Fractional Lengthening of Forearm Flexor Tendons: A Cadaveric Biomechanical Analysis.

PURPOSE: Multiple procedures have been described for wrist and finger flexion contractures and spasticity. Fractional lengthening of forearm flexor tendons involves making parallel transverse tenotomies at the musculotendinous junction to elongate the muscle. Currently, there is limited literature to define the biomechanical consequences of this lengthening technique. METHODS: Forty-eight flexor tendons were harvested from eight paired upper limbs including flexor carpi radialis, flexor carpi ulnaris, flexor pollicis longus, and flexor digitorum superficialis tendons. Each tendon that was lengthened was paired with the contralateral tendon as a control. A pair of transverse tenotomies were completed for the fractional lengthening. The first tenotomy was performed at the musculotendinous junction where the tendon narrowed to 75% of its maximal width. The second tenotomy was made 1 cm distal to the first. Tendon length was measured before and after fractional lengthening at a constant resting tension of 1 N. The maximum load at failure of each tendon and the mechanism of failure were each measured and compared with the contralateral side. RESULTS: After fractional lengthening, the mean increase in resting tendon length was 4 mm. When loaded to failure, the mean maximum load of fractionally lengthened tendons was 42% of the mean maximum load of intact tendons. All lengthened tendons failed at the distal tenotomy site. CONCLUSIONS: Fractional lengthening resulted in an increase of 3-6 mm (mean: 4 mm) in tendon length at resting tension. There was a significant loss in tensile strength and load to failure following fractional lengthening compared with an intact musculotendinous unit. CLINICAL RELEVANCE: The reduction in tensile strength following fractional lengthening results in loads at failure that are, in some cases, lower than the estimated forces required to perform basic tasks. Caution during the healing and rehabilitation period is warranted.

Biomechanical Analysis of Headless Compression Screw Versus Tension Band Wiring for Proximal Interphalangeal Joint Arthrodesis.

PURPOSE: Proximal interphalangeal (PIP) joint arthrodesis is a procedure employed to address arthritis, instability, and deformity. Multiple fixation methods are available to maintain stability across the arthrodesis interval, including headless compression screws (HCSs), tension band wiring (TBW), plating, and Kirschner wire constructs. The purpose of this study was to compare the biomechanical properties of the HCS and TBW techniques. METHODS: Thirty-two nonthumb digits from the paired upper limbs of four fresh frozen cadavers were divided into pairs, matching contralateral digits from the same specimen. One PIP joint of each pair was fused with an antegrade 3.5 mm HCS, and the second was fused with TBW using 0.035 in. Kirschner wires with 24-gauge dental wire. Each construct was then stressed to 10 N in the radial deviation, ulnar deviation, flexion, and extension planes, and stiffness (N/mm) was calculated. The fingers were stressed to failure in extension with the ultimate load and mode of failure recorded. RESULTS: When stressed in extension, the HCS construct had a significantly greater mean stiffness than the TBW construct (16.4 N/mm vs 10.8 N/mm). The stiffness in all other planes of motion were similar between the two constructs. The mean ultimate load to failure in extension was 91.4 N for the HCS and 41.9 N for the TBW. The most common mode of failure was fracture of the dorsal lip of the proximal phalanx (13/16) for the HCS and bending of the K-wires (15/16) for TBW. CONCLUSIONS: Arthrodesis of the PIP joint using a HCS resulted in a construct that was significantly stiffer in extension with greater than double the load to failure compared to TBW. CLINICAL RELEVANCE: Although the stiffness required to achieve successful PIP joint arthrodesis has not been well quantified, the HCS proved to be the most favorable construct with respect to initial strength and stability.

Risk factors for surgical site infection after surgical treatment of closed distal radial fractures.

We assessed operatively treated closed distal radial fractures to identify independent risk factors for surgical site infection after treatment. A retrospective review was carried out of 531 operatively treated closed distal radial fractures over a 5-year period. Multiple logistic regression was performed with infection as the dependent variable, using a stepwise regression procedure to select variables to construct the final model. In total, 19 (3.6%) fractures were complicated by postoperative surgical site infection. Uncontrolled diabetes with HbA1c >7, the presence of external fixation or external Kirschner wires, and tobacco use were significant independent predictors of infection. Age and time in the operating room were also statistically significant predictors but deemed to be not clinically meaningful.Level of evidence: IV.

Evaluation of Radiographic Parameters Following Dorsal Wrist-Spanning Plate Fixation of Distal Radius Fractures to the Second Versus Third Metacarpal.

PURPOSE: Dorsal wrist-spanning plate fixation for comminuted, intra-articular distal radius fractures involves the indirect reduction of intra-articular fractures via ligamentotaxis. The reduction is maintained by application of a bridge plate from the radial diaphysis to either the second or third metacarpal. The objective of this study was to retrospectively compare radiographic outcomes between distal radius fractures managed with bridge plate fixation to the second versus third metacarpal. METHODS: A single-institution retrospective review identified 50 cases of distal radius fractures that underwent dorsal wrist-spanning plate fixation, with 9 and 41 fractures undergoing fixation to the second and third metacarpals, respectively. Radiographic parameters, such as radial height, radial inclination, volar tilt, and ulnar variance, were measured at 3 time points: immediately after surgery, immediately prior to elective plate removal, and at the final follow-up. Radiographic measurements of the 2 cohorts were compared at the 3 time points. RESULTS: Final radiographs showed an average radial height of 8.9 mm versus 9.4 mm for the second versus third metacarpal cohorts, respectively; average radial inclination of 17.4° for both the second and third metacarpal cohorts; average volar tilt of 1.9° versus 1.7° for the second versus third metacarpal cohorts, respectively; and an average ulnar variance of +0.6 mm versus +0.1 mm for the second versus third metacarpal cohorts, respectively. Radiographic parameters of the second and third metacarpal cohorts were similar across all the time points. Additionally, evaluation of the radiographic parameters across the 3 time points (immediately after surgery, immediately prior to elective plate removal, and at the final follow-up) demonstrated little to no loss of radiographic alignment. CONCLUSIONS: Radiographic outcomes for distal radius fractures managed with bridge plate fixation to the second versus third metacarpal appear similar. The distal plate fixation site can likely be determined on the basis of fracture anatomy and patient-specific features. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Use of Biologic Agents in Extremity Reconstruction.

Skin and soft tissue defects of the lower extremity present a unique challenge for the reconstructive surgeon. Successful repair of the lower extremity relies not only on strong anatomical knowledge and surgical expertise, but also on careful consideration of the numerous preoperative factors and indications that may alter the patient's response to operative management. While many of these injuries result from burns, avulsive trauma, diabetes, or vascular insufficiencies, a significant portion can be associated with resection of neoplastic pathologies. This review outlines the uses, indications, and considerations for biologic wound agents in reconstructing skin and soft tissue defects of the lower extremity following Mohs micrographic surgery.

Effect of Smoking on Short-term Postoperative Complications After Elective Upper Extremity Surgery.

Background: There is a paucity of literature exploring the impact of smoking on short-term complications, readmissions, and reoperations after elective upper extremity surgery using a large multicenter national database. We hypothesized that smokers will have an increased rate of complications, readmissions, and reoperations compared with a cohort of nonsmokers undergoing elective upper extremity surgery. Methods: Patient data were collected from the American College of Surgeons National Surgical Quality Improvement Program database between the years 2012 and 2017. Patients were included if they underwent elective surgery of the upper extremity using 338 predetermined Current Procedural Terminology codes. The data collected were divided into patient demographics, comorbidities, perioperative variables, and 30-day complications. Current smoking status was defined as smoking within 1 year prior to surgery. The incidence of surgical complications, reoperations, and readmissions was compared between the 2 cohorts using multivariable regression analysis. Results: Of the 107 943 patients undergoing elective surgeries of the upper extremity, 73 806 met the inclusion criteria. Of these, 57 986 (78.6%) were nonsmokers in the year prior to surgery, and 15 820 (21.4%) were current smokers. Between these groups, current smokers were younger (P < .001), more often men (P < .001), had lower body mass index (P < .001), and more often underwent procedures that involved bone manipulation (P < .001). Multivariate regression analysis defined current smoking as significantly associated with overall surgical site complications, superficial surgical site infections, deep surgical site infections, reoperation, and readmission. Conclusion: Current smoking was significantly associated with an increase in all surgical site complications, readmissions, and reoperations after elective upper extremity surgery. Surgeons should consider smoking a modifiable risk factor for postoperative complications and appropriately counsel patients on outcomes and complications given the elective nature of upper extremity surgery.

Patient-Related Risk Factors Associated With Surgical Site Complications After Elective Hand Surgery.

BACKGROUND: The purpose of this study was to identify independent risk factors associated with an increased rate of surgical site complications after elective hand surgery. METHODS: This study is a retrospective review of all patients who underwent elective hand, wrist, forearm, and elbow surgery over a 10-year period at a single institution. Electronic medical records were reviewed, and information regarding patient demographics, past medical and social history, perioperative laboratory values, procedures performed, and surgical complications was collected. Surgical site complications included surgical site infections, seromas or hematomas, and delayed wound healing or wound dehiscence. A univariate analysis was then performed to identify potential risk factors, which were then included in a multivariate regression analysis. RESULTS: A total of 3261 patients who underwent elective hand surgery and met the above inclusion and exclusion criteria were included in this study. The mean age was 57 years, with 65% female and 35% male patients. The overall surgical complication rate was 2.2%. Univariate analysis of patient factors identified male sex; number of procedures >1; history of drug, alcohol, or smoking use; American Society of Anesthesiologists (ASA) class III and IV; and serum albumin <3.5 mg/dL to be significantly associated with complications. However, multivariate regression analysis identified that only ASA class III and IV (odds ratio = 3.27) was significantly associated with surgical complications. CONCLUSIONS: Patients classified as ASA class III or IV were identified to be at a significantly increased risk of complications following elective hand surgery. Health factors which triage patients into these 2 groups may represent potentially modifiable factors to mitigate perioperative risk in the elective hand surgery population.

Effect of Diabetes and Hemoglobin A1c on Complications Following Elective Hand Surgery.

Background: Limited research exists investigating the association between diabetes and glycemic control on complications following elective hand surgery. The goal of this research was to assess the incidence of complications within 30 days of elective hand surgery in a large population of diabetic patients compared to a population of non-diabetics. Furthermore, we sought to examine the relationship of glycemic control, as measured by HbA1c, and postoperative complications. Methods: We performed a retrospective review of electronic medical records at our institution of all patients who underwent elective hand, forearm, or elbow surgery from the dates of January 1st, 2008 to December 31st, 2017. Patients were categorized as diabetic or non-diabetic and most recent HbA1c was documented. Multivariable analysis was employed to compare the incidence of surgical complications within 30 days between the diabetics and non-diabetic populations, adjusting for baseline patient characteristics. Results: A total of 3,261 patients met the inclusion criteria. There were 646 (20%) diabetic patients and 2,615 (80%) non-diabetic patients. No difference was found in the overall rate of complications between the cohort of diabetic and non-diabetic patients. Additionally, statistical analysis found no difference in the complication rate between insulin and non-insulin controlled diabetics. Rates of complications were stratified based on HbA1c level and statistical analysis found no increased risk of complications with increased hemoglobin A1c value. Conclusions: In our present study we were not able to demonstrate any significant difference in the 30 day complication rates between and non-diabetics undergoing elective hand surgery. This study attempted to aid in risk stratification of diabetic patients by evaluating preoperative glycemic indices in the form of HbA1c.

Rodeo Thumb: To Replant or Not.

BACKGROUND: This study investigated patient-reported outcomes after surgical treatment of rodeo thumb amputation to guide clinical decision-making. METHODS: A retrospective review was performed for rodeo thumb amputations from 2009 to 2019. Patient-reported outcomes were collected and compared by injury level, age, and treatment. Two-sided t test was used to compare continuous variables, and Pearson chi-square test was used to compare categorical data. RESULTS: The study included 37 patients. Patients with interphalangeal injuries treated with replantation had Quick Disabilities of the Arm, Shoulder and Hand questionnaire scores similar to those treated with amputation (1 versus 8; p = 0.07). There was no significant difference in percentage of patients with similar or better roping ability after treatment (40 percent versus 79 percent; p = 0.26), and similar percentages were satisfied (80 percent versus 71 percent; p = 1.00). Patients with metacarpophalangeal injuries treated with replantation and those treated with amputation had similar questionnaire scores (7 versus 10; p = 0.47). Both groups had similar roping ability after treatment (67 percent versus 56 percent; p = 1.00), and there was no statistically significant difference in satisfaction (79 percent versus 44 percent; p = 0.34). Pediatric patients had questionnaire scores similar to those of adults (6 versus 8; p = 0.42). A significantly higher percentage of pediatric patients had similar roping ability following injury than adults (100 percent versus 54 percent; p = 0.02). Most patients in both groups were satisfied (89 percent versus 61 percent; p = 0.22). CONCLUSIONS: For both interphalangeal and metacarpophalangeal injuries, patient-reported outcomes were similar regardless of treatment. Children were able to return to roping and perform at a similar or higher level at a greater rate than adults, but had similar questionnaire scores and satisfaction.

Oral Antibiotics Are Effective for the Treatment of Hand Osteomyelitis in Children.

Background: Acute osteomyelitis of the hand is common in the pediatric population. Treatment with intravenous antibiotics is expensive and is associated with catheter-site infection and thrombosis. The purpose of this study is to investigate the efficacy of managing osteomyelitis of the hand in children with oral antibiotics. Methods: A retrospective review of cases of acute osteomyelitis of the hand at a single pediatric institution over a 4.5-year period was performed. Demographic and clinical data were reviewed, and treatment courses and outcomes were analyzed. Results: In total, 21 patients with acute osteomyelitis of the hand were included in the study. Of the 21 patients, 17 were initiated on a 6-week course of oral antibiotics upon diagnosis. Thirteen were successfully treated with oral antibiotics alone, 3 required subsequent surgical debridement, and 3 required conversion to intravenous antibiotics. Of the 21 patients, 4 were treated with surgical debridement upon diagnosis due to gross purulent drainage and then initiated on a 6-week course of oral antibiotics. All patients who underwent debridement were treated successfully with postoperative oral antibiotics. Conclusions: Most cases of osteomyelitis of the hand in children can be treated with oral antibiotics, either as the primary treatment or as postoperative therapy. Surgical debridement is indicated when purulence is present at the time of initial diagnosis or if the infection progresses during treatment with oral antibiotics. The use of oral antibiotics for treating acute osteomyelitis of the hand in children may result in decreased cost and fewer catheter-associated complications.

Comparison of Fracture Location and Extent of Comminution in Isolated Scaphoid Fractures Versus Transscaphoid Fracture-Dislocations.

Background: Isolated scaphoid fractures (ISFs) are common, whereas transscaphoid fracture-dislocations (TSFDs) are not. Scaphoid fracture location and the extent of comminution are factors that affect treatment and outcome. The purpose of this study is to compare the radiographic characteristics of ISFs with TSFDs associated with greater arc injury. Methods: This study is a retrospective review of all ISFs and TSFDs that presented to our institution during a 5-year period. Fracture location (along the long axis of the scaphoid) was calculated by dividing the distance from the proximal pole to the fracture by the entire length of the scaphoid. The extent of comminution was measured in millimeters along the mid-axis of the scaphoid and divided by the entire length of the scaphoid. Results: One-hundred thirty-eight scaphoid fractures in 137 patients were identified. One-hundred twelve fractures (81%) were ISFs, and 26 (19%) were associated with a TSFD. The mean fracture location was more proximal in TSFDs than in ISFs. However, fractures occurred in the distal third of the scaphoid in 12% of ISFs compared with 0% of TSFDs. Nine percent of ISFs demonstrated comminution as compared with 12% of TSFDs. Extent of comminution was 16% and 28% for ISFs and TSFDs, respectively. Conclusion: Scaphoid fractures associated with greater arc injuries are located more proximally and are more comminuted than ISFs, and distal pole fractures rarely occur in the setting of TSFDs. The increased incidence and extent of comminution in TSFDs may be suggestive of a higher energy injury mechanism.

Arthroscopic Ganglionectomy in the Pediatric Population.

BACKGROUND: Arthroscopic dorsal wrist ganglionectomy is an established alternative to open excision in the adult population. The purpose of this study was to retrospectively compare outcomes of arthroscopic and open dorsal wrist ganglionectomy in the pediatric population. METHODS: All patients who underwent arthroscopic or open dorsal wrist ganglionectomy at a single pediatric institution between 2011 and 2014 were retrospectively evaluated by chart review and telephone interview. The primary outcome variable was whether or not the cyst had recurred. Other outcome measures included the incidence of complications, and patient-rated outcome measures such as satisfaction, pain, function, and aesthetics. RESULTS: There were eight cases of arthroscopic and 19 cases of open ganglionectomy, with a mean age of 14 years. At an average follow-up of 2 years, the recurrence rate was one of eight for the arthroscopic group and two of 19 for the open group. No patients in the arthroscopic group reported functional limitations, compared with three patients in the open group. On a 10-point scar appearance scale, with 1 being not satisfied at all and 10 being highly satisfied, the median score in the arthroscopic group was 9.5, compared with 8 in the open group. No patients in the arthroscopic group had residual pain at the surgical site, compared with nine patients in the open group, a finding that was statistically significant. All patients in the arthroscopic group reported that they would undergo surgery again, whereas two patients in the open group would not undergo surgery again. CONCLUSION: Arthroscopic dorsal wrist ganglionectomy compares favorably with open ganglionectomy in the pediatric population.

Brachial Artery Aneurysm in a 7-Month-Old Infant: Case Report and Literature Review.

Congenital upper extremity aneurysms are very rare and can be challenging to diagnose and treat. Although they can present as an isolated finding, they are often associated with other systemic conditions. We present a rare case of brachial artery aneurysm in a 7-month-old boy. The patient was evaluated with ultrasound, magnetic resonance angiography, and vein mapping before surgical reconstruction. After excision of the aneurysm, the brachial artery was reconstructed with an interposition saphenous vein graft. Because of potentially associated diagnoses and the possibility of concurrent aneurysms, this condition requires multidisciplinary management.

Accuracy of Visual Estimates of Partial Flexor Tendon Lacerations.

PURPOSE: To determine whether hand surgeons could accurately and consistently estimate the size of partial flexor tendon lacerations. MATERIALS AND METHODS: Thirty-two partial flexor tendon lacerations were made in the flexor digitorum profundus tendons of a fresh-frozen cadaveric hand. Four hand surgeons and 5 residents estimated the size of the lacerations. Estimates were repeated 3 days later. Magnified images of the laceration cross-section were used to calculate the true size of each laceration. Inter- and intrarater reliability were calculated using the intraclass correlation coefficient. Accuracy was measured with the mean bias error and the mean absolute error. RESULTS: Interrater and intrarater reliabilities were both high. There was a high level of consistency for both surgeons and residents. In terms of accuracy, there was a 3% bias toward underestimation. The mean absolute error was 11%. There was no statistically significant difference between the accuracy of attending hand surgeons and that of residents. Participants were less accurate when estimating lacerations close to a 60% laceration threshold for surgical repair (lacerations in the 50%-70% range). For lacerations within this range, an incorrect management decision would have been made 17% of the time, compared with 7% of the time for lacerations outside that range. CONCLUSIONS: The accuracy and reliability of surgeon estimates of partial flexor tendon laceration size were high for surgeons and residents. Accuracy was lower for lacerations close to the threshold for repair. CLINICAL RELEVANCE: Visual estimation is acceptable for evaluating partial flexor tendon lacerations, but it may be less reliable for lacerations near the threshold for repair. Therefore, surgeons should be cautious when deciding whether or not to repair partial lacerations in the borderline range.

Reconstruction of scaphoid non-union and total scaphoid avascular necrosis in a pediatric patient: a case report.

BACKGROUND: The medial femoral condyle vascularized bone graft has grown in popularity for treating recalcitrant fracture non-unions and has become particularly useful in treating scaphoid non-union with avascular necrosis of the proximal pole. The medial femoral condyle is an excellent source of dense, well-vascularized bone and results in minimal donor site morbidity. METHODS: We describe an unusual case of chronic scaphoid non-union and total scaphoid avascular necrosis in a skeletally immature patient. Scaphoid reconstruction was performed with a vascularized medial femoral condyle graft, with successful graft incorporation, and restoration of pain-free wrist motion. CONCLUSIONS: Technical considerations for harvest of the medial femoral condyle bone graft in the skeletally immature patient are discussed.

Practical Management of Metacarpal Fractures.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the indications for metacarpal fixation. 2. Understand the rationale for various surgical treatment options, based on high-level evidence where available. 3. Describe selected operative techniques and their postoperative management. BACKGROUND: Metacarpal fractures are extremely common, constituting one in five fractures that present to the emergency department. Although many metacarpal fractures can be treated nonoperatively, some require surgery. The purpose of this CME article is to present a practical, up-to-date guide to the management of these common injuries. METHODS: A review of nonoperative management, surgical indications, and selected surgical techniques is provided. The authors reviewed the literature related to the treatment of metacarpal fractures, and the highest level evidence available to help guide decision-making is presented. CONCLUSIONS: Metacarpal fractures can often be treated nonoperatively, although some fractures will benefit from surgical treatment. Although there is some high-level evidence to guide decision-making, there are many clinical scenarios for which there is little high-quality applicable research. As a general principle, the treatment option that achieves the desired reduction and degree of fixation, allows early motion, and minimizes soft-tissue injury should be preferred.

Atypical Infections versus Inflammatory Conditions of the Hand: The Role of Imaging in Diagnosis.

Atypical infections may manifest in the setting of low clinical suspicion and, because of some similarity to other inflammatory conditions regarding their clinical and imaging findings, misdiagnosis or delayed diagnosis is not infrequent. The latter may lead to elevated risk of severe bone and joint destruction, and higher morbidity. This review addresses the challenging subject of discussing the imaging characteristics of atypical infections and a variety of inflammatory conditions of the hand, and emphasizes the key points that assist in the differentiation of the two broad clinical categories of infections versus inflammatory causes.

Salvage Operations for Wrist Ligament Injuries with Secondary Arthrosis.

Wrist ligamentous injuries can be challenging to treat successfully. In some cases the ligament repair or reconstruction fails, resulting in instability and progressive degenerative changes. In other cases the original injury is missed, and the patient presents for the first time with established wrist arthritis. Multiple operations have been devised to treat patients with arthrosis secondary to wrist ligament injuries. This article discusses definitive salvage operations such as intercarpal arthrodeses and proximal row carpectomy, as well as other alternatives such as wrist denervation and radial styloidectomy.

Management of complications with flap procedures and replantation.

Replantation and flap procedures employ microvascular techniques to salvage or reconstruct a severely damaged limb or digit. The most devastating complications include complete or partial flap loss, or replantation failure due to vascular complications. Often, these complications can be prevented by appropriate patient selection, careful surgical planning, meticulous technique, and proper postoperative management. This article discusses complications related to replantation and flap procedures in the upper limb, focusing on preventing and managing these complications.

An Association between Carpal Tunnel Syndrome and Migraine Headaches-National Health Interview Survey, 2010.

BACKGROUND: Migraine headaches have not historically been considered a compression neuropathy. Recent studies suggest that some migraines are successfully treated by targeted peripheral nerve decompression. Other compression neuropathies have previously been associated with one another. The goal of this study is to evaluate whether an association exists between migraines and carpal tunnel syndrome (CTS), the most common compression neuropathy. METHODS: Data from 25,880 respondents of the cross-sectional 2010 National Health Interview Survey were used to calculate nationally representative prevalence estimates and 95% confidence intervals (95% CIs) of CTS and migraine headaches. Logistic regression was used to calculate adjusted odds ratios (aORs) and 95% CI for the degree of association between migraines and CTS after controlling for known demographic and health-related factors. RESULTS: CTS was associated with older age, female gender, obesity, diabetes, and smoking. CTS was less common in Hispanics and Asians. Migraine was associated with younger age, female gender, obesity, diabetes, and current smoking. Migraine was less common in Asians. Migraine prevalence was 34% in those with CTS compared with 16% in those without CTS (aOR, 2.60; 95% CI, 2.16-3.13). CTS prevalence in patients with migraine headache was 8% compared with 3% in those without migraine headache (aOR, 2.67; 95% CI, 2.22-3.22). CONCLUSIONS: This study is the first to demonstrate an association between CTS and migraine headache. Longitudinal and genetic studies with physician verification of migraine headaches and CTS are needed to further define this association.