Dorsal lunate dislocation and en bloc proximal row carpectomy: a case report.

An unhelmeted 59-year-old male involved in a motorcycle accident presented with a right dorsal lunate dislocation in the context of a polytrauma evaluation. Soft-tissue attachments were minimal across the carpus, which allowed for an en bloc proximal row carpectomy. Two-year follow-up yielded a satisfactory outcome given the high energy injury mechanism. Proximal row carpectomy is a useful tool which preserves wrist range of motion in the acute trauma setting and is durable, as demonstrated by our patient's postoperative mobilization using a wheelchair.

Outcomes of Threaded Intramedullary Headless Nail Fixation for Metacarpal Fractures.

Metacarpal fractures are common and may require operative treatment; however, there is no gold standard fixation technique. K-wires are used for simplicity and flexibility but require immobilization and can lead to complications. Dorsal plating provides greater stability than K-wires but is subject to its own limitations. Intramedullary threadless nails have reduced time to union and improved range of motion (ROM) but may not provide the stability of plating. Intramedullary screws allow rapid return to activity and increased stability; however, compression forces may shorten metacarpals, producing non-anatomic reduction. The ExsoMed INnateTM threaded intramedullary nail (ExsoMed, Aliso Viejo, CA, USA) was developed with tall threads, a diameter fitting the metacarpal canal cortical purchase, stability, and no compression to prevent fracture displacement and shortening. We designed a prospective study to evaluate INnateTM nail fixation in metacarpal fractures. Visual analog scale (VAS) pain score, total active motion (TAM), radiographic union, and return to normal activity were recorded at each postoperative visit. Descriptive statistics were performed for endpoints. Fifty-eight patients were included with a median age of 38.7 years. The INnateTM nail was used in 80 fractured metacarpals. The 4th and 5th metacarpals were most frequently involved. The most common mechanisms of injury were blunt trauma and motor vehicle collisions. Approximately 31% of patients had multiple, concurrent fractures (16 patients required two nails; two required three nails). The mean follow-up was 9.9 weeks. The mean time to radiographic union was 9.1 weeks. The final visual analog scale (VAS) pain score was 1.1. The mean time to return to work and/or normal activities was 9.7 weeks, and the mean percentage of normal activity resumed was 89.1%.

Elevated Hemoglobin A1c and the Risk of Postoperative Complications in Elective Hand and Upper Extremity Surgery.

BACKGROUND: Studies addressing the utility of hemoglobin A1c (HbA1c) levels in predicting surgical complications have reported mixed results. In practice, many surgeons use HbA1c cutoffs to determine a patient's eligibility for elective surgery. The literature is especially limited in evaluating HbA1c as a risk factor in elective hand and upper extremity surgery. This study aims to evaluate the association of elevated HbA1c levels with the risk of postoperative complications in elective hand and upper extremity surgeries. METHODS: We performed a chart review of patients who underwent these elective operations performed by a single surgeon at a single institution. The outcomes of 930 surgeries were collected up to three months postoperatively, 334 of which had pre or postoperative HbA1c levels recorded. All 930 surgeries were evaluated for association between diabetes mellitus (DM) and complication rates using Fisher's exact test, absolute risk, odds ratio, and regression analysis. RESULTS: DM alone was not associated with an increased risk of postoperative complications. In diabetic patients with both diagnosed DM and HbA1c > 10%, the absolute risk of complications was significantly higher. None of the other HbA1c categories (between 6.5% and 10%) were associated with significantly higher odds of complications in patients with diagnosed DM. CONCLUSIONS: In the context of elective hand and upper extremity surgery, glycemic control (measured by HbA1c) should be included as an element of the surgical preparedness algorithm, rather than an independent disqualifying factor.

Biomechanical Strength of a Novel Tendon Splicing Open Book Technique Compared to the Pulvertaft Method Using Unembalmed Human Cadaveric Tissue.

Background: Extensor pollicis longus (EPL) tendon rupture is a known complication of distal radius fractures. The Pulvertaft graft technique is currently used for tendon transfer of extensor indicis proprious (EIP) to EPL. This technique can produce unwanted tissue bulkiness and cosmetic concerns as well as hinder tendon gliding. A novel "open book" technique has been proposed, but relevant biomechanical data are limited. We designed a study to examine the biomechanical behaviours of the "open book" versus Pulvertaft techniques. Methods: Twenty matched forearm-wrist-hand samples were harvested from 10 fresh frozen cadavers (2 female, 8 male) with a mean age of 61.7 (±19.25) years. The EIP was transferred to EPL using the Pulvertaft versus "open book" techniques for each matched pair (sides randomly assigned). The repaired tendon segments were mechanically loaded using a Materials Testing System to examine graft biomechanical behaviours. Results: Mann-Whitney U test outcomes demonstrated that there was no significant difference between "open book" versus Pulvertaft techniques for peak load, load at yield, elongation at yield, or repair width. The "open book" technique demonstrated a significantly lower elongation at peak load and repair thickness, as well as significantly higher stiffness when compared with the Pulvertaft technique. Conclusions: Our findings support the use of the "open book" technique, producing comparable biomechanical behaviours compared to the Pulvertaft technique. Incorporating the "open book" technique potentially requires smaller repair volume, producing size and appearance that is more anatomic when compared with the Pulvertaft.

Contexte: La rupture du tendon du long extenseur du pouce (EPL - Extensor pollicis longus) est une complication connue des fractures distales du radius. La technique de greffe de Pulvertaft est actuellement utilisée pour un transfert tendineux de l'extenseur propre de l'index (EIP - extensor indicis proprious) à l'EPL. Cette technique peut produire une masse de tissu volumineuse non désirée et des préoccupations cosmétiques, mais aussi gêner le glissement du tendon. Une nouvelle technique en « livre ouvert ¼ a été proposée, mais les données biomécaniques pertinentes sont limitées. Nous avons conçu une étude visant à examiner les comportements biomécaniques de la technique « en livre ouvert ¼ comparativement à la technique de Pulvertaft. Méthodes: Vingt échantillons appariés avant-bras-poignet-main ont été prélevés sur 10 cadavres récemment congelés (2 femmes, 8 hommes) d'âge moyen 61,7 (± 19,25) ans. Les EIP ont été transférés aux EPL en utilisant la technique de Pulvertaft et la technique en livre ouvert pour chaque paire appariée (l'affectation du côté à chaque technique a été faite de manière aléatoire). Les segments tendineux réparés ont été chargés mécaniquement au moyen d'un système pour tester les matériaux afin d'étudier les comportements biomécaniques des greffes. Résultats: Les résultats du test U de Mann-Whitney ont montré qu'il n'y avait pas de différence significative entre la technique « en livre ouvert ¼ et la technique de Pulvertaft pour la charge maximum, la charge à la limite apparente d'élasticité, l'allongement à la limite apparente d'élasticité ou la largeur de réparation. La technique « en livre ouvert ¼ a démontré un allongement à la charge maximum et une épaisseur de réparation significativement moindres, ainsi qu'une significativement plus grande raideur, comparativement à la technique de Pulvertaft. Conclusions: Nos constatations étayent l'utilisation de la technique « en livre ouvert ¼ qui procure des comportements biomécaniques comparables à ceux de la technique de Pulvertaft. L'incorporation de la technique « en livre ouvert ¼ requiert potentiellement un plus petit volume de réparation, aboutissant à des dimensions et à un aspect plus anatomiques par rapport à la technique de Pulvertaft.

Avive Soft Tissue Membrane Improves Outcomes of Revision Upper-extremity Nerve Decompression Surgery.

Revision nerve decompression remains a challenge for surgeons. Avive Soft Tissue Membrane is processed human umbilical cord membrane that may reduce inflammation and scarring, thereby improving tissue gliding. Although synthetic conduits have been reported in revision nerve decompression, the use of Avive has not. Methods: Prospective study of revision nerve decompression with Avive application. VAS pain, two-point discrimination, Semmes-Weinstein, pinch and grip strength, range of motion, Quick Disability of Arm, Shoulder & Hand (QuickDASH), and satisfaction were recorded. Using a propensity-matched cohort, VAS pain and satisfaction were retrospectively collected to compare with cohort outcomes. Results: In the Avive cohort, 77 patients (97 nerves) were included. Mean follow-up was 9.0 months. Avive was applied to the median nerve in 47.4%, ulnar nerve in 39.2%, and radial nerve in 13.4%. VAS pain was 4.5 preoperatively and 1.3 postoperatively. S4 sensory recovery was achieved in 58% of patients, S3+ in 33%, S3 in 7%, S0 in 2%, and improvement from baseline in 87%. Strength improved in 92%. Mean total active motion was 94.8%. Mean QuickDASH score was 36.1, and 96% reported improved or resolved symptoms. Preoperative pain was not significantly different between Avive cohort and controls (P = 0.618). Postoperative pain was significantly lower in cohort patients (1.3 ± 2.2 versus 2.7 ± 3.0, P = 0.001). In the Avive cohort, more had improved or resolved symptoms (P < 0.0001). Clinically important improvement in pain was reported in 64.9% of Avive group patients versus 40.8% of controls (P = 0.002). Conclusion: Avive contributes to improved outcomes in revision nerve decompression.

CO2 laser resurfacing for burn and traumatic scars of the hand and upper extremity.

BACKGROUND: Scar formation is a normal part of the proliferative phase in wound healing where collagen is remodelled to better approximate normal skin. When collagen is not effectively redistributed, excessive scarring may occur. Recently, CO2 laser has emerged as an adjunct in improving scar quality via remodelling and redistribution of dermal collagen fibres. Due to the paucity of literature related to its use in the hands and upper extremities, we created a study to examine its effects on hypertrophic scars focused on the hands and upper extremities. METHODS: Patients treated with CO2 laser for hypertrophic scars of the hand and upper extremity were included. The Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS) were used to assess the progression of scar quality. Unpaired t-tests were performed to determine statistical difference between pre- and post-treatment scores on each scale. Pearson correlation coefficients were used to understand the relationship between number of treatments and scar quality. RESULTS: Of the 90 patients enrolled, 54 patients completed serial scar assessment forms. All patient and observer-reported POSAS domains showed improvement (P < 0.05) apart from Itching. All VSS domains showed improvement (P < 0.05). There was moderate correlation between overall patient-reported opinion of scar quality and Discoloration, Stiffness and Thickness, and strong correlation between overall patient opinion and Irregularity (r = 0.715). All observer-reported domains were strongly correlated (r = 7.56-8.74) with overall observer opinion of scar quality. CONCLUSION: The results of this study may further substantiate CO2 laser as a treatment modality for excessive scarring in a variety of surgical subspecialties. LAY SUMMARY: Complex trauma and burns that impact the skin sometimes result in abnormal healing of the skin called, "hypertrophic scarring". In our study we assessed how using focused CO2 laser therapy impacts patients and health care provider assessment of wound progression. Our results were based upon patient reported and healthcare provider observations based upon two standardized forms the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS). What we found is that after CO2 Laser Therapy, our 64 patients with 77 treated scars received on average almost 3 treatments and these treatments helped them with physical function and improved aesthetic appearance of their scars. The health care providers also found that the treatments improved functional and aesthetic end points. Overall, our study helps substantiate the body of evidence that using CO2 laser therapy improves aesthetics and function of hypertrophic scars in the upper extremity.

Evaluation of postoperative outcomes in patients following multi-level surgical reconstructions with the use Avive™ soft tissue membrane on nerve after traumatic injury of the upper extremity and lower extremity.

BACKGROUND: Treatment of patients with traumatic axonotmesis presents challenges. Processed human umbilical cord membrane has been recently developed with improved handling and resorption time compared to other amniotic membrane wraps, and may be beneficial in nerve reconstruction. This study evaluates postoperative outcomes after traumatic peripheral nerve injury after placement of commercially available processed human umbilical cord membrane. METHODS: We performed a prospective, single-center pilot study of patients undergoing multi-level surgical reconstruction for exposed, non-transected peripheral nerve. Functional outcomes including pain, range of motion, pinch and grip strength, and the QuickDASH and SF-36 patient-reported outcome measures were recorded, when possible, at the 1-week and 3, 6, and 9 months postop visit. One-tailed paired t-tests were performed to evaluate outcome improvement at final follow-up. RESULTS: Twenty patients had processed human umbilical cord membrane placement without surgical complications. Mean follow-up was 7.5 months (range: 3-10 months) and mean age was 39 years (range: 15-65). Twelve (67%) patients were male, and the majority of placement sites were in the upper extremity (85%). Mean preoperative visual analog scale pain score was significantly reduced at most recent follow-up, as were QuickDASH scores. All patients had improved functional outcomes at the 9-month follow-up, and SF-36 outcomes at 9 months showed improvement across all dimensions. CONCLUSION: This study indicates that processed human umbilical cord membrane may be a useful adjunct in nerve surgery with noted improvements in postoperative function, pain, and patient-reported outcome measures. Future studies are needed to assess long-term outcomes after traumatic nerve injury treated with processed human umbilical cord membrane.

Evidence-Based Approach to Timing of Nerve Surgery: A Review.

ABSTRACT: Events causing acute stress to the health care system, such as the COVID-19 pandemic, place clinical decisions under increased scrutiny. The priority and timing of surgical procedures are critically evaluated under these conditions, yet the optimal timing of procedures is a key consideration in any clinical setting. There is currently no single article consolidating a large body of current evidence on timing of nerve surgery. MEDLINE and EMBASE databases were systematically reviewed for clinical data on nerve repair and reconstruction to define the current understanding of timing and other factors affecting outcomes. Special attention was given to sensory, mixed/motor, nerve compression syndromes, and nerve pain. The data presented in this review may assist surgeons in making sound, evidence-based clinical decisions regarding timing of nerve surgery.

A Multicenter Matched Cohort Study of Processed Nerve Allograft and Conduit in Digital Nerve Reconstruction.

PURPOSE: Biomaterials used to restore digital nerve continuity after injury associated with a defect may influence ultimate outcomes. An evaluation of matched cohorts undergoing digital nerve gap reconstruction was conducted to compare processed nerve allograft (PNA) and conduits. Based on scientific evidence and historical controls, we hypothesized that outcomes of PNA would be better than for conduit reconstruction. METHODS: We identified matched cohorts based on patient characteristics, medical history, mechanism of injury, and time to repair for digital nerve injuries with gaps up to 25 mm. Data were stratified into 2 gap length groups: short gaps of 14 mm or less and long gaps of 15 to 25 mm. Meaningful sensory recovery was defined as a Medical Research Council scale of S3 or greater. Comparisons of meaningful recovery were made by repair method between and across the gap length groups. RESULTS: Eight institutions contributed matched data sets for 110 subjects with 162 injuries. Outcomes data were available in 113 PNA and 49 conduit repairs. Meaningful recovery was reported in 61% of the conduit group, compared with 88% in the PNA group. In the group with a 14-mm or less gap, conduit and PNA outcomes were 67% and 92% meaningful recovery, respectively. In the 15- to 25-mm gap length group, conduit and PNA outcomes were 45% and 85% meaningful recovery, respectively. There were no reported adverse events in either treatment group. CONCLUSIONS: Outcomes of digital nerve reconstruction in this study using PNA were consistent and significantly better than those of conduits across all groups. As gap lengths increased, the proportion of patients in the conduit group with meaningful recovery decreased. This study supports the use of PNA for nerve gap reconstruction in digital nerve reconstructions up to 25 mm. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Peripheral nerve repair throughout the body with processed nerve allografts: Results from a large multicenter study.

BACKGROUND: Peripheral nerve damage resulting in pain, loss of sensation, or motor function may necessitate a reconstruction with a bridging material. The RANGER® Registry was designed to evaluate outcomes following nerve repair with processed nerve allograft (Avance® Nerve Graft; Axogen; Alachua, FL). Here we report on the results from the largest peripheral nerve registry to-date. METHODS: This multicenter IRB-approved registry study collected data from patients repaired with processed nerve allograft (PNA). Sites followed their own standard of care for patient treatment and follow-up. Data were assessed for meaningful recovery, defined as ≥S3/M3 to remain consistent with previously published results, and comparisons were made to reference literature. RESULTS: The study included 385 subjects and 624 nerve repairs. Overall, 82% meaningful recovery (MR) was achieved across sensory, mixed, and motor nerve repairs up to gaps of 70 mm. No related adverse events were reported. There were no significant differences in MR across the nerve type, age, time-to-repair, and smoking status subgroups in the upper extremity (p > .05). Significant differences were noted by the mechanism of injury subgroups between complex injures (74%) as compared to lacerations (85%) or neuroma resections (94%) (p = .03) and by gap length between the <15 mm and 50-70 mm gap subgroups, 91 and 69% MR, respectively (p = .01). Results were comparable to historical literature for nerve autograft and exceed that of conduit. CONCLUSIONS: These findings provide clinical evidence to support the continued use of PNA up to 70 mm in sensory, mixed and motor nerve repair throughout the body and across a broad patient population.

Distal Digital Nerve Repair Using Nerve Allograft With a Dermal Substitute: A Case Report.

Background: Distal digital nerve repairs can present unique challenges for hand surgeons due to their sensitive location and ongoing difficulty obtaining soft tissue coverage in this region. Although autografts and nerve conduits have been shown to be of benefit with nerve gaps, they can have morbidities associated with their use. Nerve allografts have become a viable option over the past decade as their use has increased and data are now showing similar outcomes, particularly in short gap segments. Flaps and skin grafts are traditional coverage options for full thickness wounds but can pose challenges with multiple digit involvement, depth of wound, and critical structures exposed. Methods: We present a case where nerve allograft was used for distal digital nerve repair. Due to the distal nature of the nerve repair in the index digit distal to the trifurcation, the distal end of the nerve graft was connected to multiple small nerve ends. Dermal substitute was placed to achieve distal coverage of the affected digits. Results: At 6-month follow-up, the patient demonstrated improved strength, normal sensation, and full return of digital function. Conclusion: Nerve allograft can be used in combination with dermal skin substitute to achieve normal sensation and return of digital function following distal digital nerve injuries.

Novel Use of Joint Replacement in a Thumb Interphalangeal Joint.

Arthrodesis of the interphalangeal (IP) joint of the thumb is widely acknowledged as the indicated treatment for trauma and osteoarthritis of this joint. Joint replacement was offered to a young patient as an alternative treatment after traumatic joint loss of the IP joint in her thumb. This allowed her to maintain motion of the joint as she did not wish to move forward with fusion. In the present case, a Humanitarian Use Device (HUD) was utilized in an off-label manner and placed into the interphalangeal joint of the patient's thumb. The patient did well postoperatively with reasonable pain-free range of motion of the interphalangeal joint with an arc of 40 degrees. We propose that joint replacement is a viable alternative to arthrodesis in select patients who do not wish to be fused. We believe this represents the first thumb IP joint replacement using a semiconstrained joint presented in the medical literature.

Congenital Ulnar Drift in a Surgeon.

Windblown hand is a term used in many instances to describe ulnar deviations of the fingers with or without other malformations. In 1994 Wood reviewed all of the descriptions of cases of windblown hand and pointed out how many variants of congenital ulnar drift there are, suggesting that the many variations seen may all belong to a larger type of arthrogryposis. While the most common cause of ulnar deviation of the fingers is rheumatoid arthritis, it can also be caused by other conditions such as windblown hand or Jaccoud's arthropathy. While most hand surgeons are familiar with presentations of congenital ulnar drift, few of them are knowledgeable about Jaccoud's arthropathy as this is usually discussed within medical communities such as Rheumatology. We present a case of a surgeon who has had noticeable ulnar deviation of the digits at the level of the metacarpophalangeal joint since his early 20s. We propose that the current case is a demonstration of a type of windblown hand that has some hereditary component but is not immediately obvious at birth and presents physically more like Jaccoud's arthropathy than traditional windblown hand.

Guidelines for ethical and professional use of social media in a hand surgery practice.

In growing numbers, patients are using social media platforms as resources to obtain health information and report their experiences in the health care setting. More physicians are making use of these platforms as a means to reach prospective and existing patients, to share information with each other, and to educate the public. In this ever-expanding online dialogue, questions have arisen regarding appropriate conduct of the physician during these interactions. The purpose of this article is to review the laws that govern online communication as they pertain to physician presence in this forum and to discuss appropriate ethical and professional behavior in this setting.

Endovascular treatment of a thoracic aortic pseudoaneurysm after previous open repair.

The use of endovascular stents to treat descending thoracic aortic pathologies is emerging as a less invasive therapy to treat high-risk patients. This case report describes the presentation of a patient with a pulsatile mass on her back. The patient's computed tomographic scan revealed the mass to be an extension of a large psuedoaneurysm from the site of a previous repair of her thoracic aorta for a dissecting aneurysm several years earlier. The psuedoaneurysm was successfully treated with an endovascular stent and the patient was discharged home on postoperative day 5.