Relevant landmarks to navigate the suture locations for the arthroscopic triangular fibrocartilage complex foveal reattachment.

INTRODUCTION: Key step of arthroscopic triangular fibrocartilage complex (TFCC) foveal reattachment is to suture dorsal and palmar deep components of radioulnar ligaments (RULs) to the fovea of ulnar head to ensure distal radioulnar joint stability. However, the deep components are covered and cannot be identified arthroscopically from standard radiocarpal joint view. Suturing sites described in previous studies have not been proved gasping of the deep components. The purpose of this study was to investigate our TFCC suture locations using relevant landmarks on securing the RULs' deep components for arthroscopic TFCC foveal reattachment. MATERIALS AND METHODS: Wrist arthroscopy and horizontal mattress suture was performed in 20 fresh-frozen cadaver wrists. Based on close proximity of the ulnocarpal ligaments to the palmar RUL and fovea, palmar suture location was designated at the junction between ulnolunate, ulnotriquetral ligaments and palmar border of TFCC disc, whereas dorsal suture location was at dorsal border of TFCC disc, opposite the palmar location, at same distance between prestyloid recess and palmar location. The radiocarpal and ulnocarpal joint was subsequently opened to evaluate grasping of RULs' deep components and evaluate the relevant landmarks. RESULTS: Thirty-nine of 40 (97%) RULs' deep components were successfully grasped by the sutures. With 0.98-0.99 interobserver agreement for the measurements, mean distance between sigmoid notch to suture and suture to ulnar capsule were 5.6 ± 1.1 and 4.0 ± 0.9 mm, respectively. Whereas, the dissecting point of deep component from the superficial component of the RULs was detected immediately radial to the midpoint between the sigmoid notch and the ulnar capsule (4.5 ± 0.9 mm from sigmoid notch). CONCLUSIONS: We determined the relevant anatomical landmarks to navigate the TFCC suture locations, which reliably secure the deep components of the radioulnar ligaments for the arthroscopic TFCC foveal reattachment.

Arthroscopic Treatment of Scaphoid Nonunion With Olecranon Bone Graft and Screw Fixation Leads to Union and Improved Outcomes.

PURPOSE: To evaluate the outcomes of arthroscopic treatment of scaphoid nonunion using olecranon bone graft and screw fixation and to analyze the outcomes in accordance with variations in the chronicity, location, and severity of nonunion. METHODS: Between March 2012 and December 2020, patients with diagnoses of scaphoid delayed nonunion and nonunion with substantial bone resorption (Slade and Dodds grade IV-VI) underwent arthroscopic-assisted olecranon bone graft and screw fixation. Preoperative and postoperative measurements included the visual analog scale score for pain; range of motion; grip strength; the Modified Mayo Wrist Score; the Disabilities of the Arm, Shoulder and Hand (DASH) score; and the minimal clinically important difference for the DASH score. Union rate and duration were also evaluated. The outcomes between groups of patients with different conditions were analyzed. RESULTS: Twenty-two patients were included. The average follow-up period was 32.5 months. The visual analog scale pain score, range of motion, grip strength, Modified Mayo Wrist Score, and DASH score were significantly improved after surgery (P < .001). The minimal clinically important difference threshold for the DASH score was reached by 100% of patients. At final follow-up, all patients had united scaphoid with no complications. The average time to union was 15.3 weeks. Group analysis showed significant improvements in mean grip strength between patients with delayed union (3-6 months) and those with chronic nonunion (> 1 year) (17.75 kg vs 12.25 kg, P = .032), between grade IV nonunion and grade V nonunion (14.86 kg vs 10.43 kg, P = .035), and between grade V nonunion and grade VI nonunion (10.43 kg vs 15.63 kg, P = .013). Patients with grade VI nonunion achieved union at 17.8 weeks postoperatively, a significantly longer period than that for patients with grade IV nonunion (11.4 weeks, P = .014). CONCLUSIONS: Arthroscopic treatment of scaphoid nonunion using olecranon bone graft and screw fixation provided satisfactory outcomes regardless of the chronicity, location, and severity of nonunion. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Outcomes of Endoscopic Carpal Tunnel Release With Ring Finger Flexor Digitorum Superficialis Opponensplasty in Severe Carpal Tunnel Syndrome.

PURPOSE: To evaluate the outcomes of endoscopic CTR with ring finger flexor digitorum superficialis (FDS) opponensplasty for the treatment of patients with severe carpal tunnel syndrome (CTS). METHODS: We prospectively studied 52 patients who were graded as having severe CTS by physical examination and electrodiagnostic studies and who underwent endoscopic CTR-ring finger FDS opponensplasty. Preoperative and postoperative data were collected for active perpendicular thumb abduction; Kapandji score for thumb opposition; grip, key, and tip pinch strength; Medical Research Council score on sensory and motor recovery; Semmes-Weinstein monofilament testing; thenar muscle bulk recovery; and work status. RESULTS: Follow-up was 17.5 months on average (range, 7-34 months). Thumb abduction improved significantly from 13.2° (±4.6°) before surgery to 61.7° (±6.4°) afterward. Mean thumb opposition (as measured by Kapandji score) improved significantly from grade 1.5 to 8.7. Tip pinch strength significantly improved from 38.9% to 72.9% of the contralateral side. Medical Research Council scores improved to S3+ and S4 in 85% of patients and to M4 and M5 in 96% of patients. Sensory threshold recovery to 3.61 and 4.31 monofilament occurred in 85% of patients. We observed thenar muscle bulk recovery in 51.9% of patients. Time to return to work was 5 weeks after surgery, on average. Two patients reported scar pain, 2 reported pillar pain, and we found ring finger proximal interphalangeal joint contracture in 3. CONCLUSIONS: Endoscopic CTR with FDS opponensplasty provides satisfactory outcomes of improved thumb abduction and opposition, sensory and motor recovery, and early return to work in patients with severe CTS. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The Metacarpal Locked Intramedullary Nail: Comparative Biomechanical Evaluation of New Implant Design for Metacarpal Fractures.

BACKGROUND: The optimal fixation of metacarpal fracture should provide sufficient stability to permit early functionfor all types of fracture. However; it must preserve surrounding soft tissue during application and not require secondary removal due to its prominence. The prototype of metacarpal locked intramedullary nail (MCLN) was designed by our institute aiming to achieve those allfeatures. OBJECTIVE: To biomechanically test our newly designed, locked metacarpal nail and compare with common current available fixation methods. MATERIAL AND METHOD: Thirty chicken humeri were devided into 3 groups (n = 1 per group) according tofixation techniques: MCLN, 1.5 mm miniplate (Synthes), and Kirschner wire. After complete fixation, all specimens were osteotomized at mid-shaft creating transverse fractures. Five specimens from each group were tested by load of failure under axial compression, and another five under bending force. RESULTS: In axial compression model, the loads tofailure in MCLN group was greatest (460 ± 17 N), which was significant higher than the Kirschner wire group. The MCLN group also showed the highest load to failure in bending test (341 ± 10 N). This value reaches statistical significance when compared with plate and Kirschner wire groups. CONCLUSION: The MCLN construct provided higher stability than miniplate and Kirschner wire fixation both in axial and bending mode. Together with the minimally invasive and soft tissue-friendly design concept, this study suggests that MCLN is promising fixation option for metacarpal fracture.

Locked intramedullary nail: metacarpal geometry study in adults.

BACKGROUND: Ideal fixation for metacarpal fracture should provide immediate stability to allow early rehabilitation. Locked intramedullary nail may fulfill the need. Metecarpal geometry has to be studied in order to design the locked intramedullaly nail. OBJECTIVE: To study metacarpal geometry in adult cadaver for locked intramedullary nail design. MATERIAL AND METHOD: Radiographs of metacarpals taken from 50 embalmed adult cadavers were measured for essential parameters for locked intramedullary nail design. Total length, proximal metaphyseal width, distal metaphyseal width, isthmus width and medullary canal width were measured. The parameters were analyzed by descriptive statistic. RESULTS: The average total lengths were rangedfrom 44.53 to 65.42 mm. The average metaphyseal widths ofmetacarpal bone were between 11.42 to 16.42 mm. The average medullary canal widths were between 3.05 to 6.74 mm. The extreme small (less than 3 mm) medullary canals were found in index, middle, ring and small metacarpals. CONCLUSION: The results of our study provide crucial preliminary data for locked metacarpal nail design for adult patient.

Metacarpal Locked Intramedullary Nail: Surgical Technique and Preliminary Outcome Report.

In surgically indicated metacarpal fractures, the ideal fixation should provide an ample stability for early rehabilitation. Damage to surrounding tissue should be minimized as well, to prevent stiffness which determine the outcomes. We have created the metacarpal locked intramedullary nail (MCLN) that allows immediate motion even in unstable fractures. This preliminary report is objected to demonstrate the surgical technique and outcomes of novel metacarpal fixation. Three surgical indicated metacarpal fractures were treated by MCLN. Unlimited motion was started a day after surgery without external immobilization. Clinical and radiographic control were performed up to two years after the surgery. All of patients returned to previous level of daily activities within six weeks with minimal scar. All fractures were united. The total active motions were above 260° in every patient. Complications were not observed. With this encouraged clinical results, the MCLN could be the promising alternative surgical fixation for metacarpal shaft fractures.

The New Smartphone Application for Wrist Rehabilitation.

BACKGROUND: The rehabilitation after wrist surgery is extremely important. An instructed therapy in hospital is widely practiced. However, a dependent aging society and rush life style in younger generation have precluded patients to access to the frequent formal therapy. With the advancement in telecommunication technology, we have invented an application for smartphone for home-based wrist motion rehabilitation. METHODS: Twenty participants were included in four-week wrist motion rehabilitation programme after wrist surgery. Participants were instructed to use the application by physical therapist and informed details of home-based wrist rehabilitation. The feasibility of application was evaluated by satisfaction level in various aspects and the adherence to the therapy was monitored by function provided in the application. The degrees of motion were compared at the end of prescribed programme. RESULTS: Patient satisfaction was consistently high in every aspects. Also, the adherence to the therapy was high (90.42%). Ranges of motion significantly gained in every plane of wrist motion ([Formula: see text]). CONCLUSIONS: This novel smartphone application seems to be a promising and convenient alternative for patients who need to gain wrist motion without formal rehabilitation in the hospital. Adherence to the therapy is also easily traced with this application.

A novel therapy to promote axonal fusion in human digital nerves.

BACKGROUND: Peripheral nerve injury can have a devastating impact on our military and veteran population. Current strategies for peripheral nerve repair include techniques such as nerve tubes, nerve grafts, tissue matrices, and nerve growth guides to enhance the number of regenerating axons. Even with such advanced techniques, it takes months to regain function. In animal models, polyethylene glycol (PEG) therapy has shown to improve both physiologic and behavioral outcomes after nerve transection by fusion of a portion of the proximal axons to the distal axon stumps. The objective of this study was to show the efficacy of PEG fusion in humans and to retrospectively compare PEG fusion to standard nerve repair. METHODS: Patients with traumatic lacerations involving digital nerves were treated with PEG after standard microsurgical neurorrhaphy. Sensory assessment after injury was performed at 1 week, 2 weeks, 1 month, and 2 months using static two-point discrimination and Semmes-Weinstein monofilament testing. The Medical Research Council Classification (MRCC) for Sensory Recovery Scale was used to evaluate the level of injury. The PEG fusion group was compared to patient-matched controls whose data were retrospectively collected. RESULTS: Four PEG fusions were performed on four nerve transections in two patients. Polyethylene glycol therapy improves functional outcomes and speed of nerve recovery in clinical setting assessed by average MRCC score in week 1 (2.8 vs 1.0, p = 0.03). At 4 weeks, MRCC remained superior in the PEG fusion group (3.8 vs 1.3, p = 0.01). At 8 weeks, there was improvement in both groups with the PEG fusion cohort remaining statistically better (4.0 vs 1.7, p = 0.01). CONCLUSION: Polyethylene glycol fusion is a novel therapy for peripheral nerve repair with proven effectiveness in animal models. Clinical studies are still in early stages but have had encouraging results. Polyethylene glycol fusion is a potential revolutionary therapy in peripheral nerve repair but needs further investigation. LEVEL OF EVIDENCE: Therapeutic study, level IV.