Advances in the Treatment of Hand and Wrist Injuries in the Elite Athlete.

Caring for hand and wrist injuries in the elite athlete brings distinct challenges, with case-by-case decisions regarding surgical intervention and return-to-play. Metacarpal fractures, thumb ulnar collateral ligament tears, and scaphoid fractures are common upper-extremity injuries in the elite athlete that can be detrimental to playing time and future participation. Treatment should therefore endure the demand of accelerated rehabilitation and return-to-activity without compromising long-term outcomes. Fortunately, the literature has supported emerging management options that support goals specific to the athlete. This review examined the advances in surgical and perioperative treatment of metacarpal fractures, thumb ulnar collateral ligament injuries, and scaphoid fractures in the elite athlete.

Relative Increase in Distal Radius Exposure with Extension of the FCR Approach.

Objectives: Major surgical approaches for volar plating of the distal radius include the standard flexor carpi radialis (FCR) approach, the extended FCR (eFCR) approach, and the extended FCR approach combined with radial-sided carpal tunnel release (eFCR+CTR). The purpose of this study was to determine which of these three surgical approaches offers the greatest exposure and visualization of the distal radius. Methods: Sequential dissections were performed on each of 30 fresh frozen below elbow cadaveric samples in order to simulate the three surgical approaches for distal radius volar plating, starting with the standard FCR approach, advancing to eFCR, and finishing with eFCR+CTR. Prior to the initial dissection of each cadaveric sample, radiographs were taken in order to calculate the total area of the distal radius. Then, following each sequential dissection, photographs were taken of each specimen and analyzed with an image measuring software in order to obtain the area of distal radius exposed. The percentage of total distal radius exposure was then calculated for each of the three surgical approaches. Results: The eFCR+CTR approach offered the greatest average distal radius exposure at 87% of total distal radius visualized. The eFCR approach provided the next greatest exposure with an average of 73% visualized, followed by the standard FCR approach with an average of 61% visualized. Conclusion: The extended FCR approach with radial-sided carpal tunnel release is both safe and efficacious for osteosynthesis of distal radius fractures in the setting of concomitant carpal tunnel syndrome. This study demonstrates that an additional advantage of this approach includes improved surgical exposure and visualization of the distal radius. This surgical approach is a valuable addition to any upper extremity surgeon's armamentarium and should be considered when treating difficult distal radius fractures.

Is This Going to Hurt, Doc? Predicting Pain with Corticosteroid Injections for Upper Extremity Conditions.

Corticosteroid injections (CSIs) are used in a wide variety of upper extremity pathologies for both diagnostic and treatment purposes. Many patients ask about pain associated with the procedure before agreeing to proceed. The purpose of this study was to correlate perceived pain tolerance and resilience with patient-reported injection pain during and immediately after injection. Methods: One-hundred patients indicated for a CSI for an upper extremity condition were recruited for the study. Patients completed a Brief Resilience Scale, Patient-Reported Outcomes Measurement Information System pain interference form, and assessment of pain tolerance before injection. Physicians predicted pain tolerance and resilience for each patient. Immediately after the procedure, patients completed a second survey, assessing pain during and 1 minute after injection. Results: Physician-predicted patient resilience and pain tolerance was lower than that self-reported by patients. Pain with injection was inversely correlated with physician-predicted pain tolerance and resilience but not with patient-reported pain tolerance. Injection pain ratings did not correspond with patients' willingness to undergo subsequent injections. Conclusions: Procedural pain is an important consideration for many patients, especially in awake procedures. Appropriate counseling is crucial to support informed consent and enhance patient outcomes. This study demonstrated that a physician's clinical experience can be used to predict a patient's pain with CSI and should be considered when counseling patients.

Role of Iron Therapy in Heart Failure: A Consensus Statement from India.

Iron deficiency (ID) with or without anemia is frequently observed in patients with heart failure (HF). Uncorrected ID is associated with higher hospitalization and mortality in patients with acute HF (AHF) and chronic HF (CHF). Hence, in addition to chronic renal insufficiency, anemia, and diabetes, ID appears as a novel comorbidity and a treatment target of CHF. Intravenous (IV) ferric carboxymaltose (FCM) reduces the hospitalization risk due to HF worsening and improves functional capacity and quality of life (QOL) in HF patients. The current consensus document provides criteria, an expert opinion on the diagnosis of ID in HF, patient profiles for IV FCM, and correct administration and monitoring of such patients.

Arthrodesis of the First to Second Metacarpal for Definitive Management of Failed Thumb Carpometacarpal Arthroplasty: A Case Series.

Thumb carpometacarpal (CMC) arthroplasty with resection of the trapezium and soft tissue interposition, with or without ligament reconstruction, has historically proven to be an efficacious treatment for thumb CMC arthritis. The incidence of failure following primary thumb CMC arthroplasty is low; however, the evaluation and management of a patient experiencing an unsatisfactory outcome following CMC arthroplasty is challenging. If symptoms are refractory to conservative measures, then revision surgical treatment may be indicated. Clinical decision making becomes even more complicated in cases of failure after an initial revision surgery has already been performed. In patients with a failed CMC arthroplasty revision in whom all soft tissue options have been exhausted, the senior author considers arthrodesis of the first metacarpal base to the second metacarpal base as a salvage procedure. The authors describe this surgical technique and present our experience with 4 cases in 3 patients who underwent this surgical intervention. Successful radiographic fusion was achieved in all 4 cases, with satisfactory clinical outcome in 3 out of 4 cases, supporting this surgical technique as a definitive option for patients who have failed multiple CMC arthroplasty revision surgeries.

Perioperative Narcotic Use and Carpal Tunnel Release: Trends, Risk Factors, and Complications.

Background: The goals of the study were to: (1) evaluate trends in preoperative and prolonged postoperative narcotic use in carpal tunnel release (CTR); (2) characterize risks for prolonged narcotic use; and (3) evaluate narcotic use as an independent risk factor for complications following CTR. Methods: A query of a large insurance database from 2007-2016 was conducted. Patients undergoing open or endoscopic CTR were included. Revision surgeries or patients undergoing median nerve repair at the forearm, upper extremity fasciotomies, or with distal radius fractures were excluded. Preoperative use was defined as narcotic use between 1 to 4 months prior to CTR. A narcotic prescription between 1 and 4 months after surgery was considered prolonged postoperative use. Demographics, comorbidities, and other risk factors for prolonged postoperative use were assessed using a regression analysis. Subgroup analysis was performed according to the number of preoperative narcotic prescriptions. Narcotic use as a risk factor for complications, including chronic regional pain syndrome (CRPS) and revision CTR, was assessed. Results: In total, 66 077 patients were included. A decrease in prescribing of perioperative narcotics was noted. Risk factors for prolonged narcotic use included preoperative narcotic use, drug and substance use, lumbago, and depression. Preoperative narcotics were associated with increased emergency room visits, readmissions, CRPS, and infection. Prolonged postoperative narcotic use was linked to CRPS and revision surgery. Conclusions: Preoperative narcotic use is strongly associated with prolonged postoperative use. Both preoperative and prolonged postoperative prescriptions narcotic use correlated with increased risk of complications. Preoperative narcotic use is associated with a higher risk of postoperative CRPS.

The Extended Flexor Carpi Radialis Approach for Concurrent Carpal Tunnel Release and Volar Plate Osteosynthesis for Distal Radius Fracture.

PURPOSE: To determine the relative benefits of an extended flexor carpi radialis (FCR) (eFCR) approach with prophylactic carpal tunnel release at the time of volar plate osteosynthesis for distal radius fracture via a single incision into the traditional volar Henry (VH) approach. METHODS: This was a prospective cohort comparison of preoperative and postoperative median nerve function of 27 patients (15 eFCR and 12 VH) with unilateral, isolated distal radius fractures requiring open reduction internal fixation without preoperative acute carpal tunnel syndrome. Patients were operated on via either the eFCR or VH approach. The validated Levine-Katz Carpal Tunnel Questionnaire (symptom and functional severity scores) was administered and Semmes-Weinstein monofilament and 2-point discrimination testing were conducted preoperatively and at 6 weeks and 3 months postoperatively. Grip and pinch strength were measured at 6 weeks and 3 months. The groups were comparable in terms of age, sex, and fracture type and displacement. RESULTS: Comparing across groups, there were no statistically significant differences in any outcome measured preoperatively or postoperatively. The eFCR and VH groups demonstrated significant improvement in functional severity scores, symptom severity, and grip strength. The symptom severity score improved to statistical significance at 6 weeks in the eFCR group and at 3 months in the VH group. CONCLUSIONS: In this small comparative study, the eFCR approach was found to be safe and efficacious. There was no increased surgical morbidity, which suggests that this technique can be used safely for all patients undergoing volar plating and not just in cases of concurrent carpal tunnel syndrome. It allows easier retraction of carpal tunnel contents; therefore, it is our preferred approach.

Adipose-derived mesenchymal stem cells treated with growth differentiation factor-5 express tendon-specific markers.

OBJECTIVES: Adipose-derived mesenchymal stem cells (ADMSCs) are a unique population of stem cells with therapeutic potential in the treatment of connective tissue injuries. Growth differentiation factor-5 (GDF)-5 is known to play a role in tendon repair and maintenance. The aim of this study was to investigate the effects of GDF-5 on proliferation and tendonogenic gene expression of rat ADMSCs. METHODS: ADMSCs were treated in culture with different concentrations of GDF-5 (0-1000 ng/mL) for 12 days. Biochemical, temporal, and concentration kinetic studies were done. Extracellular matrix (ECM) synthesis, tendonogenic differentiation, and matrix remodeling gene and protein expression were analyzed. RESULTS: GDF-5 led to increased ADMSC proliferation in a dose- and time-dependent manner. ADMSCs demonstrated enhanced ECM (collagen type I, decorin, and aggrecan) and tendonogenic marker (scleraxis, tenomodulin, and tenascin-C) gene expression with 100 ng/mL of GDF-5 (p < 0.05). ECM and tendon-specific markers showed time-dependent increases at various time points (p < 0.05), although decorin decreased at day 9 (p < 0.05). GDF-5 did alter expression of matrix remodeling genes, with no specific trends observed. Western blot analysis confirmed dose- and time-dependent increases in protein expression of tenomodulin, tenascin-C, Smad-8, and matrix metalloproteinase-13. CONCLUSION: In vitro GDF-5 treatment can induce cellular events leading to the tendonogenic differentiation of ADMSCs. The use of combined GDF-5 and ADMSCs tissue-engineered therapies may have a role in the future of tendon repair.

Rehabilitation considerations of a brachial plexus injury with complete avulsion of c5 and c6 nerve roots in a college football player: a case study.

Severe brachial plexus injuries are rare in sports, but they have catastrophic results with a significant loss of function in the involved upper extremity. Nerve root avulsions must be timely managed with prompt evaluation, accurate diagnosis, and surgical treatment to optimize the potential for a functional outcome. This case report describes the mechanism of injury, diagnostic evolution, surgical management, and rehabilitation of a college football player who sustained a traumatic complete nerve root avulsion of C5 and C6 (upper trunk of the brachial plexus). Diagnostics included clinical evaluation, magnetic resonance imaging, computed tomography myelogram, and electromyogram. Surgical planning included nerve grafting and neurotization (nerve transfer). Rehabilitation goals were to bring the hand to the face (active biceps function), to stabilize the shoulder for abduction and flexion, and to reduce neuropathic pain. Direct current stimulation, bracing, therapeutic exercise, and biofeedback were used to maximize the use of the athlete's upper extremity. Although the athlete could not return to sport or normal function by most standards, his results were satisfactory in that he regained an ability to perform many activities of daily living.

Interposition arthroplasty with bone-tendon allograft: a technique for treatment of the unstable sternoclavicular joint.

Sternoclavicular joint instability is an uncommon but challenging clinical problem for the orthopaedic surgeon. Although most cases can be treated nonoperatively with minimal long-term pain or functional limitation, a small percentage may require surgical intervention. This includes chronic anterior instability associated with persistent pain or functional limitation as well as irreducible or recurrent posterior instability. Although numerous procedures have been described for treatment of the unstable sternoclavicular joint, the optimal method for stabilization has not been determined. Here we describe a technique using Achilles tendon allograft to create an interpositional arthroplasty and briefly present 3 illustrative cases in which we performed the procedure. We believe this method effectively stabilizes the joint, restores function, relieves pain, and has applications for traumatic sternoclavicular instability as well as instability related to other etiologies.

Mechanical modulation of cartilage structure and function during embryogenesis in the chick.

The mechanical behavior of cartilage is intimately related to its biochemical composition, and tissue composition is known to be influenced by its local mechanical loading environment. Although this phenomenon has been well-studied in adult cartilage, few investigations have examined such structure-function relationships in embryonic cartilage. The goal of this work was to elucidate the role of mechanical loading on the development of cartilage composition during embryogenesis. Using an embryonic chick model, cartilage from the tibiofemoral joints of immobilized embryos was compared to that of controls. The normal time course of changes in glycosaminoglycan/DNA and hydroxyproline/DNA were significantly influenced by loading history, with the most pronounced effects observed between days 9 and 14 during the period of most rapid increase in motility in control embryos. Stress-relaxation tests conducted on samples from day 14 indicate that the effects of embryonic immobilization on cartilage matrix composition have direct consequences for the mechanical behavior of the tissue, resulting in compromised material properties (e.g. 50% reduction in E(inst)). Because embryogenesis provides a unique model for identifying key factors which influence the establishment of functional biomechanical tissues in the skeleton, these data suggest that treating mechanical loading as an in vitro culture variable for tissue engineering approaches to cartilage repair is likely to be a sound approach.