted procedures offer better visualisation, less invasiveness and faster recovery than traditional open procedures; it also helps to guide decision making if further treatment is necessary. Methods: A review of cases who received arthroscopic procedures from April 2002 to August 2013 was performed. First carpometacarpal joint arthroscopic debridement was done in 76 patients, and synovectomy was performed in 65 patients (female 51, male 14) with an average age of 56. All patients failed nonoperative care for 6 months. The average follow-up duration was 59 months. 38 cases were Eaton & Littler Stage II, 36 Stage III, I Stage IV and I Stage I. The operation was done under local or regional anaesthesia. Synovectomy, debridement of frayed capsule and radio-frequency ablation were done in all, loose bodies were removed in 25, and thermal shrinkage was done in 30 cases. Post-thermal shrinkage immobilisation was given for 3-6 weeks. 12 cases had smoothening of the bony surface & prominent osteophytes. Results: 69 cases experienced pain relief after the operation. 20 cases had excellent and 14 had good result. Mean grip strength of 88.3% of the contralateral side while pinch power of 81.7%. Kapandji index was 8. DASH score was 26.5%. Patient satisfaction was 77 of 100. There was no complication encountered. 7 patients requested the same operation on the other thumb after the operation. 3 requested repeating the same operation on the same thumb as pain relief lasted only for 1-3 years. Better outcomes were found to be statistically related to bone surface smoothening, or thermal shrinkage and immobilisation for ≥ 4 weeks. Conclusion: Long-term results of arthroscopic debridement and synovectomy, the surgical techniques, and the examples of arthroscopic assisted procedures at the thumb base were demonstrated and discussed. Arthroscopic surgery for thumb base arthritis is a safe and feasible procedure that can provide long-lasting symptom relief.