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Articular congruity is the most important prognostic factor when dealing with a distal intra-articular radius fracture or the correction of intra-articular malunion. This article details our approach with tips and tricks for effectively managing these complex injuries with the aid of dry arthroscopy.

Treatment of the destroyed scaphotrapezial (ST) joint in young patients is challenging due to the limited available options as they might not tolerate the stiffness, loss of grip strength and long-term complications of partial fusions, bone resections, and interposition implants or arthroplasties. This report presents the results of a free osteocutaneous joint transfer used to reconstruct the ST joint in a young patient suffering from ST destruction and carpal collapse. This 34-year-old patient was previously treated for a right scaphoid nonunion with distal scaphoid excision and interposition implant that evolved to destruction of the ST space, symptomatic carpal collapse associated and a ST height loss of 7 mm. The DASH score was 34 and the grip strength of 32 kg. The patient was treated with an osteocutaneous vascularized free transfer from the second metatarsophalangeal joint vascularized by the first dorsal metatarsal artery and anastomosed to the palmar carpal branch of the radial artery and a palmar superficial vein. After 3.5 months, the patient returned to full duty work as a mechanic. At the last follow-up, 3 years after the surgery, the patients had complete range of motion without clinical nor radiological degenerative changes. There were no postoperative complications. The DASH score was 3 and the grip strength was 53 kg. This reconstructive procedure allows to recreate a functional ST joint and to correct a carpal collapse avoiding degenerative wrist changes. It may be proposed to young patients who aim to recover a near normal function of their wrist.

Mutilated upper limbs suffer loss of substance of various tissues with loss of prehension. The most important factor in salvage of a mutilated hand is involvement of a senior surgeon at the time of initial assessment and debridement. A regional block given on arrival helps through assessment and investigations in a pain-free state. Infection still remains the important negative determinant to outcome and is prevented by emergent radical debridement and early soft tissue cover. Radical debridement and secure skeletal stabilization must be achieved on day one in all situations. Dermal substitutes and negative pressure wound therapy are increasingly used but have not substituted regular soft tissue cover techniques. Ability to perform secondary procedures and the increased use of the reconstructed hand with time keeps reconstruction a better option than prosthesis fitting. Toe transfers and free functioning muscle transfers are the two major secondary procedures that have influenced outcomes.

In this article we will do an overview of the general and specific complications that occur after the most common wrist and hand surgeries. Knowledge of the different surgical techniques is essential for postoperative imaging evaluation. General complications include infection, complex regional pain syndrome, problems related with the surgical approach (open or arthroscopic) and bone healing problems. The most frequent fractures of the wrist with specific complications are distal radius fractures and scaphoid fractures as associated with tendon ruptures secondary to friction, nonunion or secondary malignment. We will briefly review the different approaches for triangular fibrocartilage injuries, including acute and degenerative lesions. Scapholunate instability is the most common instability and an important indication for surgery with pin fixation in the acute setting and arthroplasty or arthrodesis in the chronic irreparable injuries. One of the most common surgeries of the wrist is carpal tunnel release, although complications are uncommon, radiologists should be familiar with the normal appearance and pathological changes after surgery. Trapeziometacarpal joint osteoarthritis is frequent especially in postmenopausal women and has several treatment options depending on the stage.

Extra-articular malunions of metacarpals and phalanges may cause palmar pain, finger scissoring, and splaying, and interfere with function. Current treatment involves open osteotomy and fixation with plates and screws. We present a minimally invasive method using cannulated headless screws for correction of malunions and examine the outcomes in a series of patients.Twenty malunions were operated on in 17 patients. In 16 cases, the malunion involved the metacarpal and in 4 it involved the proximal phalanx. All proximal phalanx and 3 metacarpal malunions were malrotation types, while the rest of the metacarpal malunions were dorsal angulations. The operation consisted of an opening wedge osteotomy in 8 patients; closing wedge osteotomy in 5; and a transverse osteotomy and derotation in the rest. Concomitant surgery to release tendon adhesions or contracted joints or to perform adipofascial flaps was performed in 8 cases. Fixation was achieved by means of a cannulated headless screw. Immediate range of motion was permitted in all cases.Correction of the malunion and osteotomy union was achieved in all cases. One patient required manipulation of a digit that was found rotated at the first follow-up visit. Eleven fingers achieved more than 280° of total active motion. In 9 digits, the total active motion was less than 280° after the operation, yet improved 76° (range, 140°-30°) from their preoperative total active motion. The mean single-assessment numeric evaluation score for the whole group was 9.1.The fixation provided by the cannulated headless screw is sufficient to permit immediate range of motion. Due to the minimal tissue disruption, this approach may be a reasonable alternative to the standard approach.Therapeutic IV.

Ulnar wrist pain, caused by a broad spectrum of bone and soft tissue injuries, is the most common clinical condition of the wrist. Multiple surgical techniques and their variants in the treatment of these injuries are constantly evolving. Postoperative evaluation of the wrist for many surgeons is limited to serial clinical and radiographic monitoring. However, imaging methods such as ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and arthrographic techniques (arthrographic CT and arthrographic MRI) play a fundamental role in diagnosing and managing postsurgical complications.The several critical aspects in evaluating the postsurgical wrist imaging spectrum are familiarity with the surgical techniques, knowledge of the original clinical problem, understanding the strength and limitations of the different radiologic modalities, and effective communication between surgeon and radiologist.

The clinical features of classic carpal tunnel syndrome are well known. However, some patients who display atypical symptoms and signs of pain and dysesthesias in the hand, worsening of symptoms at night, and above all, inability to make a full fist, respond equally well to carpal tunnel release. This same clinical picture was shared by some patients labeled as having complex regional pain syndrome. Because of the poor outcome of complex regional pain syndrome patients with current regimens, the authors tested the hypothesis that carpal tunnel release could be effective on them. The purpose of this article is to report the outcome of carpal tunnel release in complex regional pain syndrome patients who presented the above signs and symptoms.Fifty-three patients with an average age of 55 years presenting the above cluster of symptoms were operated on. All were unilateral cases, had sustained trauma, and were treated for complex regional pain syndrome before referral for an average of 16 months. All patients underwent carpal tunnel release.At a minimum of 6 months' follow-up, pain dropped 7.5 points on a numerical rating scale of 0 to 10 ( p0.001). Disabilities of the Arm, Shoulder and Hand scoring fell from 82 to 17 ( p0.001). Six patients had an unsatisfactory result.Some patients with complex regional pain syndrome may respond successfully to a carpal tunnel release operation. Recognition of this possibility is crucial, as the symptoms and signs might lead the clinician away from the proper diagnosis and treatment.Therapeutic, IV.

The main goals of treating severe crush injuries are debriding away devitalized tissue and filling any resultant dead space with vascularized tissue. In the authors' experience, the most ideal methods for soft tissue coverage in treating crush injuries are the iliac flap, the adipofascial lateral arm flap, and the gracilis flap. Accompanying bone defects respond very well to free corticoperiosteal flaps. Digital defects often require the use of complete or subtotal toe transfer to avoid amputation and restore function to the hand.

4-corner arthrodesis is a widely implanted procedure to treat degenerated joints in the wrist such as SLAC and SNAC stage II and III. Arthroscopy in combination with headless cannulated screws, permits reproducing the same intervention with the advantages of a minimally invasive surgery. This technique has already been published in the past supported by the early experience in this new exciting field. The purpose of this paper is to present new technical refinements collected over the years in order to speed up the surgery while obtaining optimum results. In this paper we also present extreme scenarios solved by combining the scope with cannulated screws.Die mediokarpale Teilversteifung unter Resektion des Skaphoids ist eine gut etablierte Behandlung degenerativer Veränderungen des Handgelenkes beim karpalen Kollaps Stadium II und III bei SLAC- und SNAC-wrist. Die Kombination von Arthroskopie und Verwendung von kanülierten kopflosen Schrauben macht es möglich, den Eingriff minimal invasiv durchzuführen. Hierüber wurde bereits in der Vergangenheit berichtet. In dieser Arbeit präsentieren wir über Jahre entwickelte Verfeinerungen der Operationstechnik, deren Ziel es ist, die Operationszeit zu verkürzen und die Ergebnisse zu optimieren. Zugleich stellen wir an extremen Fallbeispielen dar, welche Möglichkeiten die Kombination von Arthroskopie mit kanülierten Schrauben bietet.

The development of wrist arthroscopy has been useful in diagnosis, prognosis, and treatment of both ligament and osseous injuries. As the treatment indications and techniques become more refined, this article explores the role of dry arthroscopy to treat radial-sided disorders of the wrist.

The management of distal radius fractures has evolved considerably in the last two decades. Techniques and hardware have improved so much that the surgeon can usually assure good results in these debilitating fractures. Yet no one method can be used for all injuries, as the personality of each fracture demands a customized approach. Furthermore, what works in one age group may not work in another. For this reason, every available treatment has its own space in our options. The need for surgeons to be well versed in all techniques is critical. We offer a concise update of important evolutionary and current treatment guidelines for this common fracture.

The use of wrist arthroscopy to assist fixation of distal radius fractures with volar locking plates (VLPs) has been gaining popularity in recent years; however, there is no consensus on its benefits. This meta-analysis compares outcomes of arthroscopic-assisted VLP to fluoroscopic-assisted VLP in distal radius fractures through a systematic review of the published literature.A systematic search of publications from databases (Medline, EMBASE, Scopus, and Cochrane) was obtained from inception to May 2020. A random-effects meta-analysis was used to calculate effect sizes. Outcomes included postoperative radiographic reduction (gap, stepoff, radial inclination, volar tilt, and ulnar variance), procedural outcomes (operative time, additional soft tissue injuries and complications), and functional outcomes (range of motion; visual analog scale score; Disabilities of the Arm, Shoulder, and Hand score; Patient-Rated Wrist Evaluation score; Mayo clinic score; and grip strength).Six studies, involving 280 patients, met the final inclusion criteria. The meta-analysis for postoperative stepoff was statistically significant, favoring arthroscopic-assisted VLP. In addition, there was greater identification of associated soft tissue injuries, increased wrist extension, and a longer operative duration when performing arthroscopic-assisted VLP fixation. There were no differences in other postoperative radiographic outcomes, complications, or functional outcomes.The current literature suggests that arthroscopic-assisted VLP is a useful adjunct to intra-articular reduction and treatment of associated soft tissue injuries in distal radius fractures. Considerations should include operative time, costs, and the additional training required. Further studies are needed to assess functional outcomes.Therapeutic II.

Objectives The purpose of this agreement was to establish evidence-based consensus statements on imaging of scapholunate joint (SLJ) instability by an expert group using the Delphi technique. Methods Nineteen hand surgeons developed a preliminary list of questions on SLJ instability. Radiologists created statements based on the literature and the authors’ clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panellists consisted of twenty-seven musculoskeletal radiologists. The panellists scored their degree of agreement to each statement on an eleven-item numeric scale. Scores of ‘0’, ‘5’ and ‘10’ reflected complete disagreement, indeterminate agreement and complete agreement, respectively. Group consensus was defined as a score of ‘8’ or higher for 80% or more of the panellists. Results Ten of fifteen statements achieved group consensus in the second Delphi round. The remaining five statements achieved group consensus in the third Delphi round. It was agreed that dorsopalmar and lateral radiographs should be acquired as routine imaging work-up in patients with suspected SLJ instability. Radiographic stress views and dynamic fluoroscopy allow accurate diagnosis of dynamic SLJ instability. MR arthrography and CT arthrography are accurate for detecting scapholunate interosseous ligament tears and articular cartilage defects. Ultrasonography and MRI can delineate most extrinsic carpal ligaments, although validated scientific evidence on accurate differentiation between partially or completely torn or incompetent ligaments is not available. Conclusions Delphi-based agreements suggest that standardized radiographs, radiographic stress views, dynamic fluoroscopy, MR arthrography and CT arthrography are the most useful and accurate imaging techniques for the work-up of SLJ instability. Key Points • Dorsopalmar and lateral wrist radiographs remain the basic imaging modality for routine imaging work-up in patients with suspected scapholunate joint instability. • Radiographic stress views and dynamic fluoroscopy of the wrist allow accurate diagnosis of dynamic scapholunate joint instability. • Wrist MR arthrography and CT arthrography are accurate for determination of scapholunate interosseous ligament tears and cartilage defects.

Massive carpal loss following trauma, tumor, or infection poses a difficult reconstructive challenge. There are limited reconstructive options for such cases, particularly when the metacarpal bases are also lost. We describe a method of carpal reconstruction using closing wedge osteotomies in a triangular vascularized free fibular flap, and a proposed algorithm for the management of metacarpal instability in this setting.

Treatment of intra-articular malunion of the distal radius has evolved over the past 20 years, from open treatment to wet then dry arthroscopic techniques that provide excellent results with less morbidity than open approaches. Dry wrist arthroscopy provides a well-visualized surgical space in treating intra-articular malunion and results in less edema than wet techniques. The best results are attained in the first 3 months after injury. Alternative methods for avoiding total wrist arthrodesis in those who present later have been developed. The dry arthroscopic "inside-out" osteotomy technique for intra-articular malunions should be considered in patients with this condition.

The main goals of treating severe crush injuries are debriding away devitalized tissue and filling any resultant dead space with vascularized tissue. In the authors' experience, the most ideal methods for soft tissue coverage in treating crush injuries are the iliac flap, the adipofascial lateral arm flap, and the gracilis flap. Accompanying bone defects respond very well to free corticoperiosteal flaps. Digital defects often require the use of complete or subtotal toe transfer to avoid amputation and restore function to the hand.

With the evolution of dry wrist arthroscopy, there is an ever-increasing role for its use in the treatment of disorders of the wrist including ligament repair or reconstruction, bony procedures such as distal radius corrective osteotomies or fracture fixation, and partial arthrodesis. We describe some of the tips and tricks that can be used to manage ulnar-sided wrist pain. We particularly emphasize the different technical points to perform dry wrist arthroscopy compared with previously described wet arthroscopic procedures.

Background Historically, complex amputations of the thumb have been managed in two stages and often require additional soft-tissue and tendon transfer for successful outcomes. This article provides several novel strategies to address these problems in a single stage using existing muscles, immediate free tissue transfer, and toe transfer. Methods From a personal experience of 482 toe transfers, 24 cases were performed to reconstruct extreme thumb losses. All thumbs were reconstructed in one stage. In only one case, the thumb was reconstructed with a second toe transfer; the remainder had a great toe (or a part of it) used for reconstruction. Suture, advancement, or tendon transfers were performed in all to restore intrinsic muscle function. In 19 cases, the web needed to be resurfaced with free (n = 18) or local (n = 1) flaps. Results All toes and flaps survived. Three patients required a secondary adductorplasty. Six of the seven patients with a metacarpal hand were able to perform tripod pinch. The rest had an average Kapandji opposition score of 7.5. Patients rated their functional and cosmetic result with a visual analogue scale score (ranging from 0 to 10) of 8.5 and 8.4, respectively. Conclusions In proximal thumb amputations, the surgeon should pay attention not only to the obvious thumb loss but also to the first web and the thenar muscles. The author recommends abandoning the standard approach of a pedicled groin flap followed by a toe. Otherwise, the thenar muscles become useless, the first metacarpal contracts, and the need for tendon transfers skyrockets. Further studies are required to compare the outcomes of these results to those of more classic transfers. Clinical question/level of evidece Therapeutic, IV.

The thumb should be preserved at all costs, and major efforts to preserve it are justified. If nothing can be done (or desperate measures fail), classic procedures or a toe-to-hand are indicated. This article will not only discuss some tips to succeed in extreme acute scenarios, but will also consider the indications of other alternatives in the acute or subacute setting.

Purpose To present the technique, indications, and outcomes of metacarpal and phalangeal fractures fixed with intramedullary cannulated headless screws (CHS). Methods We retrospectively reviewed all charts of patients whose metacarpal and phalangeal fractures had been treated with intramedullary CHS in our practice. A total of 69 fractures (48 metacarpal and 21 phalangeal) were identified in 59 patients. Seventeen were open fractures. Eleven patients had multiple fractures (29 in total); of those, 21 were managed with CHS. In 4 other fractures the method was abandoned intraoperatively. The defect created by the entrance of the screw in the proximal phalanx was identified by computed tomography in 20 patients. Results In 63 fractures a single screw was used; in 6 fractures 2 screws were used to provide stronger fixation. All patients returned to full duties or sport activities at an average of 76 days (range, 3 wk to 15 mo). At the latest follow-up (range, 5–54 mo; average, 19 mo) total active motion was on average 247° (range, 150° to 270°) for all fractures, 249° (range, 210° to 270°) for metacarpal, and 243° (range, 150° to 270°) for proximal phalangeal fractures. All fractures were healed and within acceptable radiological parameters. A comminuted basilar phalangeal fracture displaced secondarily yielding a poor functional result. Two patients required tenolysis and further procedures before the final result was achieved. The screw hole represents around 20% of the proximal phalanx distal articular surface. Conclusions Unstable transverse fractures in the phalanx and metacarpal are amenable to single intramedullary CHS fixation. Comminuted fractures require more complex configurations. Type of study/level of evidence Therapeutic IV.

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The main goals of treating severe crush injuries are debriding away devitalized tissue and filling any resultant dead space with vascularized tissue. In the authors' experience, the most ideal methods for soft tissue coverage in treating crush injuries are the iliac flap, the adipofascial lateral arm flap, and the gracilis flap. Accompanying bone defects respond very well to free corticoperiosteal flaps. Digital defects often require the use of complete or subtotal toe transfer to avoid amputation and restore function to the hand.

Purpose In the setting of severely comminuted diaphyseal-metaphyseal fractures of the distal radius, arthroscopic reduction of the joint surface is difficult and often results in shortening and collapse. Yet, several authors have shown the benefits of arthroscopy in articular distal radius fractures. We present a method that safely allows a combination of arthroscopic reduction and rigid fixation and describe the outcomes in a small group of patients. Methods Four consecutive patients with severely comminuted diaphyseal-metaphyseal articular fractures of the distal radius were treated using the stable reference fragment technique. For all cases, we used an extra-long volar locking plate applied to the diaphysis of the radius. Preoperative computed tomography scanning was used to identify the largest articular fragment. This reference fragment was reduced and stabilized with locking pegs or screws to the volar plate under fluoroscopic guidance. The articular reduction continued arthroscopically, using the reference fragment as a guide. Once the articular reduction was complete, the comminuted metaphysis was addressed and secured to the plate. Results All patients achieved excellent clinical and radiological results. Flexion-extension averaged 124° and pronation-supination averaged 174°. One patient showed minor signs of radiocarpal osteoarthritis on radiographs at 3 years. Conclusions By securing the reference fragment before addressing the metaphyseal comminution, a stable platform was created. Thus, intra-articular reduction was achieved while maintaining extra-articular alignment. Although the results were excellent, the number of cases was small. Type of study/level of evidence Therapeutic IV.

Purpose To present our experience in distal thumb amputations reconstructed by partial toe to hand transfers with special emphasis on manual workers. Methods Twenty-five patients who experienced amputation of the thumb distal to the interphalangeal joint, excluding pure soft tissue losses, were included in the study. All but 2 were manual workers. Twenty were reconstructed within 2 weeks after injury. The other 5 were referred late. In all patients, the ipsilateral hallux was used as donor, based on the proper digital artery (18 cases), the intermetatarsal artery (6 cases), and the dorsalis pedis artery (1 case). Results All transferred flaps survived. At a minimum follow-up of 1 year (range, 1–14 y), active range of motion at the interphalangeal joint was more than 55° in 23 patients. Two had an interphalangeal joint arthrodesis, 1 of them before referral. Pinch and grip were similar to the contralateral side. Two-point discrimination was normal in the dorsal oblique amputations and 7 to 11 mm in the rest. Patient satisfaction was high from a functional and aesthetic standpoint (9.5 out of 10 on a visual analog scale for both outcomes). All patients returned to work 2 to 4.5 months after the operation. Delayed donor site healing was noticed in 4 cases. Conclusions In contrast to classic teaching that recommends stump closure for cases of distal thumb amputation, we attained excellent results with partial toe transfer in manual workers. In our experience, the thumb can be restored to nearly normal with an acceptable donor site sequela. The best indication is for cases of dorsal oblique amputations, because thumb sensibility is unaffected, and for amputations where the germinal matrix is preserved, because nail regrowth occurs. Early transfer is strongly recommended. Type of study/level of evidence Therapeutic IV.

Contrary to general belief, arthroscopic assisted reduction in distal radius fractures can be done in an expeditious manner and with minimal consumption of operating room resources. This article presents the steps for a pleasant arthroscopic experience in detail. The technique proposed combines the benefits of rigid fixation with volar locking plates (for the extra-articular component) and arthroscopic control of the reduction (for the articular component). It is important that the operation be carried out using the dry arthroscopic technique. However, arthroscopy is just an addition to conventional methods. Thorough knowledge of and facility with classic techniques of distal radius fracture treatment is essential for a good result.

Proposito Las transferencias de dedos del pie constituyen un arma fundamental en la rehabilitacion de las lesiones de mano. Sin embargo, no gozan de mucha popularidad dada la posibilidad de fracaso y por las hipoteticas secuelas en la zona donante. Presentamos nuestra experiencia clinica, haciendo especial hincapie en las complicaciones y las nuevas aplicaciones. Material y metodos En el periodo febrero de 1995 - enero de 2010 hemos realizado 250 transferencias de dedos del pie para amputaciones de todos o parte de los dedos. En las amputaciones de todos los dedos (23 casos) se trasplantaron el hallux de un pie y el 2.° y 3.er dedos del pie contralateral para lograr una pinza tripode. El resto de los casos corresponden a amputaciones multidigitales, simples o parciales de dedos, siendo 69 casos pulgares y el resto, dedos trifalangicos. Resultados La tasa de reintervencion por isquemia aguda fue del 16% (10% intraoperatoria), con una supervivencia final del 98,8% (3 fracasos) tras la revision quirurgica. No hubo ninguna necrosis parcial. Respecto a la zona donante, un paciente fue intervenido por presentar un neuroma; el resto no refirio ningun tipo de molestias a la marcha, en el seguimiento a largo plazo. Conclusiones En nuestra experiencia, las transferencias de dedos del pie son un metodo seguro en la reconstruccion de lesiones graves de la mano. La secuela del pie es proporcional a la cantidad de dedos que se tomen, y es bien aceptada por el paciente, en especial en las graves lesiones

Purpose Toe-to-hand transfers are an essential part of hand rehabilitation after loss of a finger. Despite this, the likelihood of failure and the hypothetical morbidity in the donor area, made this procedure not very popular among surgeons. The purpose of this paper is to present our clinical experience, highlighting the pitfalls and the new indications. Material and methods Between February 1995-January 2010 we performed 250 toe-tohand transfers for finger amputations. In metacarpal hands (23 cases) we transferred the hallux from one foot and the 2nd and 3rd from the other, to achieve a three-fingered (tripod) grasp. The rest of the patients had multi-digit, simple or partial amputations. In 69 the thumb was reconstructed and the rest of transfers were for finger reconstructions. Results Re-operation rate due to acute ischaemia was 16% (10% intraoperative) and the overall success rate was 98.8% (3 failures). There was no partial necrosis in any case. Regarding the donor side, one patient was operated on due to a painful neuroma; the rest did not have complaints in the donor area. Conclusions In our experience toe-to hand transfers are a safe and reliable method to rehabilitate severe hand injuries. Donor site morbidity is directly related to the number of toes harvested, and is well-tolerated by the patients, especially in severe injuries.

Purpose To present a new arthroscopic method for treating supination losses. Methods Six patients (15–71 y) were eligible for this study. All had a history of trauma to the wrist more than 6 months previously. Five of them had sustained a distal radius fracture: 3 had been treated with a volar plate (1 of them for an extra-articular malunion), 1 with an external fixator and K-wires, and 1 had been treated in a cast. One of these patients underwent a further operation for correcting an intra-articular malunion. The last patient underwent an open reduction of a transscaphoid perilunate dislocation. During a standard radiocarpal arthroscopy, a curved periosteal elevator was inserted through the 6R portal into the volar-radial corner of the triangular fibrocartilage complex and advanced proximally gliding on the anterior ulnar head surface. The volar capsule was then distended with the periosteal elevator and by means of gentle sweeping motion adherences between them, the volar capsule and the ulnar head were freed. Finally, the arthroscopic release was combined with a gentle passive supination force applied by the surgeon. Full supination was maintained in an orthosis for 2 to 3 days. Afterward, regular physical therapy was instituted. Concomitant surgery, arthroscopic or open, was performed in all to treat associated conditions. Results Full supination (90°) was achieved in all intraoperatively. At a mean follow-up of 3.3 years, mean supination was 76° in the latest follow-up (range, 50° to 90°). Mean improvement in supination was 80° (range, 50° to 100°). No distal radioulnar instability or other complications were noted. Conclusions The method presented proved effective in severe forms of supination deficits. Type of study/level of evidence Therapeutic V.

A malunion with a step-off of 1 mm or more after an intra-articular distal radius fracture may cause pain and arthritic changes at midterm follow-up. We present our technique for treating intra-articular distal radius malunions by carrying out an osteotomy from inside the joint outward under arthroscopic guidance using the dry arthroscopy technique, with emphasis on the clinical and radiologic outcomes.We performed surgery on 11 patients for intra-articular malunion of the distal radius 1 to 5 months after the injury. Preoperative step-offs ranged from 2 to 5 mm (average, 2.5 mm) on plain radiographs. Original fracture patterns involved 1 radial styloid fracture, 1 radiocarpal fracture-dislocation, and 9 comminuted intra-articular fractures. In 5 cases an anterior-ulnar or radial styloid fragment was repositioned. In the rest, more than 1 fragment (up to 3) was osteotomized. In 1 patient the articular osteotomy was combined with an ulnar shortening osteotomy.Follow-up ranged from 12 to 48 months. Step-offs were reduced in most cases to 0 mm; however, localized gaps (2 mm) and cartilage defects were commonly seen intraoperatively because the fragments did not accurately fit. According to the Gartland and Werley score, there were 4 excellent and 7 good results (mean score of 2.8). The Modified Green and O'Brien system achieved a mean score of 83, with 3 excellent, 5 good, and 3 fair results. One patient showed radiolunate narrowing on follow-up radiographs.Arthroscopically assisted osteotomy permits direct visualization of the osteotomy site with good midterm clinical and radiologic outcomes. The technique can be used in irregularly defined fragments.Therapeutic IV.

Four free iliac flaps were used to treat or prevent flexion contracture at the elbow or wrist flexion crease. Flap size ranged from 13 x 6 cm to 18 x 8 cm. Two flaps were used for primary coverage, and the other 2 flaps were used to treat established flexion contractures. All flaps survived without vascular complications. Full range of motion was obtained at the elbow and 40 degrees of active extension was obtained at the wrist. The flap has a very thin dermis with minimal panniculus that can be thinned as required, making it ideal to cover flexion creases. Despite the fact that anatomic variations are common in the inguinal region, the flap can be expeditiously and safely elevated. If needed, pedicle length can be up to 8 to 10 cm. The donor site is comparable with that of a full-thickness skin graft harvested from the groin. The donor artery, however, can be very small.

Radiographic assessment of Kienbock’s disease has inherent limitations including the inability to directly assess the integrity of chondral surfaces. For this reason, wrist arthroscopy has become an indispensable tool in the assessment of lunate osteonecrosis. Arthroscopic classification can help guide the surgeon to the appropriate treatment option at each stage of the disease based on the status of the articular cartilage surfaces. Wrist arthroscopy is also useful in the treatment of this challenging disease. This chapter presents the benefits of wrist arthroscopy for evaluation and classification, and provides techniques and tips for utilizing arthroscopy in the surgical treatment of Kienbock’s disease.

Vascularised bone graft is a well accepted technique when dealing with long defects. Its role in refractory nonunion, in small defects and in the growing patient is rarely discussed. In this paper the authors review the different alternatives to deal with bone defects in the upper extremity. The indications of vascularised corticoperiosteal graft for solving small defects harbouring refractory nonunion, and the use of vascularised bone phalanx and metatarsal for complex - but small - defects in the fingers is presented. The ability of the bone to grow and remodel when a living epiphysis is included, and to maintain the cartilage viability when a composite osteochondral graft is transferred are also discussed.

We describe a technique to improve the appearance of the donor site after hallux harvesting. The surgery has been used in 6 consecutive patients having a trimmed-toe–type transfer. Instead of the classic stump closure advised by Wei, the following steps were performed on the donor site: (1) removal en bloc of the second metatarsal and transposition of the second toe on top of the proximal phalanx of the hallux, (2) interposition of a tibial (medial) glabrous flap from the tibial aspect of the hallux onto the tibial side of the second toe to increase its size, and (3) eponichial flap to increase the nail show on the second toe. Fixation of the toe was achieved with K-wires and cerclage wire. Crossed K-wires stabilized the first to the third metatarsals for 4 to 6 weeks. Ambulation with a stiff sole was allowed a few days after surgery. The main advantage of this technique is the improved donor site appearance. As a bonus, the amount of skin that can be harvested with the trimmed toe is slightly increased. The main drawback is that the number of toes is reduced to 4.

Purpose Most digital nerve defects can be reconstructed by means of nonvascularized nerve grafts or artificial tubes, for example. When the bed is poor, the defect is long, or there is a concomitant soft-tissue loss; however, a vascularized nerve graft may be a better option. Our purpose is to introduce a method of 1-stage reconstruction of complex neurocutaneous defects in the fingers and to report the results and clinical effectiveness at a minimum 1-year follow-up period. Methods From 1997 to 2005 there were 6 consecutive patients who had a combined soft-tissue and digital nerve defect reconstructed by a vascularized neurocutaneous flap from the tibial (medial) side of the second toe. Three were acute and 3 were chronic cases. One flap was used for the ulnar side of the thumb, 2 for the radial aspect of the index finger, 1 for the radial of the small finger, and 2 for the ulnar side of the small finger. The nerve gap averaged 4.2 cm, and the flap size averaged 3.2 × 2.1 cm. The flaps were revascularized with standard microsurgical techniques to local vessels in the fingers. The nerves were sutured with epineural stitches. A split-thickness skin graft was used to close the donor site of the toe. Results All flaps survived without complications. At the latest follow-up evaluation static two-point discrimination (s2PD) averaged 8 mm on the pulp. Three patients had normal sensation when tested with Semmes-Weinstein filaments. Subjective feeling was 78% of that of the normal side. Five patients rated their feeling as excellent on a subjective scale. The Disabilities of the Arm, Shoulder, and Hand questionnaire score averaged 5. Conclusions The tibial neurocutaneous second toe free flap is suitable for reconstructing a missing nerve and soft-tissue defect in the finger. We found good functional recovery and high satisfaction in this group of patients. The donor site morbidity has been minimal, although delayed healing is common. Type of study/level of evidence Therapeutic IV.

Purpose To examine short-term clinical results of arthroscopic partial resection for type Ia avascular necrosis of the capitate. Methods Patients who underwent arthroscopic treatment for type 1a avascular necrosis of the capitate with at least 1-year follow-up were identified through a retrospective chart review. The necrotic capitate head was arthroscopically resected with removal of the lunate facet and preservation of the scaphoid and hamate facets. Wrist range of motion, grip strength, and radiographic parameters—carpal height ratio, radioscaphoid angle, and radiolunate angle—were determined before surgery and at the latest follow-up. Patients completed a visual analog scale for pain; Disabilities of the Arm, Shoulder, and Hand measure; and the Patient-Rated Wrist Evaluation score before surgery and at the latest follow-up. Results Five patients (1 male, 4 females) with a mean age of 34 years (range, 16–49 years) and a mean follow-up duration of 20 months (range, 12–36 months) were identified during the chart review. All were type Ia (Milliez classification). Arthroscopy revealed fibrillation or softening with cartilage detachment at the lunate facet of the capitate head and an intact articular surface at the scaphoid and hamate facet. At the latest follow-up, the mean wrist flexion-extension was 123° (vs 81° before surgery) and grip strength was 74% (vs 37% before surgery). The visual analog scale score for pain; the Disabilities of the Arm, Shoulder, and Hand score; and the Patient-Rated Wrist Evaluation score before surgery showed a significant improvement following treatment. Radiographic parameters did not significantly change at the final follow-up, although the proximal carpal row trended toward flexion. Conclusions Arthroscopic partial resection of the capitate head was an acceptable treatment for type Ia avascular necrosis of the capitate. It provided adequate pain relief and improved the range of wrist motion and grip strength during short-term follow-up. Type of study/level of evidence Therapeutic IV.

Resumen Presentamos nuestra experiencia en 9 pacientes mastectomizadas, seis de ellas radiadas, reconstruidas en fase cronica con colgajos microquirurgicos de perforante (ocho de la arteria epigastrica inferior y uno de la arteria glutea superior). El seguimiento minimo tras la reconstruccion ha sido de 12 meses. Todos los casos sobrevivieron. En uno se produjo una complicacion intraoperatoria: la avulsion del pediculo, que se pudo solucionar sin consecuencias. En dos casos hemos observado pequenas areas de necrosis grasa que evolucionaron favorablemente con tratamiento conservador. La valoracion de los resultados esteticos por parte de las pacientes ha sido muy satisfactoria. En nuestra opinion, los colgajos de perforante constituyen una excelente opcion reconstructora, incluso en pacientes sometidas a radioterapia. Su vascularizacion y vitalidad permiten reconstruir una mama con un magnifico resultado estetico y una minima morbilidad. No obstante, hay que considerar la complejidad tecnica y el mayor riesgo de complicaciones vasculares en casos de radioterapia previa.

Repair of the volar scapholunate ligament has not been performed arthroscopically. We present an all-inside technique that presents closure of the anterior scapholunate interval. A Tuohy needle and a resorbable suture are all that is required.

Purpose To present a method for reconstructing the digital web in posttraumatic defects using a free tissue transfer of the web from the foot and to present the functional and aesthetic results. Methods Nine web free flaps were performed; 8 were used to reconstruct posttraumatic web losses and 1 was used to reconstruct a defect resulting from to infection. All cases involved the first (3) or second (6) webs of the hand. Web flaps were taken from the foot first web (2 patients), from the second (6 cases), and from the third (1 case) in a patient with congenital syndactyly of second foot web space. The donor site was managed by skin grafting from the instep (1 case), creation of a syndactyly (7 cases), or both (1 case). Results All flaps survived without complications. Finger abduction and flexion-extension were similar to the contralateral side. No functional limitations, pain, or contracture were reported. One donor site healed with hypertrophic scars; otherwise, no donor site complications occurred. On a visual analog scale (0–10), the patient assessed appearance of the hand and the donor foot as 9.0 and 9.0, respectively, on average. One web was not well-positioned in the first operation and required revision. Conclusions The foot web free flap reconstructs the hand web by replacing it with a similar functional subunit rather than attempting to recreate the complex geometry, and allows for full function and excellent appearance of the hand. Type of study/level of evidence Therapeutic IV.