Comparison of patient preferences and responsiveness among common patient-reported outcome measures for hand/wrist injuries or disorders.

BACKGROUND: Patient-reported outcome measures (PROMs) were developed to examine patients' perceptions of functional health. Most studies compare the responsiveness of each type of questionnaire. However, reports of patient preferences among PROMs commonly used with patients with hand/wrist injuries or disorders are limited. This study aimed to compare patient preferences, factors associated with those preferences and responsiveness among the Disability of the Arm, Shoulder, and Hand (DASH), Michigan Hand Outcomes Questionnaire (MHQ), Patient-Rated Wrist/Hand Evaluation (PRWHE) and EQ-5D in patients with hand/wrist injuries or disorders. MATERIAL AND METHODS: This retrospective cohort study collected data on 183 patients with hand/wrist injuries or diseases who had visited a hand/wrist outpatient clinic or were hospitalized for surgery between 2017 and 2020. Patients had to be at least 18 years old and able to complete the four questionnaires included in the study. The four PROMs (DASH, MHQ, PRWHE and EQ-5D) were administered to the patients prior to treatment. After completing the questionnaires, patients were asked to answer two open-ended questions regarding their preferences. Multinomial logistic regression was used to identify factors related to patient preferences. Results are presented as the relative risk ratio (RRR). The standardized response mean (SRM) was used to evaluate questionnaire responsiveness. RESULTS: Of the 183 patients, most preferred the PRWHE questionnaire (n = 74, 41%), with the main reasons cited being "specific to injuries/diseases and reflects hand/wrist function (n = 23, 31%)" and "easy to complete (n = 22, 30%)." Sex was found to be associated with patient preference after adjusting for demographic data and reasons for choosing a PROM as confounders (RRR = 0.46, P value = 0.049). The PRWHE had the highest SRM, followed by DASH (0.92 and 0.88, respectively). CONCLUSIONS: The PRWHE is the most preferred by patients and is the most responsive questionnaire. It is recommended for use in clinical practice in situations where a clinician would like to use only one PROM for evaluating patients with various types of hand/wrist problems. LEVEL OF EVIDENCE: Prognostic III.

Osteocutaneous proximal fibular flap: an anatomical and computed tomographic angiographic study of skin and bone perforators.

INTRODUCTION: Vascularized proximal fibular epiphyseal transfer is a reconstruction method for joints and growing bones. The authors investigated the vascular supply of the proximal fibula, including skin perforators, for suitability in creating an osteocutaneous flap. METHODS: Twenty fresh cadaveric knees were studied using computed tomographic angiography combined with anatomical dissection. Three-dimensional angiography was used to develop an overview, and multiplanar two-dimension angiography was used for detailed data collection. Anatomical dissection verified by angiography was used to locate skin perforators of the proximal part of the anterior tibial artery. RESULTS: Proximal fibular bone perforators from the anterior tibial artery were found to arise either from the anterior tibial recurrent artery, the posterior tibial recurrent artery or the circumflex fibular artery in every specimen (100%), whereas perforators from the inferolateral genicular artery met those criteria in 12 of 18 specimens (66.7%). In the proximal half of 20 anterior tibial arteries, 129 skin perforators with a diameter larger than 0.5 mm were found. There were 54 potential septocutaneous skin perforators between the extensor digitorum longus and the peroneus longus muscles (EDL/PL), and 18 between the extensor digitorum longus and the tibialis anterior muscles (TA/EDL). Skin perforators from the inferolateral genicular artery emerging from the posterolateral corner of the knee had a diameter of < 0.5 mm. CONCLUSION: Based on this cadaveric study, the reverse flow anterior tibial artery pedicle and the EDL/PL or TA/EDL skin perforators can be considered as options for osteocutaneous proximal fibular transfers.

Double Motor Nerve Transfer for All Finger Flexion in Cervical Spinal Cord Injury: An Anatomical Study and a Clinical Report.

PURPOSE: To explore the feasibility of restoring all finger flexion after a cervical spinal cord injury. METHODS: Double nerve transfer was conducted in 22 cadaver upper extremities. Donor nerves were the brachialis branch of the musculocutaneous nerve and the extensor carpi radialis brevis (ECRB) branches of the radial nerve. Recipient nerves were the anterior interosseous nerve (AIN) and the flexor digitorum profundus (FDP) branch of ulnar nerve (ulnar-FDP). Nerve transfers were evaluated on 3 parameters: surgical feasibility, donor-to-recipient axon count ratio, and distance from the coaptation site to the muscle entry of recipient nerve. A complete C6 spinal cord injury reconstruction was accomplished in a patient using a double nerve transfer of ECRB to ulnar-FDP and brachialis to AIN. RESULTS: In the cadaver study, nerve transfers from ECRB to AIN, brachialis to AIN, and ECRB to ulnar-FDP were all feasible. The transfer from the brachialis to ulnar-FDP was not possible. Mean myelinated axon counts of AIN, brachialis, ulnar-FDP, and ECRB were 2,903 ± 1049, 1,497 ± 606, 753 ± 364, and 567 ± 175, respectively. The donor-to-recipient axon count ratios of ECRB to AIN, brachialis to AIN, and ECRB to ulnar-FDP were 0.24 ± 0.15, 0.55 ± 0.38, and 0.98 ± 0.60, respectively. The distance from coaptation of the ECRB to the ulnar-FDP muscle entry was shorter than for the other nerve transfers (54 ± 14.29 mm). At 18 months, there was restoration of flexion in all fingers and functional improvement from double nerve transfer of the brachialis to the AIN and the ECRB to the ulnar-FDP. CONCLUSIONS: Restoration of all finger flexion may be feasible by the ECRB to ulnar-FDP and brachialis to AIN double nerve transfer. CLINICAL RELEVANCE: Double nerve transfer can be used in C6-C7 spinal cord injury and patients with lower arm-type brachial plexus injury who have no finger flexion but have good brachialis and ECRB.

Biomechanical study of isolated radial head dislocation.

BACKGROUND: Isolated radial head dislocation is a rare injury with an unclear pathomechanism, and the treatment is controversial. The purpose of the present study was to investigate the biomechanical contributions of the annular ligament, quadrate ligament, interosseous membrane, and annular ligament reconstructions to proximal radioulnar joint stability. METHODS: Five fresh frozen cadaveric upper extremities were amputated above the elbow and solidly fixed on a customized jig. Radial head dislocation was reproduced by sequential sectioning of ligamentous structures and passive mobility testing. Radial head displacement during mobility testing was measured with an electromagnetic tracking device in three forearm rotation positions. The data were compared among different sectioning stages and between two types of simulated ligamentous reconstruction. RESULTS: Lateral displacement of the radial head significantly increased in the neutral forearm rotation after annular ligament sectioning (46 ± 10%, p < 0.05). After quadrate ligament sectioning, we found significant posterior (67 ± 36%, p < 0.05) and lateral (74 ± 24%, p < 0.01) displacement in neutral forearm rotation and pronation. Significant radial head displacement was found in all directions and in all forearm positions after sequential sectioning of the proximal half of the interosseous membrane. Anatomical annular ligament reconstruction stabilized the proximal radioulnar joint except for anterior laxity in neutral forearm rotation (15 ± 6%, p < 0.05). The radial head with Bell Tawse procedure was significantly displaced in all directions. CONCLUSION: The direction of radial head instability varied depending on the degree of soft tissue sectioning and specific forearm rotation. Anterior radial head dislocation may involve more severe ligament damage than other types of dislocation. Anatomical annular ligament reconstruction provided multidirectional radial head stability.

Impact of Distal Ulnar Fracture Malunion on Distal Radioulnar Joint Instability: A Biomechanical Study of the Distal Interosseous Membrane Using a Cadaver Model.

PURPOSE: Certain distal ulna fractures may contribute to distal radioulnar joint (DRUJ) instability. We hypothesized that residual distal ulna translation could affect DRUJ stability by slackening the distal interosseous membrane (DIOM). We aimed to test this hypothesis in a cadaver model. METHODS: We created an ulnar translated distal ulna fracture model in 6 cadavers. Dorsal and palmar displacements of the ulna relative to the radius were measured and DRUJ instability was staged under the following conditions: (1) 0-, 2-, and 4-mm ulnar translation of the distal ulna with an intact triangular fibrocartilage complex (TFCC) and DIOM; (2) 0-, 2-, and 4-mm translations with TFCC divided and an intact DIOM; and (3) a 0-mm translation with TFCC and DIOM divided. RESULTS: With an intact TFCC, dorsal and palmar displacements were not increased with any amount of distal ulna translation. After TFCC division with 0-mm translation, dorsal displacement increased significantly with DRUJ dislocation, whereas palmar displacement increased to a lesser extent with DRUJ subluxation. Palmar displacement gradually increased as the translation increased, and with 4-mm translation the ulnar head displaced to a perched position off the sigmoid notch. With TFCC and DIOM division, displacements increased markedly with DRUJ dislocation both dorsally and palmarly. CONCLUSIONS: Dorsal dislocation occurred when the TFCC was divided regardless of the amount of distal ulna translation. Palmar subluxation occurred when the TFCC alone was divided. Palmar displacement to a perched position occurred because of slackening of the DIOM as a result of translation of the distal ulna. Bidirectional DRUJ instability with dorsal dislocation and palmar displacement to a perched position occurred when the TFCC was divided and the distal ulna was ulnarly translated. CLINICAL RELEVANCE: Bidirectional DRUJ instability might occur when distal ulna translation deformity is associated with TFCC injury because the DIOM loses its function as a secondary stabilizer.

Wide awake technique versus local anesthesia with tourniquet application for minor orthopedic hand surgery: a prospective clinical trial.

BACKGROUND: Most minor hand operations can be performed with local anesthesia and tourniquet. Some literature supports this concept based on the believe that the "patient can tolerate it". Nowadays, the wide-awake technique with epinephrine- contained lidocaine is safe. This technique does not need a tourniquet because epinephrine provides local vasoconstriction. OBJECTIVE: The present study was designed to compare patients' comfort and effectiveness of local anesthesia as well as bleeding at the surgical site between wide-awake anesthesia and local lidocaine with tourniquet application. MATERIAL AND METHOD: Prospective Clinical Trial was performed in 60 patients who received outpatient surgery for common hand problems at Maharaj Nakorn Chiang Mai Hospital. With randomization, 30 patients were in wide-awake group, who received adrenaline-contained lidocaine as a local anesthetic agent, with tourniquet wrapping but with no pressure applied (group 1). The other 30 patients were in the conventional group that received lidocaine (no adrenaline) and a 250-mmHg tourniquet application (group 2). Operations were performed with standard methods. Visual analog scores, surgical field bleeding, amount of bleeding, any complications within 4 weeks were recorded. RESULTS: There are no significant differences between the two groups in terms of patient profiles (sex, age and diseases), injected site pain and surgeon's opinion of surgical site bleeding. Tourniquet's pain and the amount of blood loss in the conventional group were significantly higher than the wide-awake group. CONCLUSION: Wide-awake technique (no tourniquet applied) offers better comfort for patients and less total blood loss while providing effective anesthesia and patient safety as with the conventional technique.

Pull-out strength of 0°/30° Kirschner wire syringe external fixators with and without polymer augmentation: a biomechanical study.

BACKGROUND: Hand external fixators are in use worldwide and insulin syringes can generally be found in an operating room. OBJECTIVE: To compare the pull-out strength between degrees of Kirschner wire fixation (0° and 30°) and the effect of filling an insulin syringe with polymer MATERIAL AND METHOD: Pull-out strength was compared between a syringe externalfixator and a bone or plastic tube model. Fifty-two plastic tube models and 20 dry phalangeal bones were included The syringe external fixator was attached via two Kirschner wires. Four variations were studied: 0° non-polymer 0° with polymer augmentation, 30° non-polymer and 30° with polymer augmentation. The pull-out strength was measured in each group. RESULTS: The strength of polymer augmentation was higher than non-polymer augmentation at 0° (p = 0.0003) and 30° (p = 0.0002). The Kirschner wire at 30° provided more pull-out strength than at 0° (p = 0.0003) using the syringe with no polymer However, using the syringe with polymer augmentation, there was no significant difference (p = 0.5136). CONCLUSION: Polymer augmentation significantly increases the pull-out strength at both degrees offixation. The degree of fixation significantly increases the pull-out strength only in the non-polymer group, where pinning at 30° was superior to 0°.

Effect of soft tissue injury and ulnar angulation on radial head instability in a Bado type I Monteggia fracture model.

The effects of soft tissue damage and ulnar angulation deformity on radial head instability in Monteggia fractures are unclear. We tested the hypothesis that radial head instability correlates with the magnitude of ulnar angular deformity and the degree of proximal forearm soft tissue injury in Bado type I Monteggia fractures.We performed a biomechanical study in 6 fresh-frozen cadaveric upper extremities. Monteggia fractures were simulated by anterior ulnar angulation osteotomy and sequential sectioning of ligamentous structures. We measured radial head displacement during passive mobility testing in pronation, supination, and neutral rotation using an electromagnetic tracking device. Measurements at various ligament sectioning stages and ulnar angulation substages were statistically compared with those in the intact elbow.Radial head displacement increased with sequential ligament sectioning and increased proportionally with the degree of anterior ulnar angulation. Annular ligament sectioning resulted in a significant increase in displacement only in pronation (P < .05). When the anterior ulnar deformity was reproduced, the radial head displaced least in supination. The addition of proximal interosseous membrane sectioning significantly increased the radial head displacement in supination (P < .05), regardless of the degree of anterior ulnar angulation.Our Monteggia fracture model showed that radial head instability is influenced by the degree of soft tissue damage and ulnar angulation. Annular ligament injury combined with a minimal (5°) ulnar deformity may cause elbow instability, especially in pronation. The proximal interosseous membrane contributes to radial head stability in supination, regardless of ulnar angulation, and proximal interosseous membrane injury led to significant radial head instability in supination.

Descending genicular artery free flaps: Multi-purpose tissue transfers in limb reconstruction.

BACKGROUND: The descending genicular artery supplies skin, muscle, tendon, and bone structures in the medial knee area. Three types of skin perforator including musculocutaneous perforators through the vastus medialis (descending genicular artery perforator (DGAP)-vm), direct cutaneous perforators (DGAP), and saphenous artery perforators (SAP) can be elevated for the skin flap component. METHODS: This study included a prospective cohort of all patients in whom a descending genicular artery free flap was attempted in our center since January 2009. Data on patients' characteristics, type of injuries, the surgical procedures, and their outcomes were obtained for a minimum of 6 months postoperatively. FINDINGS: This cohort includes 22 descending genicular artery flaps for skin, bone, and tendon reconstruction after extensive soft tissue injury and/or bone nonunion. Of these, six were medial femoral condyle bone grafts, seven were skin flaps from the medial knee, and nine composite osteocutaneous or tendo-osteocutaneous flaps. Favorable outcome was achieved in 20 of 22 cases. We use the DGAP and DGAP-vm in 15 of 16 cutaneous and osteocutaneous flaps. CONCLUSION: The descending genicular artery flap offers a wide range of simple and composite flaps. Recognition of all types of skin perforators should enhance the options, the chance of success, and the popularity of the flap.

Anatomical variations of the saphenous and descending genicular artery perforators: cadaveric study and clinical implications for vascular flaps.

BACKGROUND: With increasing use of free vascular flaps of the saphenous artery and descending genicular artery, the authors investigated the anatomical variations in cadavers. METHODS: Thirty-one fresh cadaveric thighs were studied by anatomical dissection. The perforators and their source arteries were skeletonized along their courses to the superficial femoral artery and measured. The perforators' nomenclature and abbreviations were modified from the Gent consensus. The skin and bone perforators were evaluated for their role in skin, bone, and osteocutaneous flaps. RESULTS: The descending genicular artery was noted in 27 thighs (87 percent) and gave rise to at least one skin perforator that could be used to develop an osteocutaneous flap. The chimeric pedicle length increased and the chimeric arm length decreased, as the descending genicular artery skin perforators were more distally located. The saphenous artery was noted in all 31 thighs, and in 16 (52 percent) it originated from the superficial femoral artery. Most musculocutaneous perforators of the saphenous artery were associated with the sartorius, whereas those of the descending genicular artery were associated with the vastus medialis. Superficial femoral artery skin perforators were noted in 10 thighs (32 percent). Two clinical cases, illustrating the use of the descending genicular artery vastus medialis perforator flap and of the distal-direct perforator osteocutaneous flap, are reported. CONCLUSIONS: This study investigated the anatomical variations in the skin and bone perforators of the medial knee. Free skin or bone flaps were achieved in all specimens and osteocutaneous chimera flaps were achieved in 87 percent of the thighs.

Flow-through anterolateral thigh flap for simultaneous soft tissue and long vascular gap reconstruction in extremity injuries: anatomical study and case report.

SUMMARY: 47 dissections of cadaver thigh were studied to investigate pedicle configurations in the lateral descending branch of the lateral circumflex femoral arterial system, which can be used in harvesting a flow-through anterolateral thigh flap. The descending branch arose from the lateral circumflex femoral artery in 38 of the dissections, and the mean diameter at its origin was 3.0mm (range, 2.2-4.0mm). Skin peforators were of the solely musculocutaneous type in 37 dissections and were a combined septo-musculocutaneous type in 10 dissections. Pure septocutaneous perforator was not found in this study. During the descending branch's journey to the distal part of the thigh, several branches went into the vastus lateralis and vastus intermedius muscles. The diameters were tapering and the mean terminal diameter was 1.3mm (range 0.9-1.8mm), which required intraoperative judgment for proper matching of diameter of the flow-through pedicle and the recipient artery. The mean total length of the descending branch from its origin to terminus was 30.3 cm (range 22.5-37.1cm). In four dissections, the descending branch could not be used as a flow-through anterolateral thigh flap because the origin of the perforator arose from the transverse branch. A flow-through anterolateral thigh flap has several advantages, including a large cutaneous area, acceptable donor-site morbidity, adjustable thickness, the ability to combine adjacent muscle or fascia lata and the possibility of simultaneous reconstruction of long arterial gap and soft-tissue defects. Four patients with severe injury and a vascular gap of longer than 10 cm in the extremities were used to confirm the usefulness of this application.

Reconstruction of limb soft-tissue defects: using pedicle perforator flaps with preservation of major vessels, a report of 45 cases.

SUMMARY: We report on 45 pedicle perforator flaps without harvesting major vessels in limb reconstruction. Of our patients, 25 had major vessel injury resulting from their initial injury. In the upper extremities, there were 13 posterior interosseous artery perforator flaps, four ulnar artery perforator flaps and three radial artery perforator flaps. In the lower extremities, there were 16 peroneal artery perforator flaps with an axis on the sural nerve, five peroneal artery perforator flaps with an axis on the superficial peroneal nerve and four posterior tibial artery perforator flaps with an axis on the saphenous nerve. There were 42 successes, one total flap loss, one epidermal necrolysis and one distal tip necrosis. Greater utilisation of pedicle perforator flaps probably will occur because they are technically simple to execute, violate only the involved extremity, do not sacrifice a major source vessel, bring similar local tissues into a defect, avoid prolonged immobilisation and do not require microsurgical expertise. The concept of the pedicle perforator flap can be applied to the same axis of a neurocutaneous flap, even in cases with injured cutaneous nerves.

Distribution of nerve endings in the human dorsal radiocarpal ligament.

PURPOSE: The purpose of this investigation was to evaluate the nerve-ending apparatus populations within a large number of adult human dorsal radiocarpal (DRC) ligaments to test the hypothesis that the majority of nerve endings could be grouped into established classifications and that the nerve endings could be found in predictable locations within the substance of the ligament. METHODS: The DRC ligaments were harvested from 20 wrists of 10 fresh cadavers with an average age of 75.6 years within 12 to 18 hours of death. Before the tissues were harvested, radiographs were taken to exclude any arthritic conditions of the wrists. Tissues were fixed, sectioned with a cryostat, and serial sections were collected on glass slides. Slides were processed for fluorescence immunohistochemistry using antibody to protein gene product 9.5 and a secondary antibody conjugated to a fluorescent tag (Alexa Fluor 488). The sections were evaluated with an LSM-510 confocal laser microscope and a Kontron KS 400 image analyzer. Labeled nerve endings were counted, mapped, and reconstructed. RESULTS: The average number of nerve endings in each DRC ligament was 10.1+/-4.7. More than 76% of the nerve endings were found in the 2 ends of the ligament with 23.3% in the central third and approximately 80% distributed in the superficial layer. More than 80% of the nerve endings were discovered in the epiligamentous sheath rather than in the perifascicular spaces. CONCLUSIONS: The distribution of the nerve endings follows a consistent pattern. These results will provide a foundation of morphologic information useful in understanding normal and abnormal neural control of wrist joint mechanics.