Advances in Limb Preservation: From Replantation to Transplantation.

Over the course of the last 60 years, microsurgical techniques, instrumentation, operating microscopes, and suture materials have all been perfected. Microsurgery training became part of the standard curriculum in plastic, orthopedic, and hand surgery programs. Despite those advances, limb replantation and transplantation are still surgical emergencies owing to limits in composite tissue viability under ischemia. Amputated parts, particularly containing large volumes of muscle, have to be revascularized within 4 hours in order to prevent permanent tissue damage. Static cold storage is the current standard to prolong ischemia time with limited success. Our research for the last 7 years has focused on extending ischemia time prior to revascularization. Our long-term goal is to make replantation and transplantation procedures elective. The following essay is the summary of our efforts.

Nerve Lesions in Volkmann Ischemic Contracture.

Volkmann ischemic contracture (VIC) is a late sequela of acute compartment syndrome and consists of extensive muscle necrosis, fibrosis, contracture, and variable degrees of neural dysfunction. The outcome depends on successful restoration of muscle and neural function. The timing of surgery is often determined by the development of contractures and is delayed in the interest of observing some spontaneous recovery and infarct maturation. This period of observation may be detrimental to nerve function with gradual formation of scar tissue and worsening constrictive neuropathy. Early intervention appears to be more effective in preventing further nerve damage and restoring protective sensation. In this article, common features of compartment syndrome, frequently seen nerve lesions, and the effect of timing of surgical intervention on the outcome of VIC were reviewed in the light of the current basic and clinical science literature.

Effect of Static Cold Storage on Skeletal Muscle after Vascularized Composite Tissue Allotransplantation.

BACKGROUND: Prolonged cold ischemia associated with static cold storage (SCS) results in higher incidence of acute and chronic allograft rejection in solid organ transplantations. Deleterious effects of SCS on vascularized composite tissue allograft were studied with limited data on muscle structure and function. The aim of this study is to evaluate the long-term impact of SCS on muscle metabolism, structure, and force generation using a syngeneic rat hindlimb transplantation model. METHODS: Sixty-five male Lewis rats (250 ± 25 g) were distributed into five groups, including naive control, sciatic nerve denervation/repair, immediate transplantation, transplantation following static warm storage for 6 hours at room temperature, and transplantation following SCS for 6 hours at 4°C. Sciatic nerves were repaired in all transplantations. Muscle samples were taken for histology and metabolomics analysis following electromyography and muscle force measurements at 12 weeks after transplantation. RESULTS: All cold-preserved limbs remained viable at 12 weeks, whereas animals receiving limbs preserved in room temperature had no survivors. The SCS transplantation group showed a 73% injury score, significantly higher than groups receiving immediate transplants without cold preservation (50%, p < 0.05). A significant decline in muscle contractile force was also demonstrated in comparison to the immediate transplantation group (p < 0.05). In the SCS group, muscle energy reserves remained relatively well preserved in surviving fibers. CONCLUSION: SCS extends allograft survival but fails to preserve muscle structure and force.

Single Muscle Fibre Contractility Testing in Rats to Quantify Ischaemic Muscle Damage During Reperfusion Injury.

OBJECTIVES: In this study, the aim was to investigate the potential for single muscle fibre contractility (SMFC) testing to detect the extent of reperfusion injury following various reperfusion periods. The hypothesis was that force generated by muscle fibres will correlate inversely with the extent of reperfusion injury. METHODS: Twenty-four Lewis rats were distributed among five groups. Group 1 served as normal muscle control. In all other groups, femoral artery flow was occluded for four hours. Muscle biopsies were obtained at 0 hour, six hours, day two, and day seven after reperfusion in Groups 2, 3, 4, and 5, respectively. Samples then underwent ultrastructural analysis (H&E stain) and SMFC testing. RESULTS: The maximum isometric force (mN) generated on Days two and seven after reperfusion decreased from baseline by 21% (p < 0.05), and 53% (p < .001), respectively. The specific force (kPa) followed a similar pattern with a 13% decrease at Day two (p > 0.05) and 31% decrease at Day 7 (p < .001). These results correlated inversely with the extent of quantitative injury on histology. CONCLUSIONS: The study demonstrated an inverse relationship between single muscle fibre contractility testing and neutrophil infiltration during the reperfusion phase. Further clinical studies are needed to evaluate its potential in providing prognostic information for patient outcomes.

Temporary Bridge Plate Fixation of Pilon Fractures of the Proximal Interphalangeal Joint.

Pilon fractures of the proximal interphalangeal (PIP) joint are challenging injuries that can lead to arthritis, limited motion, and pain. Internal fixation is often difficult owing to comminution and inadequate bony support. External fixation requires a compliant patient and may result in pin-track infection, stiffness, and malunion. In this report, I describe a simple surgical technique of immediate bridge plating of the PIP joint with bone grafting followed by plate removal and joint release. This approach maintains the alignment, restores the articular congruity without the risk of pin-track infection, and allows immediate return to activities of daily living until fracture healing is completed.

Intermediate Cuneiform Resurfacing Arthroplasty for Combined Defects of the Sigmoid Notch and the Lunate Fossa of the Distal Radius.

Posttraumatic comminution and bone loss at the sigmoid notch and the lunate fossa of the distal radius result in substantial impairment. Established salvage methods do not meet the physical demands of young patients. Replacement of the articular cartilage is challenging owing to the loss of 2 articular surfaces in different planes and the lack of a defined autogenous source to replace them simultaneously. The use of an intermediate cuneiform osteoarticular autograft to reconstruct the sigmoid notch and the lunate fossa is a new surgical technique that restores joint congruity and stability while allowing early active motion. In this study, we report a cadaver study detailing the anatomy, the surgical technique, and the functional and radiographic outcomes of our index case. Unlike alternative salvage techniques, restoration of the articular surface of the sigmoid notch and the lunate fossa allows early active and stable forearm and radiocarpal joint motion.

Clinical Outcomes of Explosion Injuries to the Hand.

PURPOSE: The purpose of this study is to report clinical outcomes in a cohort of 12 patients with explosion injuries to the hand. METHODS: Twelve male patients with a mean age of 42.4 years (SD, 7.2) were examined at a mean of 54 months after sustaining explosion injuries to the hand. All patients underwent primary reconstruction and early soft tissue coverage within 72 hours after their injuries. Total active range of motion and moving 2-point discrimination in each digit were recorded along with hand injury severity score (HISS), disability of the arm, shoulder, and hand (DASH) score, and American Medical Association (AMA) impairment ratings. RESULTS: For digits saved, the average total active motion at final follow-up was 215 degrees (SD, 66.5). Twenty-two digits had 6-mm 2-point discrimination, and 17 digits had 8- to 10-mm 2-point discrimination. Eight of the 12 patients had secondary procedures. We found a strong correlation between initial HISS and DASH scores at final follow-up. There was also a strong correlation between AMA impairment rating and DASH scores. CONCLUSIONS: Early reconstruction provides protective sensation and preserves some function after explosion injuries. Preoperative HISS correlates with the long-term functional outcome as measured by DASH scores. For this group of patients, postinjury AMA impairment ratings also correlate with functional outcomes for the upper extremity.

Proximal Pole Scaphoid Nonunion Reconstruction With 1,2 Intercompartmental Supraretinacular Artery Vascularized Graft and Compression Screw Fixation.

PURPOSE: To review the incidence of union of patients with proximal pole scaphoid fracture nonunions treated using a 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) vascularized graft and a small compression screw. METHODS: This is a retrospective case series of 12 patients. Calculations of the size of the proximal pole fragment relative to the total scaphoid were performed using posteroanterior view scaphoid radiographs with the wrist in ulnar deviation and flat on the cassette. Analyses were repeated 3 times per subject, and the average ratio of proximal pole fragment relative to the entire scaphoid was calculated. We reviewed medical records, radiographs, and computed tomography (CT) scans of these 12 patients. The CT scans that were performed after an average of 12 weeks were ultimately used to confirm union of the scaphoid fractures. One patient was unable to have a CT so was excluded from the final calculation. RESULTS: All 11 (100%) scaphoid fractures that were assessed by CT were found to be healed at the 12-week assessment point. The mean proximal pole fragment size was 18% (range, 7%-27%) of the entire scaphoid. CONCLUSIONS: The 1,2 ICSRA vascularized graft and compression screw was an effective treatment for patients with proximal pole scaphoid fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Delayed-Onset Digital Ischemia After Local Anesthetic With Epinephrine Injection Requiring Phentolamine Reversal.

The use of low-dose epinephrine in hand surgery has made it possible to perform a wide range of surgical procedures in the office setting. Low-dose epinephrine use is safe, and its vasoconstrictive effects are reversible with phentolamine. In this report, we present late-onset finger ischemia beginning 3 hours after an ipsilateral carpal tunnel and A1 pulley release of the middle finger anesthetized with local anesthetic and low-dose epinephrine (1:100,000). Finger ischemia lasted 14 hours until rescued with phentolamine injection.

Effects of Volar Tilt, Wrist Extension, and Plate Position on Contact Between Flexor Pollicis Longus Tendon and Volar Plate.

PURPOSE: Volar plates positioned at, or distal to, the watershed line have been shown to have a higher incidence of attritional rupture of the flexor pollicis longus (FPL). In this study, we aimed to evaluate the effect of wrist extension and volar tilt on the contact between the plate and the FPL tendon in a cadaver model. We hypothesized that, following volar plate application, loss of native volar tilt increases the contact between the FPL and the plate at lower degrees of wrist extension. METHODS: A volar locking plate was applied on 6 fresh-frozen cadavers. To determine the contact between the plate and the FPL tendon, both structures were wrapped with copper wire and circuit conductivity was monitored throughout wrist motion. A lateral wrist radiograph was obtained at each circuit closure, indicating tendon-plate contact. Baseline measurements were obtained with plate positioned at Soong grades 0, 1, and 2. An extra-articular osteotomy was made and contact was recorded at various volar tilt angles (+5°, 0°, -5°, -10°, -15°, and -20°) in 3 different plate positions. A blinded observer measured the degree of wrist extension on all lateral radiographs. Data were analyzed using linear mixed-effects regression model. RESULTS: Plates placed distal to the watershed line had the most contact throughout wrist range of motion. Significantly, less wrist extension was required for contact in wrists with neutral or dorsal tilt and in distally placed volar plates. Volar tilt, wrist extension, and plate position were 3 independent risk factors determining contact between plate and tendon. CONCLUSIONS: Loss of volar tilt, increased wrist extension, and higher Soong grade plate position result in greater contact between wire-wrapped FPL tendon and plate. CLINICAL RELEVANCE: The FPL/plate contact chart generated in this study may be used to assess the risk of rupture in the clinical setting.

Pollicization of the Second Metacarpal Based on Dorsal Metacarpal Arteries.

Blood supply to the index finger is maintained through volar (palmar arch) and dorsal (intermetacarpal arteries) vascular networks. In traditional index finger pollicization, blood supply is maintained on the volar palmar arch. In case of index finger loss at the metacarpophalangeal joint, remaining length of the second metacarpal is often not used for pollicization because the arc of rotation is limited on digital arteries. In this report, we present a surgical technique for the transfer of the index metacarpal to the thumb on the dorsal vascular network. This method adds no further morbidity and can be used as an alternative method of thumb reconstruction in cases in which the thumb and index fingers are amputated.

The Effect of Ex Situ Perfusion in a Swine Limb Vascularized Composite Tissue Allograft on Survival up to 24 Hours.

PURPOSE: To test the potential for the ex situ limb perfusion system to prolong limb allograft survival up to 24 hours. METHODS: We used 20 swine for the study. In group 1 (control), 4 limbs were perfused with heparin solution and preserved at 4°C for 6 hours. In group 2, 4 limbs were perfused with autologous blood at 27°C to 32°C for 24 hours. In both groups, limbs were transplanted orthotopically to recipients and monitored for 12 hours. In addition to perfusion parameters, we recorded perfusate gases and electrolytes (pH, pCO2, pO2, O2 saturation, Na, K, Cl, Ca, HCO3, glucose, and lactate) and obtained functional electrostimulation hourly throughout the experiment. Histology samples were obtained for TUNEL staining and single-muscle fiber contractility testing. RESULTS: In both groups, hemodynamic variables of circulation remained stable throughout the experiment. Neuromuscular electrical stimulation remained intact until the end of reperfusion in group 2 vs no response in group 1. In group 2, a gradual increase in lactate levels during pump perfusion returned to normal after transplantation. Compared with the contralateral limb in group 2, single-muscle fiber contractility testing showed no significant difference at the end of the experiment. CONCLUSIONS: We demonstrated extended limb survival up to 24 hours using normothermic pulsatile perfusion and autologous blood. CLINICAL RELEVANCE: Successful prolongation of limb survival using ex situ perfusion methods provides with more time for revascularization of an extremity.

Arcus venosus dorsalis pedis: morphological considerations for use in superficial palmar arch reconstruction.

PURPOSE: To report the branching patterns, vessel diameters, and location of the valves in the arcus venosus dorsalis pedis (AVDP) as a graft option for use in superficial palmar arch reconstruction after mutilating hand injuries. METHODS: We dissected 10 cadaveric feet and measured vessel diameters, recorded number of branches, and located valves within the tibial, middle, and fibular thirds of the system. We used retrograde india ink injection to locate valves. RESULTS: The AVDP branching pattern was grossly different from side to side in the 4 cadavers with bilateral feet available. Mean flat diameters were 4.7, 2.9, and 2.1 mm in the tibial, middle, and fibular thirds of the arch, respectively. There was a mean of 1.7 valves (range, 1-4 valves) in the tibial third, 1.5 valves (range 0-4 valves) in the middle third, and 0 valves in the fibular third. There was an average of 3.4 branches off the middle third with a mean branch diameter of 2.1 mm. In 65% of these branches, valves were within 1 cm distal to the main arch. The direction of flow within the middle third was from fibular to tibial. CONCLUSIONS: Valves were commonly found within the middle and tibial thirds of the AVDP and within branches just distal to bifurcations. By contrast, the fibular third of the AVDP contained no valves. Valvular anatomy suggests that the direction of flow within the middle third was from fibular to tibial direction. CLINICAL RELEVANCE: The AVDP is morphologically similar to the palmar arch. When rendering valves within the AVDP incompetent, attention should be paid not just to the main arch itself, but also to branches off the AVDP. The fibular and middle thirds of the AVDP can safely be used for palmar arch reconstruction without blockage of flow owing to valves. The branches off the middle third must be used within a few millimeters of their takeoff to avoid valves.

Osseoscopy-Assisted Femoral Head Restoration and Vascularized Graft for Slipped Capital Femoral Epiphysis: A Case Report.

CASE: A 13-year-old obese adolescent boy with hypothyroidism developed left femoral head avascular necrosis with collapse after slipped capital femoral epiphysis. We restored the femoral head congruity with the aid of osseoscopy and vascularized free fibular graft (VFFG). Four years after surgery, the patient had painless hip range of motion and femoral head contour was maintained. CONCLUSION: This case highlights a novel use of an arthroscopic camera inside the femoral head to visualize and debride the area of collapse, fill the cavity with cancellous bone graft, and use a VFFG to restore articular support preventing further deterioration of the hip joint.

Comparison of 4 fluoroscopic views for dorsal cortex screw penetration after volar plating of the distal radius.

PURPOSE: To determine whether use of the dorsal tangential view improves the diagnostic accuracy of intraoperative fluoroscopy compared with conventional views in detecting dorsal screw penetrations during volar distal radius plating. METHODS: Dorsal cortices of 10 cadaveric distal radii were penetrated in each of the second, third, and fourth dorsal extensor compartments at 0, 1, 2, and 3 mm penetration. We obtained 4 standardized fluoroscopic images of the wrist: lateral, supination, pronation, and dorsal tangential views. Using high-definition digital images, 2 observers blinded to the experimental paradigm determined whether screws were penetrating the dorsal cortex. RESULTS: For screws that penetrated the floor of the second dorsal compartment, the 45° supination view was 92% sensitive for detecting screw penetration of 2 mm, and 98% for 3 mm. For screws that penetrated the third dorsal compartment, the lateral view was 68% and 80% sensitive in detecting screw penetrations of 1 and 2 mm, respectively. However, the dorsal tangential view showed 95% sensitivity for 1 mm and 98% for 2 mm penetrations. On the floor of the fourth dorsal compartment, pronation and dorsal tangential views were both 88% sensitive for 1 mm screw penetration and 90% and 93% for 2 mm, respectively. CONCLUSIONS: The standard lateral view of the wrist failed to detect all screw penetrations. The dorsal tangential view increased the accuracy of detecting screw penetrations on the floor of the third dorsal compartment, whereas we needed oblique views to detect screw penetrations on the floors of second and fourth dorsal compartments. CLINICAL RELEVANCE: Routine clinical use of the dorsal tangential view has the potential to increase accuracy in detecting dorsal screw penetration during volar plating of the distal radius.

Persistent median artery in a pediatric trauma patient: case report.

A persistent median artery is a well-described variation in the vascular anatomy of the upper extremity and hand, with an incidence of 1% to 30% in the general population. We present a case of a persistent median artery in a pediatric trauma patient. The median artery helped maintain blood flow to the nearly amputated hand after complete transection of radial and ulnar arteries.

The role of bone allografts in the treatment of angular malunions of the distal radius.

PURPOSE: Two cohorts of patients who had corrective osteotomies and volar platings for malunited fractures of the distal radius were compared retrospectively to determine whether the time to union and the outcome were affected by bone allograft. METHODS: Patients in the first group (n = 14) did not receive any bone graft; patients in the second group (n = 14) had allograft bone chips following volar plating. Indications for surgery, surgical technique, and postoperative rehabilitation were the same in both groups. Volar cortical contact was maintained using a volar locking plate in all patients. Radiographic parameters of deformity correction, time to union, wrist and forearm range of motion, grip strength, patient-rated wrist evaluation and Disabilities of the Arm, Shoulder, and Hand questionnaire were used to evaluate the outcome before and after the surgery. Average follow-up time was 36 weeks. Patients who had diabetes, who smoked, who had a body mass index of more than 35, and who required lengthening for deformity correction were excluded from the study. RESULTS: Osteotomies in both groups healed without loss of surgical correction. Final outcome and time to union revealed no significant differences, clinically or statistically, between the 2 groups. The Disabilities of the Arm, Shoulder, and Hand score was improved in both groups. CONCLUSIONS: When volar cortical contact was maintained using a volar locked plate, bone allograft at the osteotomy site did not improve the final outcome. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Comparison of autologous blood, corticosteroid, and saline injection in the treatment of lateral epicondylitis: a prospective, randomized, controlled multicenter study.

PURPOSE: We compared saline, corticosteroid, and autologous blood injections for lateral epicondylitis in a prospective, blinded, randomized, controlled trial. The null hypothesis was that patient-rated outcomes after autologous blood injection would not be superior to corticosteroid and saline injections. METHODS: Patients with clinically diagnosed lateral epicondylitis of less than 6 months' duration were randomized into 1 of 3 groups to receive a 3-mL injection of saline and lidocaine, corticosteroid and lidocaine, or autologous blood and lidocaine. Of 34 subjects who enrolled, 28 completed follow-up. A total of 10 were randomized to the saline group, 9 to the autologous blood group, and 9 to the steroid group. Every participant had 3 mL blood drawn, and the injection syringe was foil-covered to prevent the subject from knowing the contents. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Patients completed a pain visual analog scale, DASH, and the Patient-Rated Forearm Evaluation before injection and at 2 weeks, 2 months, and 6 months after injection. We performed statistical analysis using repeated measures of analyses of variance. RESULTS: There were no significant differences in DASH scores among the 3 groups at 2- and 6-month follow-up points, with the mean scores for saline at 20 and 10, respectively, compared with 28 and 20 for autologous blood and 28 and 13 for steroid injections. Secondary measures showed similar findings, with outcomes scores showing improvement in all 3 groups. CONCLUSIONS: In this prospective, randomized, controlled trial, autologous blood, corticosteroid, and saline injection provide no advantage over placebo saline injections in the treatment of lateral epicondylitis. Patients within each injection group demonstrated improved outcome scores over a 6-month period.

Replantation versus revision of amputated fingers in patients air-transported to a level 1 trauma center.

PURPOSE: To assess the rate of replantation versus revision of amputated fingers in patients air-transported to a tertiary care hand trauma center. METHODS: We included 40 consecutive subjects (70 digits) who were transported via air after digit(s) amputation distal to the metacarpophalangeal joint. The primary outcome measure was type of surgery (attempted replantation vs revision of the amputation). Data were collected prospectively. RESULTS: We identified 3 groups of patients. In group 1 (15 patients, 23 digits), replantation of one or more digits was attempted. In group 2 (6 patients, 8 digits), replantation was not elected. In group 3 (19 patients, 39 digits), no digits were suitable for replantation. The mean age was 36.2 years (range, 5-69 years) and mean time of transport was 5.15 hours (range, 1-24 hours). Mechanisms of finger injury were crush (n = 34), followed by clean cut (n = 15), avulsion/crush (n = 15), and gunshot (n = 6). No significant differences were found between groups for age or time elapsed from injury to hospital arrival. Most patients (n = 25; 65%) transported via air did not undergo replantation surgery. Injury characteristics (n = 18 patients, 72%) were the main reason not to replant. The most common reason for the refusal of replantation was inability to return to work immediately. The most common reasons for surgeon's decision to not to replant were single digit amputations proximal to flexor digitorum superficialis attachment (7 patients), and crush/avulsion type injuries (7 patients), followed by health status and age (5 patients). CONCLUSIONS: This study shows that a considerable portion of patients transported via air do not undergo replantation surgery. Further studies are needed to establish whether this is an overused service.

Psychiatric risk factors in pediatric hand fractures.

BACKGROUND: Various psychopathologies are becoming more commonly recognized as a cause of violence in the pediatric population. In this study, we aimed to investigate (1) the link between the pediatric hand fractures and psychopathology and (2) the prevalence of repeated hand injuries in the same population. METHOD: We retrospectively reviewed 208 patients treated at a level 1 trauma center and recorded age, sex, past medical and psychiatric history as well as type, etiology, and treatment of hand fractures for analysis. A mental health professional has confirmed psychiatric diagnosis. Fisher exact tests and independent samples t tests were performed for analysis. RESULTS: Metacarpal fractures were the most common hand fracture seen in patients with a psychiatric history (P=0.05). More than half (52.9%, n=18) of the patients with a positive psychiatric history had a subsequent injury whereas only 14.6% (n=29) of patients negative for psychiatric issues had a subsequent injury (P<0.001). The most common psychiatric disorders were attention-deficit hyperactivity disorder, depression, and substance abuse. Psychiatric diagnosis was significantly more frequent in those sustaining an injury due to punching compared with other mechanisms (38% vs. 8%, P<0.001). Twenty one (38%) of the 55 children whose injuries were due to punching had a documented psychiatric diagnosis. Of the 55 injuries due to a punching mechanism, 39 (68.4%) sustained metacarpal fractures and 18 (31.6%) sustained another type of hand fracture (P<0.001). CONCLUSIONS: The high rate of repeated hand injuries in children with punching may require in depth psychiatric assessment due to its high association with mental illness. LEVEL OF EVIDENCE: IV.