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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.

Purpose Enthusiasm for peripheral nerve transfers increased over the past several years, but further studies are still needed to establish the role of these procedures in peripheral nerve reconstruction. The primary goal of this study was to describe the frequency of nerve transfer surgery among newly trained orthopedic surgeons. Methods We queried the American Board of Orthopaedic Surgery Part II case log database for all nerve reconstruction Current Procedural Terminology codes for examination years 2004 to 2018 for surgeries performed between 2003 and 2017. Information collected for each patient included examination year, year of surgery, surgeon fellowship training subspecialty, geographic region (as defined by the American Board of Orthopaedic Surgery Part II case log database), patient age, and patient sex. Results A total of 3,359 nerve reconstruction cases were logged by 1,542 individual candidates from examination years 2004 to 2018. Of the nerve reconstruction codes, 2.1% were nerve transfer codes. There was a statistically significant increase in the proportion of nerve transfer codes over the study period, from 0% of nerve reconstruction codes in examination years 2004 to 2006 to 4.1% of nerve reconstruction codes in examination years 2016 to 2018 (Z = –6.82; P Conclusions There has been an increase in the number of nerve transfer procedures relative to all nerve reconstruction codes for peripheral nerve conditions. Clinical relevance There is a modest but significant increase in nerve transfer procedures over time among newly trained orthopedic surgeons, which suggests the need for long-term outcomes studies for nerve transfers procedures performed in the setting of peripheral nerve conditions.

A 61-year-old woman presented with a failed proximal ulna allograft-prosthetic composite after revision total elbow arthroplasty (TEA). The ulnar deficiency was addressed using an osteomuscular flap from the distal radius pedicled on the radial artery. At final follow-up, she had minimal pain and a flexion-extension arc of 0° to 130°. Radiographs demonstrated graft incorporation and a stable TEA construct.This demonstrates utilization of a vascularized osteomuscular flap from the radius for treatment of proximal ulnar deficiency in the setting of revision TEA. This technique offers an alternative option for the challenge of a failed TEA with ulnar bone loss.

OBJECTIVEPatients with cervical spinal cord injury (SCI)/tetraplegia consistently rank restoring arm and hand function as their top functional priority to improve quality of life. Motor nerve transfers traditionally used to treat peripheral nerve injuries are increasingly used to treat patients with cervical SCIs. In this article, the authors present early results of a prospective clinical trial using nerve transfers to restore upper-extremity function in tetraplegia.METHODSParticipants with American Spinal Injury Association (ASIA) grade A–C cervical SCI/tetraplegia were prospectively enrolled at a single institution, and nerve transfer(s) was performed to improve upper-extremity function. Functional recovery and strength outcomes were independently assessed and prospectively tracked.RESULTSSeventeen participants (94.1% males) with a median age of 28.4 years (range 18.2–76.3 years) who underwent nerve transfers at a median of 18.2 months (range 5.2–130.8 months) after injury were included in the analysis. Preoperative SCI levels ranged from C2 to C7, most commonly at C4 (35.3%). The median postoperative follow-up duration was 24.9 months (range 12.0–29.1 months). Patients who underwent transfers to median nerve motor branches and completed 18- and 24-month follow-ups achieved finger flexion strength Medical Research Council (MRC) grade ≥ 3/5 in 4 of 15 (26.7%) and 3 of 12 (25.0%) treated upper limbs, respectively. Similarly, patients achieved MRC grade ≥ 3/5 wrist flexion strength in 5 of 15 (33.3%) and 3 of 12 (25.0%) upper limbs. Among patients who underwent transfers to the posterior interosseous nerve (PIN) for wrist/finger extension, MRC grade ≥ 3/5 strength was demonstrated in 5 of 9 (55.6%) and 4 of 7 (57.1%) upper limbs 18 and 24 months postoperatively, respectively. Similarly, grade ≥ 3/5 strength was demonstrated in 5 of 9 (55.6%) and 4 of 7 (57.1%) cases for thumb extension. No meaningful donor site deficits were observed. Patients reported significant postoperative improvements from baseline on upper-extremity–specific self-reported outcome measures.CONCLUSIONSMotor nerve transfers are a promising treatment option to restore upper-extremity function after SCI. In the authors’ experience, nerve transfers for the reinnervation of hand and finger flexors showed variable functional recovery; however, transfers for the reinnervation of arm, hand, and finger extensors showed a more consistent and meaningful return of strength and function.

Metacarpal nonunion is a rare outcome of metacarpal injury, and little has been published about its management. Care typically includes open reduction and internal fixation with a possible bone graft, similar to the treatment of other nonunions. However, there is no literature guidance if traditional methods do not lead to union. To improve the treatment of these recalcitrant metacarpal diaphyseal nonunions, we proposed a new surgical technique using a "top hat" bone graft harvested from the iliac crest. The graft is carefully shaped to create a cancellous "crown," which is inserted into the nonunion site, and cortical "brims," which are used to secure the graft to the metacarpal. This has been successful in treating 2 cases of metacarpal nonunion that failed to heal with first-line intervention.

Giant cell tumor of the distal radius is a rare, locally destructive, and frequently recurrent tumor. We present a case of Campanacci Grade III giant cell tumor of the distal radius with pathologic fracture and cortical destruction which was treated with neoadjuvant denosumab. This facilitated en-bloc resection of the entire distal radius, including the articular surface, while minimizing tumor contamination. Reconstruction was accomplished using a vascularized ulnar transposition flap to facilitate radioulnoscapholunate fusion, which was fixated using a long-stem contralateral variable angle locking volar distal radius plate in a dorsal position. This case illustrates multidisciplinary management of a challenging reconstructive problem and demonstrates a novel strategy for fixation which repurposes familiar and readily available hardware to provide optimal osteosynthesis.

Targeted muscle reinnervation after upper-extremity amputation has demonstrated improved outcomes with myoelectric prosthesis function and postoperative neuropathic pain. This technique has been established in the setting of shoulder disarticulation as well as transhumeral and transradial amputations, but a detailed technique of targeted muscle reinnervation with free tissue transfer from the volar forearm after forequarter amputation has not yet been described. Here, we describe a technique using a volar forearm filet flap to achieve simultaneously satisfactory soft tissue coverage after resection of a tumor from the chest wall and targeted muscle reinnervation of the brachial plexus.

Purpose Although volar plating of the distal radius is performed frequently, the necessity of distal bicortical fixation in the metaphyseal and epiphyseal areas of the distal radius has not been proven. This study aimed primarily to quantify the ability of unicortical distal screws to maintain operative reduction of adult distal radius fractures and secondarily to determine if unicortical screw lengths could be predicted based on anatomical measurements. Methods This prospective trial enrolled 75 adult patients undergoing volar locking plate fixation of a unilateral distal radius fracture at a tertiary center. Study inclusion required screw fixation in the distal rows of the plate performed with unicortical screw placement. The primary outcome was maintenance of operative reduction, according to predefined parameters, quantified by comparing initial operative reduction to final reduction after fracture healing. Repeated measures analysis of variance analyzed for systematic change in radiographic parameters between injury, operative, and healed images. Correlation coefficients quantified the relationship of screw lengths with lunate width and other anatomical measurements. Results Seventy-five patients (mean age, 54 years ± 15 years; 79% women) were enrolled and followed to fracture union. Fracture severity varied and included AO type A (40%), B (12%), and C (48%) fractures. There was no significant change in mean lateral translation, intra-articular gap, intra-articular stepoff, radial inclination, or lateral tilt of the radius between the time of fixation and union for the cohort. Two patients lost reduction (increased dorsal tilt, 10°, 20°, respectively), potentially attributable to provision of unicortical fixation (3%; 95% confidence interval [95% CI], 0%–9%). No extensor tenosynovitis or extensor tendon ruptures occurred. Eighty percent of screws were 18 mm or less and screw lengths were not correlated with lunate width or any other anatomical measurements. Conclusions Unicortical distal fixation during volar locking plate fixation effectively maintains operative reductions of distal radius fractures while potentially minimizing the incidence of extensor tendon ruptures. Type of study/level of evidence Therapeutic IV.

Objectives To compare the timing of soft-tissue (flap) coverage and occurrence of complications before and after the establishment of an integrated orthopaedic trauma/microsurgical team. Design Retrospective cohort study. Setting A single level 1 trauma center. Patients Twenty-eight subjects (13 pre- and 15 post-integration) with open tibia shaft fractures (OTA/AO 42A, 42B, and 42C) treated with flap coverage between January 2009 and March 2015. Intervention Flap coverage for open tibia shaft fractures treated before ("preintegration") and after ("postintegration") implementation of an integrated orthopaedic trauma/microsurgical team. Main outcome measure Time from index injury to flap coverage. Results The unadjusted median time to coverage was 7 days (95% confidence interval, 5.9-8.1) preintegration, and 6 days (95% confidence interval, 4.6-7.4) postintegration (P = 0.48). For preintegration, 9 (69%) of the patients experienced complications, compared with 7 (47%) postintegration (P = 0.23). Conclusions After formation of an integrated orthopaedic trauma/microsurgery team, we observed a 1-day decrease in median days to coverage from index injury. Complications overall were lowered in the postintegration group, although statistically insignificant. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The complexity of each brachial plexus injury (BPI) pattern and physiologic limitations of nerve regeneration create challenges for BPI patients and their surgeons. Detailed assessment via physical examination, electrodiagnostic studies, and advanced imaging can aid the surgeon in predicting the prognosis for each patient’s neurologic recovery and provide an outline for reconstructive priorities. Surgical exploration of the brachial plexus confirms the injury pattern and guides the overall treatment strategies. A multimodal reconstructive strategy including nerve grafting, extraplexal nerve transfers, distal intraplexal nerve transfers, and free-functioning muscle transfers is designed for each patient to accomplish the goals of providing a pain-free helper hand. Additional reconstructive procedures such as tendon transfers and selective joint arthrodeses are used after the results of the initial reconstructive efforts have been declared. Beyond the neurologic components of BPI, the surgeon must be attuned to the social and psychological sequelae of this devastating injury. This review contains 10 figures, 1 table, and 60 references. Key Words: brachial plexus injury, elbow flexion, free-functioning muscle transfer, nerve grafting, nerve transfer, reconstruction, shoulder abduction, , tendon transfer

There is a significant burden of disease associated with infected fractures, and their management is challenging. Prevention of infection after musculoskeletal trauma is essential because treatment of an established infection continues to be a major obstacle. Despite the need for evidence-based decision making, there is a lack of consensus around strategies for prevention and surgical management of the infected fracture. The current evidence for the prevention of the infected fracture is reviewed here with a focus on evidence for antibiotic therapy and debridement, the induced membrane technique, management of soft-tissue defects, patient optimization, and adjuncts to prevent infection.

There are number of significant issues outside of the bone and/or fracture that are important to consider in the treatment of orthopaedic trauma. Joint contractures, heterotopic bone formation, managing a traumatized soft-tissue envelope or substantial soft-tissue defects represent a few of these important issues. This article reviews these issues, including the best available evidence on how to manage them.

OBJECTIVEPatients with cervical spinal cord injury (SCI)/tetraplegia consistently rank restoring arm and hand function as their top functional priority to improve quality of life. Motor nerve transfers traditionally used to treat peripheral nerve injuries are increasingly being used to treat patients with cervical SCIs. In this study, the authors performed a systematic review summarizing the published literature on nerve transfers to restore upper-extremity function in tetraplegia.METHODSA systematic literature search was conducted using Ovid MEDLINE 1946–, Embase 1947–, Scopus 1960–, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and clinicaltrials.gov to identify relevant literature published through January 2019. The authors included studies that provided original patient-level data and extracted information on clinical characteristics, operative details, and strength outcomes after nerve transfer procedures. Critical review and synthesis of the articles were performed.RESULTSTwenty-two unique studies, reporting on 158 nerve transfers in 118 upper limbs of 92 patients (87 males, 94.6%) were included in the systematic review. The mean duration from SCI to nerve transfer surgery was 18.7 months (range 4 months–13 years) and mean postoperative follow-up duration was 19.5 months (range 1 month–4 years). The main goals of reinnervation were the restoration of thumb and finger flexion, elbow extension, and wrist and finger extension. Significant heterogeneity in transfer strategy and postoperative outcomes were noted among the reports. All but one case report demonstrated recovery of at least Medical Research Council grade 3/5 strength in recipient muscle groups; however, there was greater variation in the results of larger case series. The best, most consistent outcomes were demonstrated for restoration of wrist/finger extension and elbow extension.CONCLUSIONSMotor nerve transfers are a promising treatment option to restore upper-extremity function after SCI. Flexor reinnervation strategies show variable treatment effect sizes; however, extensor reinnervation may provide more consistent, meaningful recovery. Despite numerous published case reports describing good patient outcomes with nerve transfers, there remains a paucity in the literature regarding optimal timing and long-term clinical outcomes with these procedures.

Wound healing complications associated with total knee arthroplasty present a considerable challenge to the orthopaedic surgeon. To ensure preservation of a functional joint, the management of periprosthetic soft-tissue defects around the knee requires rapid assessment, early and aggressive débridement, and durable, contoured coverage. Several reconstructive options are available to tailor soft-tissue coverage to the location, size, and depth of the wound. Special consideration should be given to the timing of the intervention, management of infection, and prosthesis salvage. The merits of each reconstructive option, including perforator, fasciocutaneous, muscular, and free microvascular flaps, should be weighed to select the most appropriate option. The proposed approach can guide surgeons in treating patients with these complex soft-tissue defects.

The purpose of this study was to determine if simultaneous bilateral carpal tunnel release (CTR) is a cost-effective strategy compared with bilateral staged CTR for the treatment of bilateral carpal tunnel syndrome. Methods A decision analytic model was created to compare the cost effectiveness of three strategies (ie, bilateral simultaneous CTR, bilateral staged CTR, and no treatment). Direct medical costs were estimated from 2013 Medicare reimbursement rates and wholesale drug costs in US dollars. Indirect costs were derived from consecutive patients undergoing unilateral or simultaneous bilateral CTR at our institution and from national average wages for 2013. Health state utility values were derived from a general population of volunteers using the Short Form-6 dimensions (SF-6D) health questionnaire. Results Both surgical strategies were cost effective compared with the no-treatment strategy. Bilateral simultaneous CTR had lower total costs and higher total effectiveness than bilateral staged CTR, and had an incremental cost-effectiveness ratio of $921 per quality-adjusted life year compared with the no-treatment strategy. The conclusions of the analysis remained unchanged though all sensitivity analyses, displaying robustness against parameter uncertainty. Conclusions Surgical management is cost effective for the treatment of bilateral carpal tunnel syndrome. Bilateral simultaneous CTR, however, has lower total costs and higher total effectiveness compared with bilateral staged CTR. Level of evidence Economic and Decision Analysis I.

Purpose To determine whether simplification of the Eaton-Glickel (E-G) classification of trapeziometacarpal (TMC) joint arthrosis (eliminating evaluation of the scaphotrapezial [ST] joint) and information about the patient's symptoms and examination influence interobserver reliability. We also tested the null hypotheses that no patient and/or surgeon factors affect radiographic rating of TMC joint arthrosis and that no surgeon factors affect the radiographic rating of ST joint arthrosis.Methods In an on-line survey, 92 hand surgeons rated TMC joint arthrosis and ST joint arthrosis separately on 30 radiographs (Robert, true lateral, and oblique views) according to the (modified) E-G classification. We randomly assigned 42 observers to review radiographs alone and also informed 50 of the patient's symptoms and examination. Information about symptoms and examination was randomized. Interobserver reliability was determined with the s* statistic. Because of the hierarchical data structure, cross-classified ordinal multilevel regression analyses were performed to identify factors associated with the severity of arthrosis.Results Shortening the E-G classification to the first 3 stages significantly improved the interobserver reliability, which approached substantial agreement. Providing clinical information to observers marginally improved interobserver reliability. Factors associated with a lower E-G stage for TMC joint arthrosis, among observers who rated the severity of TMC joint arthrosis based on radiographs and clinical information, included female surgeon, practice setting, supervising surgical trainees in the operating room, self-reported number of patients with TMC joint arthrosis typically treated annually, male patient, higher patient age, pain limiting daily activities, and shoulder sign. A self-reported larger number of patients with TMC joint arthrosis treated annually was the only variable associated with a higher modified E-G classification to rate ST joint arthrosis.Conclusions Our findings suggest that simpler classifications that focus on a single anatomical area are reliable and that surgeon and patient factors can bias interpretation of objective pathophysiology such as radiographic findings. Copyright (C) 2016 by the American Society for Surgery of the Hand. All rights reserved.

Purpose Prescription opioid abuse is an epidemic in the United States; multimodal analgesia has been suggested as a potential solution to decrease postoperative opioid use. The primary aim of this study was to determine the effect of perioperative celecoxib on opioid intake. Secondary goals were to determine whether perioperative administration of celecoxib decreased postoperative patient-reported pain and whether patient demographic characteristics could predict postoperative pain and opioid intake. Methods This prospective cohort study enrolled patients undergoing mass excision or carpal tunnel, trigger finger, or de Quervain release by 1 of 3 fellowship-trained hand surgeons. Patients in the experimental group were given 200 mg celecoxib tablets taken twice a day starting the day before surgery and continued for 5 days after surgery. Both groups received hydrocodone–acetaminophen tablets 5 mg/325 mg as needed after surgery. After surgery, patients completed daily opioid consumption and pain logs for 7 days and underwent a pill count. Outcomes included morphine milligram equivalents (MME) consumed and postoperative pain. Results A total of 123 patients were enrolled: 68 control patients and 54 celecoxib patients. Fifty (74%) and 37 (69%) patients, respectively, completed the study. Overall, the median number of MMEs consumed was 25 (range, 0–330). During the first postoperative week, patients in the celecoxib and control groups were similar with respect to postoperative pain experienced (median visual analog scale score, 2.0 vs 1.4, respectively) and amount of opioid taken (median MMEs = 30 vs 20, respectively). Conclusions Patients taking perioperative celecoxib had similar postoperative pain and opioid intake compared with patients not prescribed celecoxib in the study. Regardless of study group, 4 to 10 hydrocodone tablets were sufficient to control postoperative pain for most patients undergoing soft tissue ambulatory hand surgery. This may be the result of the limited duration and mild nature of pain after outpatient elective hand surgery. Type of study/level of evidence Therapeutic II.

Background: In clinical research, minimizing patients lost to follow-up is essential for data validity. Researchers can employ better methodology to prevent patient loss. We examined how orthopedic surgery patients’ contact information changes over time to optimize data collection for long-term outcomes research. Methods: Patients presenting to orthopedic outpatient clinics completed questionnaires regarding methods of contact: home phone, cell phone, mailing address, and e-mail address. They reported currently available methods of contact, if they changed in the past 5 and 10 years, and when they changed. Differences in the rates of change among methods were assessed via Fisher’s exact tests. Whether participants changed any of their contact information in the past 5 and 10 years was determined via multivariate modeling, controlling for demographic variables. Results: Among 152 patients, 51% changed at least one form of contact information within 5 years, and 66% changed at least one form within 10 years. The rate of change for each contact method was similar over 5 (15%–28%) and 10 years (26%–41%). One patient changed all four methods of contact within the past 5 years and seven within the past 10 years. Females and younger patients were more likely to change some type of contact information. Conclusion: The type of contact information least likely to change over 5–10 years is influenced by demographic factors such as sex and age, with females and younger participants more likely to change some aspect of their contact information. Collecting all contact methods appears necessary to minimize patients lost to follow-up, especially as technological norms evolve.

Background Although cubital tunnel syndrome is the second most common peripheral mononeuropathy (after carpal tunnel syndrome) encountered in clinical practice, its prevalence in the population is unknown. The objective of this study was to evaluate the prevalence of cubital tunnel syndrome in the general population. Methods We surveyed a cohort of adult residents of the St. Louis metropolitan area to assess for the severity and localization of hand symptoms using the Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQ-SSS) and the Katz hand diagram. We identified subjects who met our case definitions for cubital tunnel syndrome and carpal tunnel syndrome: self-reported hand symptoms associated with a BCTQ-SSS score of >2 and localization of symptoms to the ulnar nerve or median nerve distributions. Results Of 1,001 individuals who participated in the cross-sectional survey, 75% were women and 79% of the cohort was white; the mean age (and standard deviation) was 46 ± 15.7 years. Using a more sensitive case definition (lax criteria), we identified 59 subjects (5.9%) with cubital tunnel syndrome and 68 subjects (6.8%) with carpal tunnel syndrome. Using a more specific case definition (strict criteria), we identified 18 subjects (1.8%) with cubital tunnel syndrome and 27 subjects (2.7%) with carpal tunnel syndrome. Conclusions The prevalence of cubital tunnel syndrome in the general population may be higher than that reported previously. When compared with previous estimates of disease burden, the active surveillance technique used in this study may account for the higher reported prevalence. This finding suggests that a proportion of symptomatic subjects may not self-identify and may not seek medical treatment. Clinical relevance This baseline estimate of prevalence for cubital tunnel syndrome provides a valuable reference for future diagnostic and prognostic study research and for the development of clinical practice guidelines.

Loss of contact between radial head fracture fragments is strongly associated with other elbow or forearm injuries. If this finding has adequate interobserver reliability, it could help examiners identify and treat associated ligament injuries and fractures (eg, forearm interosseous ligament injury or elbow dislocation). (1) What is the interobserver agreement on radiographic loss of contact between radial head fracture fragments? (2) Are there factors associated with the observer such as location of practice or subspecialization that increase interobserver reliability? Fully trained practicing orthopaedic and trauma surgeons from around the world evaluated 27 anteroposterior and lateral radiographs of radial head fractures on a web-based platform for the following characteristics: (1) loss of contact between at least one radial head fracture fragment and the remaining radial head and neck; (2) a gap between fragments of 2 mm or greater; (3) anticipated fracture instability (mobility) on operative exposure; (4) anticipated associated ligament injuries; and (5) recommendation for treatment. Agreement among observers was measured using the multirater kappa measure. Kappas for various observer characteristics were compared using 95% confidence intervals. The overall interobserver agreement was moderate (range, 0.49-0.55) for each question except associated ligament injury, which was fair (0.33). Shoulder and elbow surgeons had substantial agreement (range, 0.51-0.61) in many areas, but kappas were generally in the moderate range (0.41-0.59) based on number of years in practice, radial head fractures treated per year, and trainee supervision. Radiographic signs of radial head fracture instability such as loss of contact have moderate reliability. This characteristic seems clinically useful, because loss of contact between at least one radial head fracture fragment and the remaining radial head and neck is strongly associated with associated ligament injury or other fractures. Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence

Purpose To quantify diabetic patients' change in blood glucose levels after corticosteroid injection for common hand diseases and to assess which patient-level risk factors may predict an increase in blood glucose levels. Methods Patients were recruited for this case-crossover study in the clinic of fellowship-trained hand surgeons at a tertiary care center. Patients with diabetes mellitus type 1 or 2, who received a corticosteroid injection, recorded the morning fasting blood glucose levels for 14 days after the injection. Fasting glucose levels on days 1 to 7 after injection qualified as case data; levels on days 10 to 14 provided control data. A mixed model with a priori contrasts was used to compare postinjection blood glucose levels with baseline levels. We used a linear regression model to determine patient predictors of a postinjection rise in blood glucose levels. Results Of 67 patients recruited for the study returned, 40 (60%) completed blood glucose logs. There was a significant increase in fasting blood glucose levels after injection limited to postinjection days 1 and 2. Among patient risk factors in the linear regression model, type 1 diabetes and use of insulin each predicted a postinjection increase in blood glucose levels from baseline, whereas higher glycated hemoglobin levels did not predict increases. Conclusions Corticosteroid injections in the hand transiently increase blood glucose levels in diabetic patients. Patients with type 1 diabetes and insulin-dependent diabetics are more likely to experience this transient rise in blood glucose levels. Type of study/level of evidence Therapeutic III.

Purpose To compare the tensile properties of a 3-0, 4-strand flexor tendon repair with a 4-0, 4-strand repair and a 4-0, 8-strand repair. Methods Following evaluation of the intrinsic material properties of the 2 core suture calibers most commonly used in tendon repair (3-0 and 4-0), we tested the mechanical properties of 40 cadaver flexor digitorum profundus tendons after zone II repair with 1 of 3 techniques: a 3-0, 4-strand core repair, a 4-0, 8-strand repair, or a 4-0, 4-strand repair. We compared results across suture caliber for the 2 sutures and across tendon repair methods. Results Maximum load to failure of 3-0 polyfilament caprolactam suture was 49% greater than that of 4-0 polyfilament caprolactam suture. The cross-sectional area of 3-0 polyfilament caprolactam was 42% greater than that of 4-0 polyfilament caprolactam. The 4-0, 8-strand repair produced greater maximum load to failure when compared with the 2 4-strand techniques. Load at 2-mm gap, stiffness, and work to yield were significantly greater in the 4-0, 8-strand repair than in the 3-0, 4-strand repair. Conclusions In an ex vivo model, an 8-strand repair using 4-0 suture was 43% stronger than a 4-strand repair using 3-0 suture, despite the finding that 3-0 polyfilament caprolactam was 49% stronger than 4-0 polyfilament caprolactam. These results suggest that, although larger-caliber suture has superior tensile properties, the number of core suture strands across a repair site has an important effect on time zero, ex vivo flexor tendon repair strength. Clinical relevance Surgeons should consider using techniques that prioritize multistrand core suture repair over an increase in suture caliber.

Distal radius fractures are common, and internal fixation for operative management of these injuries is widely accepted. Although use of the volar approach for plate fixation has become more popular, benefits of the dorsal surgical approach include the potential for direct reduction and assessment of articular alignment, evaluation and management of concomitant intrinsic intercarpal ligament injury, and initiation of early range of motion. For certain fracture patterns, dorsal plate fixation is the preferred surgical technique. Improvements in implant design, in particular the use of low-profile dorsal plates, has decreased the rate of complications seen previously with this technique. Here, we provide an overview of the evaluation of patients with distal radius fractures, as well as the surgical indications and contraindications, techniques, and complications after dorsal locked plate fixation of intra-articular distal radius fractures.

In this article, a group of international leaders in tendon surgery of the hand provide details of their current methods of primary flexor tendon repair. They are from recognized hand centers around the world, from which major contributions to the development of methods for flexor tendon repair have come over the past 2 decades. Changes made since the early 1990s regarding surgical methods and postoperative care for the flexor tendon repair are also discussed. Current practice methods used in the leading hand centers are summarized, and key points in providing the best possible clinical outcomes are outlined.

Purpose It is our impression that there is substantial, unexplained variation in hand surgeon recommendations for treatment of peripheral mononeuropathy. We tested the null hypothesis that specific patient and provider factors do not influence recommendations for surgery. Methods Using a web-based survey, hand surgeons recommended surgical or nonsurgical treatment for patients in 2 different scenarios. Six elements of the first scenario (symptoms, circumstances, mindset, diagnosis, objective testing, and expectations) had 2 possibilities that were each independently and randomly assigned to each rater. For the second scenario, 2 different scenarios were randomly assigned to each rater. Multivariable logistic regression sought factors associated with a recommendation for surgery. Results A total of 186 surgeons of the Science of Variation Group completed a survey regarding recommendation of surgery for 2 different patients based on clinical scenarios. Recommendations for surgery did not vary significantly according to provider characteristics. For the various elements in scenario 1, recommendation for surgery was more likely for patients who were self-employed and continued to work and who had objective electrodiagnostic abnormalities. For the 2 vignettes used in scenario 2, a recommendation for surgery was associated with abnormal electrophysiology. Conclusions The findings of this study suggest that—at least in a survey setting—surgeons prefer to offer peripheral nerve decompression to patients with abnormal electrophysiology, particularly those with effective coping strategies. Clinical relevance The role of objective verification of pathophysiology is debated, but it is an influential factor in recommendations for hand surgery.

Purpose Previous studies have identified the association between trigger digit and carpal tunnel syndrome (CTS). However, whether the presence of multiple trigger digits affects the prevalence of CTS is unknown. The purpose of this study was to determine the incidence of carpal tunnel symptoms in patients treated for single versus multiple trigger digits. Methods We performed a retrospective review of 300 patients treated for trigger digit by injection or surgical release and recorded CTS symptoms, signs, and treatment for either the ipsilateral or contralateral hand documented within 24 months before trigger digit treatment and for an average of 35 months (range, 7– 66 mo) after treatment. Patients were categorized as having single (n = 160) or multiple (n = 140) trigger digits. Binary logistic regression modeled risk factors for development of CTS. Patient age, sex, number of trigger digits (single or multiple), and presence of diabetes, gout, thyroid disease, or thumb osteoarthritis were considered independent variables. Results A total of 58 of 140 patients (41%) who presented with multiple trigger digits exhibited concomitant carpal tunnel symptoms, compared with 26 of 160 (16%) patients who presented with a single trigger digit. Significant independent predictors of CTS associated with trigger digits in the final regression model included multiple trigger digits (odds ratio=3.6; subjects with multiple trigger digits had significantly higher odds of carpal tunnel presentation than subjects with a single trigger digit) and diabetes (odds ratio=1.9; diabetic subjects had significantly higher odds of carpal tunnel presentation than nondiabetics). Conclusions A greater than 3-fold increase in the relative risk of CTS development exists in patients undergoing treatment for multiple trigger digits, compared with those undergoing treatment for a single trigger digit. Awareness of this association may aid in the early diagnosis and treatment of CTS in patients presenting with multiple trigger digits. Type of study/level of evidence Prognostic III.

Orthopedic surgery lacks racial and sexual diversity, which we hypothesized stems from absence of exposure to orthopedics during medical school. We conducted a study to determine whether diversity of matched orthopedic surgery residency applicants increased after introduction of a required third-year rotation. We compared 2 groups: precurriculum and postcurriculum. The postcurriculum group was exposed to a required 1-month musculoskeletal rotation during the third year of medical school. Comparisons were made of percentage of total students exposed to orthopedics, percentage who applied to and matched to orthopedic surgery, and proportion of women and underrepresented minorities. A prospective survey was used to determine when students chose orthopedics and what influenced their decisions. The required rotation increased the percentage of third-year students rotating on orthopedics (25%) with no change in application rate (6%). It also led to an 81% relative increase in the proportion of female applicants and a 101% relative increase in underrepresented minority applicants. According to survey data, 79% of students chose orthopedics during their third year, and 88% thought they were influenced by their rotation. A required third-year rotation exposes more medical students to orthopedics and increases the diversity of matching students.

Double crush syndrome, the association between proximal and distal nerve lesions, has been established. This investigation compares the outcomes of nerve surgery in patients with isolated peripheral compression versus those with double crush syndrome treated with peripheral nerve and cervical spine operations.This case-controlled study enrolled 80 patients: 40 underwent carpal or cubital tunnel surgery and cervical spine surgery (double crush group); and 40 controls, matched by age and sex, underwent only peripheral nerve decompression (peripheral nerve group). A minimum of 18 months was required after peripheral nerve and cervical spine surgery for office assessment (mean, 4.9 years and 6.0 years, respectively). Statistical analysis compared postoperative function and symptom severity questionnaires, physical examination, and patient-reported satisfaction between groups.Patients in the double crush group reported significantly more disability and persistent symptoms on the QuickDASH questionnaire (29 versus 13) and Levine Katz symptom severity (2.0 versus 1.4) and functional status scales (1.9 versus 1.4). Double crush patients reported significantly lower satisfaction. The double crush group exhibited a greater frequency of persistent signs of nerve irritability and muscle weakness compared with the control group.At a minimum of 18 months after peripheral nerve surgery, patients with a history of cervical spine surgery are likely to have inferior patient-reported outcomes, persistent nerve dysfunction, and lower satisfaction after peripheral nerve release compared with patients following isolated peripheral nerve surgery. Double crush syndrome was associated with poorer outcome after peripheral nerve surgery despite treatment of cervical spine nerve compression.Therapeutic, III.

This prospective, randomized controlled study was designed to determine if applying ice to the site of corticosteroid injections in the hand and wrist reduces post-injection pain. Patients receiving corticosteroid injections in the hand or wrist at a tertiary institution were enrolled. Subjects were randomized to apply ice to the injection site and take scheduled over-the-counter analgesics ( n = 36) or take scheduled over-the-counter analgesics alone ( n = 32). There were no significant differences in the mean pain score between the two groups at any time-point (pre-injection or 1–5 days post-injection). In regression modelling, the application of ice did not predict pain after injection. Visual analogue pain scores increased at least 2 points (0–10 scale) after injection in 17 out of 36 patients in the ice group versus ten out of 32 control patients. We conclude that the application of ice in addition to over-the-counter analgesics does not reduce post-injection pain after corticosteroid injection in the hand or wrist. Level of Evidence: I Therapeutic Study

Displaced, unstable intra-articular distal radius fractures are usually treated with reduction and fixation to allow early motion and minimize the potential for development of posttraumatic arthritis. The dorsal surgical approach allows direct visualization of the articular surface to ensure an anatomic reduction. Low profile, locked plates have minimized the unacceptable complication rates previously associated with dorsal plates. This study reviews the historical perspective, indications, technique, complications, and rehabilitation for dorsal, locked plate fixation of intra-articular distal radius fractures. The authors report a strategy for simplifying the fixation of these fractures.

Purpose The volar approach with locked plating is a common treatment for intra-articular distal radius fractures. The purpose of this study was to arthroscopically assess the articular surface after internal fixation through the volar approach as a means to evaluate the ability of an extra-articular reduction to anatomically restore the joint surface. Methods Sixteen patients with intra-articular distal radius fractures were prospectively enrolled. A volar approach and internal fixation using a locked volar plate was performed. Using a visual analog scale (VAS), the fracture reduction was clinically graded on the quality of reduction of the visible metaphyseal fracture lines, fluoroscopically graded, and arthroscopic graded. Maximum step and gap deformity were recorded from arthroscopy and plain radiograph. Results The mean VAS score for the fracture reduction based on extra-articular fracture lines was 7.4. The mean VAS score for the fluoroscopic reduction was 8.2. The mean VAS score for the arthroscopic reduction was 6.4. The arthroscopic VAS score was significantly lower than the VAS score for fluoroscopy but was not significantly different than the VAS score for metaphyseal reduction. Mean arthroscopic measurement of maximum step and gap deformity were 1 mm and 2 mm, respectively. Mean postoperative radiographic maximum step and gap deformity were both less than 1 mm. The arthroscopic step and gap deformities were significantly greater than the radiographic deformities. Conclusions A volar approach, indirect reduction, and locked plate fixation is a useful technique in restoring articular congruity after distal radius fracture. The number of fracture lines and presence of step and gap deformity can be adequately assessed using clinical and fluoroscopic assessment. However, the magnitude of step and gap deformity may be underestimated. Type of study/level of evidence Therapeutic IV.

Purpose To evaluate the timing of improvement after extra-articular steroid injection, the incidence of a postinjection pain flare (a delayed postinjection transient increase in pain), and the role of the injection acidity in the postinjection flare. Methods One hundred twenty-five patients with trigger finger (88 patients) or de Quervain's tenosynovitis (37 patients) were prospectively randomized in this double-blind study to receive either an injection of steroid, lidocaine, and bupivacaine alone (standard injection, acidic pH) or an injection of steroid, lidocaine, bupivacaine, and bicarbonate (balanced injection, neutral pH). All patients completed a visual analog scale for pain before and immediately after the injection, daily for 7 days, and then again at 6 weeks. A flare reaction was defined as an increase in the visual analog scale score by 2 or more points any time after the injection. Results All patients immediately responded to the steroid injection, but pain rebounded to preinjection levels by day 1. In both groups the pain then gradually declined over the course of 7 days. In the balanced group, 23 of the 68 patients had flare reactions. In the standard group, 18 of the 57 patients had flare reactions. The difference between groups was not significant. Conclusions Patients respond to extra-articular steroid injections with gradual improvement over the course of the first week. An increase in pain, or flare reaction, in the days following a steroid injection was noted in 33% of patients. A pH-balanced injection did not significantly decrease the risk of a flare reaction. Type of study/level of evidence Therapeutic I.

Background: It is generally accepted that the initial treatment for trigger finger is injection of corticosteroid into the flexor tendon sheath. In this study, the efficacy of corticosteroid injections for the treatment of trigger finger in patients with diabetes mellitus was evaluated in a prospective, randomized, controlled, double-blinded fashion and the efficacy in nondiabetic patients was evaluated in a prospective, unblinded fashion. Methods: Thirty diabetic patients (thirty-five digits) and twenty-nine nondiabetic patients (twenty-nine digits) were enrolled. The nondiabetic patients were given corticosteroid injections in an unblinded manner. The cohort with diabetes was randomized into a corticosteroid group (twenty digits) or a placebo group (fifteen digits). Both of these groups were double-blinded. Additional injections, surgical intervention, and recurrent symptoms of trigger finger were recorded. Treatment success was defined as complete or nearly complete resolution of trigger finger symptoms such that surgical intervention was not required. Results: After one or two injections, twenty-five of the twenty-nine digits in the nondiabetic group had a successful outcome compared with twelve of the nineteen in the diabetic corticosteroid group (p = 0.03) and eight of the fifteen in the diabetic placebo group (p = 0.006). With the numbers studied, no significant difference was found between the diabetic groups. Surgery was performed in three of the twenty-nine digits in the nondiabetic group compared with seven of the nineteen in the diabetic corticosteroid group and six of the fifteen in the diabetic placebo group. There was a significant difference in the prevalence of surgery between the nondiabetic group and both the diabetic corticosteroid group and the diabetic placebo group (p = 0.035 and p = 0.020, respectively). With the numbers studied, no difference was found between the diabetic groups with regard to the persistence of symptoms. Nephropathy and neuropathy were significantly associated with the need for surgery (p = 0.008 and p = 0.03, respectively). Conclusions: Corticosteroid injections were significantly more effective in the digits of nondiabetic patients than in those of diabetic patients. In patients with diabetes, corticosteroid injections did not decrease the surgery rate or improve symptom relief compared with the placebo. The use of corticosteroid injections for the treatment of trigger finger may be less effective in patients with systemic manifestations of diabetes mellitus. Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

Purpose To explore the course of the radial nerve in the brachium and to identify practical anatomic landmarks that can be used to avoid iatrogenic injury during humerus fracture fixation. Methods Data were collected from 27 adult cadaveric specimens, including 18 embalmed cadavers and 9 fresh-frozen limbs. Measurements were taken using osseous landmarks to define the relationship of the radial nerve and the posterior and lateral humerus. The extremities were studied further to determine the association of the radial nerve and anatomic landmarks on both longitudinal and cross-sectioned specimens. Results A 6.3 cm ± 1.7 segment of radial nerve was found to be in direct contact with the posterior humerus from 17.1 cm ± 1.6 to 10.9 cm ± 1.5 proximal to the central aspect of the lateral epicondyle, centered within 0.1 cm ± 0.2 of the level of the most distal aspect of the deltoid tuberosity. The radial nerve lay in direct contact with the periosteum in all specimens, without evidence of a structural groove in the humerus in any specimen. On entering the anterior compartment, the radial nerve had very little mobility as it was interposed between the obliquely oriented lateral intermuscular septum and the lateral aspect of the humerus. As it extended distally, the nerve coursed anterior to the humerus and became protected by brachialis muscle at the level of the proximal aspect of the lateral metaphyseal flare. Conclusions The radial nerve is at risk of injury with fractures of the humerus and with subsequent operative fixation in 2 areas. The first is along the posterior midshaft region for a distance of 6.3 cm ± 1.7 centered at the distal aspect of the deltoid tuberosity. The second is along the lateral aspect of the humerus in its distal third from 10.9 cm ± 1.5 proximal to the lateral epicondyle to the level of the proximal aspect of the metaphyseal flare. The deltoid tuberosity is a consistent and practical anatomic landmark that can be used to determine the level of the radial nerve along the posterior aspect of the humerus during operative fixation from an anterior approach.

Trapeziometacarpal arthrodesis (TMA) has been complicated by nonunion and hardware failure.We hypothesized that modification of the TMA technique with a locking cage plate construct would afford reliable bony union while producing greater hand function than trapeziectomy with ligament reconstruction and tendon interposition (LRTI) at early follow-up.We enrolled 36 consecutive patients with trapeziometacapal osteoarthritis (14 TMA patients (15 thumbs), 22 LRTI patients (22 thumbs)). The study was powered to detect a minimal clinically important difference on the QuickDASH questionnaire between groups. Secondary outcomes included Michigan Hand Questionnaire (MHQ), VAS-pain, and EQ-5D-3L scores. Patients were examined to evaluate thumb motion and strength. TMA patients were evaluated clinically and radiographically for union.Mean follow-up was 15.6 months, and the mean age was 59.2 years. Union was achieved in 14/15 (93%) of TMA thumbs. Improvement in QuickDASH scores was similar after TMA and LRTI (49 to 28 and 50 to 18, respectively). Postoperative patient-rated upper extremity function, health status, and pain were similar between groups. Pinch strength was significantly greater after TMA (5.9 vs 4.7 kg). No differences in thumb or wrist range of motion were observed postoperatively with the exception of greater total metacarpophalangeal joint motion after TMA. Complications after TMA included nonunion (7%), development of symptomatic scaphotrapezotrapezoidal (STT) arthrosis (7%), symptomatic hardware (7%), and superficial branch of the radial nerve (SBRN) paresthesia (7%). Complications after LRTI included subsidence (5%), MP hyperextension deformity (5%), and SBRN paresthesias (5%).At early follow-up, patient-rated function was similar among patients undergoing TMA and LRTI. TMA produced 25% greater pinch strength compared with LRTI. Despite historical concerns regarding global loss of ROM with arthrodesis, motion was similar between groups. Our observed TMA nonunion rate of 7% is low relative to historically reported nonunion rates (7-16%). Locking cage plate technology affords rigid fixation for TMA with promising early results noting reliable bony union while minimizing complications.

Purpose To determine the impact of uninterrupted use of warfarin on hand and wrist surgery. Methods This single-center, prospective cohort trial enrolled adult patients undergoing hand and wrist surgery. Between May 2009 and August 2014, 47 surgical patients receiving uninterrupted warfarin (50 procedures) were enrolled and matched as a group by age and procedure type to 48 surgical patients (50 procedures) who were not prescribed warfarin. Complications, defined as bleeding, infection, or wound dehiscence requiring reoperation, were recorded for each group. Surgical outcome measures were composed of objective findings affected by surgical site bleeding (ie, ecchymosis extent, hematoma presence, 2-point discrimination) and standardized patient-rated assessments ( Quick –Disabilities of the Arm, Shoulder, and Hand, and visual analog scales: pain and swelling). We collected data preoperatively and at 2 and 4 weeks postoperatively. Statistical analyses contrasted complications and outcomes data between patient groups. Results One procedure (2%; 95% confidence interval, 0% to 11%) in a patient taking warfarin was complicated by hematoma requiring reoperation resulting from an elevated postoperative international normalized ratio of 5.4. There were no complications among controls (0%; 95% confidence interval, 0% to 7%). At 2 weeks postoperatively, patients receiving warfarin more frequently had hematomas (28% vs 10%) and demonstrated a greater extent of ecchymosis from the surgical incision (50 vs 19 mm). At 4 weeks, no differences existed in hematoma presence or extent of ecchymosis between groups. The incidence of transiently elevated 2-point discrimination was not different between groups (10% warfarin; 6% controls). Visual analog scores for pain and swelling were not significantly different between groups at any time. Differences in Quick –Disabilities of the Arm, Shoulder, and Hand scores between groups did not exceed a minimal clinically important difference. Conclusions Uninterrupted use of warfarin in patients undergoing surgery of the hand and wrist was associated with an infrequent risk of bleeding complication requiring reoperation. Increased rates of hematoma and ecchymosis in patients taking warfarin normalized by 4 weeks postoperatively. Type of study/level of evidence Therapeutic II.

Purpose To evaluate objective functional and radiographic outcomes after internal fixation of acute, displaced, and unstable fractures of the distal aspect of the radius in adults by using a low-profile dorsal plating system. Our hypothesis was that the low-profile dorsal plating system would allow for a reduction of extensor tendon irritation and pain and provide stable osseous fixation. Methods Sixty consecutive unstable fractures in 59 patients were treated by open reduction internal fixation using a low-profile dorsal plating system. There were 29 type A, 14 type B, and 8 type C fractures (AO classification system). Fifty patients with 51 fractures returned for outcomes assessment by physical examination, plain radiographs, and completion of a validated musculoskeletal function assessment questionnaire. The minimum follow-up period was 1 year; the mean follow-up period was 24 months. Clinical evaluation was performed and plain radiographs were assessed for maintenance of immediate postoperative reduction and implant position. Objective functional assessment was obtained through the Disabilities of the Arm, Shoulder, and Hand questionnaire. Results Outcomes analysis showed no cases of extensor tendon irritation or rupture. Hardware removal was performed in 1 patient but no extensor tendon irritation or rupture was evidenced. The mean Disabilities of the Arm, Shoulder, and Hand score was 11.9; implant-related discomfort was minimal. All patients had an excellent (31 patients) or good (19 patients) result according to the scoring system of Gartland and Werley. The mean active range of motion was greater than 80% of that of the contralateral wrist in flexion/extension, pronation/supination, and ulnar/radial deviation. Extensor tendon function was unimpaired in all patients. Grip and pinch strength averaged 90% and 94% of the contralateral sides, respectively. Radiographic evaluation showed no change in fracture reduction or implant position. Conclusions The treatment of distal radius fractures with a low-profile stainless steel dorsal plating system is a safe and effective method that provides stable internal fixation and allows for full extensor tendon glide and full metacarpophalangeal joint motion. Objective outcome testing showed uniformly good to excellent recovery of wrist and hand function in all patients. Type of study/level of evidence Therapeutic, Level IV.

Flexor tendon reconstruction is uncommon today given the advances in flexor tendon repair and postrepair rehabilitation. Nonetheless, patients with a delay in the diagnosis of a flexor tendon laceration or patients with a failed flexor tendon repair may be candidates for reconstruction. Flexor tendon reconstruction includes flexor tenolysis, 1-stage tendon grafting, and 2-stage tendon grafting. This article reviews the surgical indications, the surgical techniques, and the reported outcomes of these procedures.

Although advances in the treatment of flexor tendon injuries have led to improved clinical outcomes during the past several decades, a subset of patients continue to experience a loss of function. Using a canine model of sharp transection of the flexor digitorum profundus tendon followed by repair and rehabilitation using clinically relevant techniques, we have examined the influence of multistrand suture and postoperative rehabilitation variables on digital function and tendon strength. Our findings highlight the critical role of repair technique in providing a stiff and strong repair and indicate that continued refinement of suture techniques is warranted in order to minimize repair-site elongation (gap). Gap formation continues to occur at a high frequency, and the formation of gaps greater than 3 mm delays the accrual of repair-site strength that occurs with time. Furthermore, our results indicate that passive-motion rehabilitation that produces a moderate amount of tendon excursion (2 mm) at low levels of tendon force (5 N) is sufficient to inhibit adhesion formation and to promote healing. Increases in excursion or force beyond these levels do not accelerate the healing process. These findings suggest that we are approaching the limit of the extent to which we can modulate healing by manipulating rehabilitation variables such as tendon excursion and force. Future advances will probably require manipulation of the biological factors that promote healing.

Insertion site injuries of the flexor digitorum profundus (FDP) tendon often present for delayed treatment. Apart from gross observations made at the time of surgery, the changes that occur in the flexor tendon stump during the interval from injury to repair are unknown. These changes may include tendon softening and loss of viability, which may contribute to the poor outcomes observed clinically and experimentally. Thirty-eight FDP tendons from 23 adult dogs were transected sharply from their insertions on the distal phalanges and were not repaired. Dogs were allowed full weight bearing and were euthanized 7 or 21 days after injury. Biomechanical testing indicated that the resistance of injured tendons to pullout of a Kessler-type suture was not different from control tendons at 7 days and was increased at 21 days by 25% (p

Ulnar-sided wrist pain has often been equated with low back pain because of its insidious onset, vague and chronic nature, intermittent symptoms, and frustration that it induces in patients. Chronic ulnar-sided wrist pain may be accompanied by a history of workers' compensation claims and unrelenting and irresolvable pain, and it may occur in patients with dfficult personalities. Despite these issues, many patients with ulnar-sided wrist pain have pathologic lesions that may be amenable to surgical treatment.