Management of Brachial Plexus Birth Palsies: The Stanford Experience.

The start of Stanford's brachial plexus birth palsy (BPBP) experience dates back to 1983, when Dr. Vincent Rod Hentz visited Dr. Alain Gilbert on sabbatical. Since then, our principles of care for patients with BPBP have evolved based on our group's longitudinal experience caring for children with the entire spectrum of sequelae that arise in children with BPBP. We base our clinical decision making on frequent serial examinations and use intraoperative evoked potentials to guide surgical decisions. Here, we discuss our current principles on surgical indications, timing of surgery, and preferred techniques for secondary surgery in patients with BPBP.

Tendon transfers after peripheral nerve injuries: my preferred techniques.

While there is now keen interest in restoring function lost through irreparable nerve injury by performing nerve-to-nerve transfer, for some time to come, tendon transfers will remain the primary reconstructive procedure for paralytic injuries of the upper limb. A career spanning more than 50 years has permitted the author to try many tendon transfers promoted by past and present colleagues for the three common nerve injuries (median, radial and ulnar) affecting hand function and, eventually, to settle upon those which have provided the most predictable and consistent outcomes. This article describes the author's preferred tendon transfers for high radial and low median and ulnar palsies, providing the rationale behind these choices, operative details supplemented with illustrations, technical tips and advice regarding postoperative rehabilitation.

Long-Term Outcomes of Brachial Plexus Reconstruction with Sural Nerve Autograft for Brachial Plexus Birth Injury.

BACKGROUND: Infants with brachial plexus birth injury who do not recover motor function spontaneously in a timely manner are candidates for brachial plexus reconstruction with nerve autograft. Outcomes of this intervention are incompletely understood. The authors present the long-term outcomes of brachial plexus reconstruction with sural nerve autograft in infants with brachial plexus birth injury. METHODS: The authors retrospectively reviewed all infants with brachial plexus birth injury who underwent brachial plexus reconstruction with sural nerve autograft between 1992 and 2014 with a minimum 2-year follow-up. The authors used Active Movement Scale scores to determine the presence and timing of shoulder, elbow, and wrist recovery. They assessed recovery of hand function in infants with global brachial plexus birth injury with the Raimondi scale. The number and type of secondary reconstructive procedures were identified. RESULTS: Forty-three infants who underwent brachial plexus reconstruction at age 7 ± 2 months old were followed for 7 ± 5 years. Most infants recovered antigravity elbow flexion (91 percent) and shoulder abduction (67 percent), but fewer recovered antigravity shoulder external rotation (19 percent) and wrist extension (37 percent). Mean postoperative times until observed antigravity motor strength (Active Movement Scale score >5) at the shoulder, elbow, and wrist were all greater than 12 months; evidence of initial motor recovery (Active Movement Scale score >2) was observed earlier. The mean Raimondi score in infants with global brachial plexus birth injury was 2.2 (range, 0 to 5) at final follow-up. Thirty-three children underwent 2 ± 1.2 secondary reconstructive procedures. CONCLUSIONS: Brachial plexus reconstruction with sural nerve autograft reliably results in recovery of shoulder abduction and elbow flexion, but recovery of shoulder external rotation and wrist extension is less predictable, and recovery often takes more than 1 year. Secondary procedures are often performed to optimize function. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A Double-Blind Placebo Randomized Controlled Trial of Minocycline to Reduce Pain After Carpal Tunnel and Trigger Finger Release.

PURPOSE: Minocycline is a microglial cell inhibitor and decreases pain behaviors in animal models. Minocycline might represent an intervention for reducing postoperative pain. This trial tested whether perioperative administration of minocycline reduced time to pain resolution (TPR) after standardized hand surgeries with known prolonged pain profiles: carpal tunnel release (CTR) and trigger finger release (TFR). METHODS: This double-blinded randomized controlled trial included patients undergoing CTR or TFR under local anesthesia. Before surgery, participants recorded psychological and pain measures. Participants received oral minocycline, 200 mg, or placebo 2 hours prior to procedure, and then 100 mg of minocycline or placebo 2 times a day for 5 days. After surgery, participants were called daily assessing their pain. The primary end point of TPR was when participants had 3 consecutive days of 0 postsurgical pain. Futility analysis and Kaplan-Meier analyses were performed. RESULTS: A total of 131 participants were randomized and 56 placebo and 58 controls were analyzed. Median TPR for CTR was 3 weeks, with 15% having pain more than 6 weeks. Median TPR for TFR was 2 weeks with 18% having pain more than 6 weeks. The overall median TPR for the placebo group was 2 weeks (10% pain > 6 weeks) versus 2.5 weeks (17% pain > 6 weeks) for the minocycline group. Futility analysis found that the likelihood of a true underlying clinically meaningful reduction in TPR owing to minocycline was only 3.5%. Survival analysis found minocycline did not reduce TPR. However, subgroup analysis of those with elevated posttraumatic distress scores found the minocycline group had longer TPR. CONCLUSIONS: Oral administration of minocycline did not reduce TPR after minor hand surgery. There was evidence that minocycline might increase length of pain in those with increased posttraumatic stress disorder symptoms. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Multicenter Survey of the Effects of Rehabilitation Practices on Pinch Force Strength After Tendon Transfer to Restore Pinch in Tetraplegia.

OBJECTIVE: To identify key components of conventional therapy after brachioradialis (BR) to flexor pollicis longus (FPL) transfer, a common procedure to restore pinch strength, and evaluate whether any of the key components of therapy were associated with pinch strength outcomes. DESIGN: Rehabilitation protocols were surveyed in 7 spinal cord injury (SCI) centers after BR to FPL tendon transfer. Key components of therapy, including duration of immobilization, participation, and date of initiating therapy activities (mobilization, strengthening, muscle reeducation, functional activities, and home exercise), were recorded by the patient's therapist. Pinch outcomes were recorded with identical equipment at 1-year follow-up. SETTING: Seven SCI rehabilitation centers where the BR to FPL surgery is performed on a routine basis. PARTICIPANTS: Thirty-eight arms from individuals with C5-7 level SCI injury who underwent BR to FPL transfer surgery (N=34). INTERVENTION: Conventional therapy according to established protocol in each center. MAIN OUTCOME MEASURES: The frequency of specific activities and their time of initiation (relative to surgery) were expressed as means and 95% confidence intervals. Outcome measures included pinch strength and the Canadian Occupational Performance Measure (COPM). Spearman rank-order correlations determined significant relations between pinch strength and components of therapy. RESULTS: There was similarity in the key components of therapy and in the progression of activities. Early cast removal was associated with pinch force (Spearman ρ=-.40, P=.0269). Pinch force was associated with improved COPM performance (Spearman ρ=.48, P=.0048) and satisfaction (Spearman ρ=.45, P=.0083) scores. CONCLUSIONS: Initiating therapy early after surgery is beneficial after BR to FPL surgery. Postoperative therapy protocols have the potential to significantly influence the outcome of tendon transfers after tetraplegia.

Technical tips for collagenase injection treatment for Dupuytren contracture.

We describe technical tips for injecting collagenase into Dupuytren cords based on experience acquired during the prerelease Food and Drug Administration clinical trials and with subsequent clinical practice. These tips include techniques for extracting the reconstituted enzyme efficiently from the vial, injecting the cord(s) with increased safety to the tendons, and anesthetizing the hand before manipulation. The tips are intended to supplement but by no means replace the manufacturer's prescribing information and training video.

Collagenase injections for treatment of Dupuytren disease.

Palmodigital fasciectomy remains the gold standard. The initial outcome is, in my experience, far more predictable than either NA or enzyme fasciotomy (EF). It is also a more durable treatment. NA and EF can be conceptualized as similar procedures--one uses a needle and the other an enzyme to weaken a cord sufficient to be able to rupture it and thus straighten a contracted joint. Both are less invasive and the hand is quick to recover. Both procedures are equally initially effective. CHH seems to offer greater durability. Today's patients are often better educated and seek a specific type of treatment, in particular, effective nonoperative treatment. Pharmaceutical companies now market directly and effectively to patients, and this strategy and Internet use have already resulted in an increase in the number of patients searching for practitioners willing to administer and capable of administering collagenase treatment.

Surgical treatment of trapeziometacarpal joint arthritis: a historical perspective.

BACKGROUND: The trapeziometacarpal (TMC) joint's unique anatomy and biomechanics render it susceptible to degeneration. For 60 years, treatment of the painful joint has been surgical when nonoperative modalities have failed. Dozens of different operations have been proposed, including total or subtotal resection of the trapezium or resection and implant arthroplasty. Proponents initially report high levels of patient satisfaction, but longer-term reports sometimes fail to support initial good results. To date, no one procedure has been shown to be superior to another. QUESTIONS/PURPOSES: This review sought to identify factors responsible for the development of many different procedures to treat the same pathology and factors influencing whether procedures remain in the armamentarium or are abandoned. METHODS: I performed a nonsystematic historical review of English-language surgical journals using the key words "carpometacarpal arthritis", or "trapeziometacarpal arthritis", and "surgery" in combination with "history" using the PubMed database. In addition, bibliographies of pertinent articles were reviewed. RESULTS: The factors that led to many surgical innovations appear to be primarily theoretical concerns about the shortcomings of previously described procedures, especially about proximal migration of the thumb metacarpal after trapezial resection. Longevity of a particular procedure seems to be related to simplicity of design, especially for prosthetic arthroplasty. The evolution of surgery for TMC joint arthritis both parallels and diverges from that in other joints. For example, for most degenerated joints (even many in the hand), treatment evolved from resection arthroplasty to implant arthroplasty. In contrast, for the TMC joint, the 60-year-old procedure of trapezial resection continues to be performed by a majority of surgeons; many modifications of that procedure have been offered, but none have shown better pain reduction or increased function over the original procedure. In parallel, many differently designed prosthetic total or hemijoint arthroplasties have been proposed and performed, again with as yet unconvincing evidence that this technology improves results over those obtained by simple resection arthroplasty. CONCLUSIONS: Many procedures have been described to treat TMC joint arthritis, from simple trapezial resection to complex soft tissue arthroplasty to prosthetic arthroplasty. In the absence of evidence for the superiority of any one procedure, surgeons should consider using established procedures rather than adopting novel ones, though novel procedures can and should be tested in properly designed clinical trials. Tissue-engineered solutions are an important area of current research but have not yet reached the clinical trial stage.

Essential hand surgery procedures for mastery by graduating plastic surgery residents: a survey of program directors.

BACKGROUND: This study was designed to establish the essential hand surgery procedures that should be mastered by graduating plastic surgery residents. This framework can then be used as a guideline for developing Objective Structured Assessment of Technical Skill to teach technical skills in hand surgery. METHODS: Ten expert hand surgeons were surveyed regarding the essential hand surgery procedures that should be mastered by graduating plastic surgery residents. The top 10 procedures from this survey were then used to survey all 89 Accreditation Council for Graduate Medical Education-approved plastic surgery program directors. RESULTS: There was a 69 percent response rate to the program director survey (n = 61). The top nine hand surgery procedures included open carpal tunnel release, open A1 pulley release, digital nerve repair with microscope, closed reduction and percutaneous pinning of metacarpal fracture, excision of dorsal or volar ganglion, zone II flexor tendon repair with multistrand technique, incision and drainage of the flexor tendon sheath for flexor tenosynovitis, flexor tendon sheath steroid injection, and open cubital tunnel release. CONCLUSIONS: Surgical educators need to develop objective methods to teach and document technical skill. The Objective Structured Assessment of Technical Skill is a valid method for accomplishing this task. There has been no consensus regarding which hand surgery procedures should be mastered by graduating plastic surgery residents. The authors have identified nine procedures that are overwhelmingly supported by plastic surgery program directors. These nine procedures can be used as a guideline for developing Objective Structured Assessment of Technical Skill to teach and document technical skills in hand surgery.

Capacity of small groups of muscles to accomplish precision grasping tasks.

An understanding of the capacity or ability of various muscle groups to generate endpoint forces that enable grasping tasks could provide a stronger biomechanical basis for the design of reconstructive surgery or rehabilitation for the treatment of the paralyzed or paretic hand. We quantified two-dimensional endpoint force distributions for every combination of the muscles of the index finger, in cadaveric specimens, to understand the capability of muscle groups to produce endpoint forces that accomplish three common types of grasps-tripod, tip and lateral pinch-characterized by a representative level of Coulomb friction. We found that muscle groups of 4 or fewer muscles were capable of generating endpoint forces that enabled performance of each of the grasping tasks examined. We also found that flexor muscles were crucial to accomplish tripod pinch; intrinsic muscles, tip pinch; and the dorsal interosseus muscle, lateral pinch. The results of this study provide a basis for decision making in the design of reconstructive surgeries and rehabilitation approaches that attempt to restore the ability to perform grasping tasks with small groups of muscles.

The fragmented proximal pole scaphoid nonunion treated with rib autograft: case series and review of the literature.

Nonunions of the proximal pole of the scaphoid are a challenge to treat given the limited vascular supply. This challenge is potentiated when the proximal pole is unsalvageable. When the proximal pole of the scaphoid is fragmented or otherwise unsalvageable, traditional reconstructive procedures such as vascularized or nonvascularized bone grafting are not possible. Salvage procedures such as proximal row carpectomy or scaphoid excision and partial wrist fusion would not be ideal in the case of an unsalvageable proximal pole scaphoid nonunion in the absence of radiocarpal arthrosis. In this relatively uncommon circumstance, we favor the use of rib osteochondral autograft reconstruction of the proximal pole of the scaphoid. We report 3 cases with greater than 2-years of follow-up evaluation and also review the literature.

Essential hand surgery procedures for mastery by graduating orthopedic surgery residents: a survey of program directors.

PURPOSE: To establish the essential hand surgery procedures that should be mastered by graduating orthopedic surgery residents. This framework can then be used as a guideline for developing an Objective Structured Assessment of Technical Skill to teach and document technical skill in hand surgery. METHODS: A select group of 10 expert hand surgeons was surveyed regarding the essential hand surgery procedures that should be mastered by graduating orthopedic surgery residents. The top 10 procedures from this survey were then used to survey all 155 American Council of Graduate Medical Education-approved orthopedic surgery program directors regarding the essential procedures that should be mastered by graduating orthopedic surgery residents. RESULTS: We had a 39% response rate to the program director survey. The top 8 hand surgery procedures as determined by the orthopedic surgery program directors included open carpal tunnel release, open A1 pulley release, open reduction internal fixation of distal radius fracture, flexor tendon sheath steroid injection, excision of dorsal or volar ganglion, closed reduction and percutaneous pinning of metacarpal fracture, open cubital tunnel release, and incision and drainage of flexor tendon sheath for flexor tenosynovitis. CONCLUSIONS: Surgical educators need to develop objective methods to teach and document technical skill. The Objective Structured Assessment of Technical Skill is a valid method to accomplish this task. However, there has been no consensus regarding which hand surgery procedures should be mastered by graduating orthopedic surgery residents. We have identified 8 procedures that were overwhelmingly supported by orthopedic surgery program directors. These 8 procedures can be used as a guideline for developing an Objective Structured Assessment of Technical Skill to teach and document technical skill in hand surgery. CLINICAL RELEVANCE: This study addresses the future of orthopedic surgery education as it pertains to hand surgery.

Advances in the management of Dupuytren disease: collagenase.

Dupuytren disease (DD) is a benign, generally painless connective tissue disorder affecting the palmar fascia that leads to progressive hand contractures. Mediated by myofibroblasts, the disease most commonly begins as a nodule in the palm or finger, and can progress where pathologic cords form leading to progressive flexion deformity of the involved fingers. The palmar skin overlying the cords may become excessively calloused and contracted and involved joints may develop periarticular fibrosis. Although there is no cure, the sequellae of this affliction can be corrected. This article focuses on the role of collagen in DD and the development of a collagen-specific enzymatic treatment for DD contractures.

The scaphotrapezial joint after partial trapeziectomy for trapeziometacarpal joint arthritis: long-term follow-up.

PURPOSE: Partial trapeziectomy addresses trapeziometacarpal (TM) joint arthritis without the risk of destabilizing the scaphotrapezial (ST) joint. However, partial trapeziectomy has been criticized because of concern that ST joint arthritis will develop, requiring additional surgery. We hypothesized that partial trapeziectomy is a durable treatment for TM joint arthritis, even in patients with radiographically abnormal but asymptomatic ST joints. METHODS: We evaluated 13 patients (16 thumbs) who underwent a partial trapeziectomy between 1995 and 2005. Assessment included grip strength, pinch strength, ST joint direct palpation, and ST joint stress testing. We classified standardized radiographs of the ST joint using a simple scoring system. Subjective data included the Disabilities of the Arm, Shoulder, and Hand questionnaire, a pain scale, and a satisfaction survey. RESULTS: The length of follow-up averaged 9 years (range, 5-13 y). No patient had pain at the ST joint with direct palpation or stress testing. Radiographs demonstrated a mean ST joint arthritis score of 1, indicating mild arthritic changes. Mean grip strength was 28 kg on the operated hand and 28 kg on the nonoperated hand. Mean pinch strength was 5 kg on the operated hand and 5 kg on the nonoperated hand. Scores on the pain scale averaged 6 (range, 0-100; 100 = worst). Average Disabilities of the Arm, Shoulder, and Hand score was 11 (range, 0-100; 100 = worst). Of 13 patients, 12 were very satisfied or extremely satisfied, and 1 was not satisfied. CONCLUSIONS: Partial trapeziectomy for TM joint arthritis provides long-lasting relief of symptoms in patients with radiographically abnormal but clinically insignificant ST joint degeneration. Satisfaction is equivalent to other published series. The radiographic appearance of the ST joint did not correlate with symptoms at this joint. Unless the patient has symptomatic ST joint arthritis, the ST joint may be retained. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Flexor tendon rupture after collagenase injection for Dupuytren contracture: case report.

Rupture of both flexor tendons after collagenase injection for Dupuytren contracture is a rare and problematic complication. We performed a 2-stage tendon reconstruction to treat this problem, with an acceptable result.

The treatment of Dupuytren disease.

The treatment of progressive Dupuytren contractures has historically been and continues to be largely surgical. Although a number of surgical interventions do exist, limited palmar fasciectomy continues to be the most common and widely accepted treatment option. Until recently, nonsurgical options were limited and clinically ineffective. However, the commercial availability and recent approval of collagenase clostridium histolyticum now provides practitioners with a nonsurgical approach to this disease. This article presents a comprehensive review of the surgical and nonsurgical treatments of Dupuytren disease, with a focus on collagenase.

Biceps-to-triceps transfer technique.

Lack of voluntary active elbow extension inhibits many important functions in persons with tetraplegia. Biceps-to-triceps transfer can restore this function in selected patients. This article outlines the basic problem, indications and contraindications, surgical technique, and postoperative rehabilitation protocol for biceps-to-triceps transfer using the medial routing technique with suture anchoring of the biceps muscle tendon unit into the triceps aponeurosis and olecranon.

Comparison of wrist and elbow stabilization following pinch reconstruction in tetraplegia.

PURPOSE: Individuals with spinal cord injuries resulting in tetraplegia may receive tendon transfer surgery to restore grasp and pinch function. These procedures often involve rerouting the brachioradialis (Br) and the extensor carpi radialis longus tendons volar to the flexion-extension axis of the wrist, leaving the extensor carpi radialis brevis (ECRB) muscle to provide wrist extension strength. The purpose of this study was to determine whether externally stabilizing the wrist after transfer procedures would improve the ability to activate the transferred Br and resulting pinch force, similar to the effect observed when the elbow is externally stabilized. METHODS: We used a one-way repeated-measures study design to determine the effect of 3 support conditions on muscle activation and lateral pinch force magnitude in 8 individuals with tetraplegia and previous tendon transfer surgeries. Muscle activation was recorded from Br and ECRB with intramuscular electrodes and from biceps and triceps muscles with surface electrodes. We quantified pinch strength with a 6-axis force sensor and custom grip. We recorded measurements in 3 support conditions: with the arm self-stabilized, with elbow stabilization, and with elbow and wrist stabilization. Pairwise differences were tested using Wilcoxon signed-rank tests. RESULTS: Maximum effort pinch force magnitude and Br activation were significantly increased in both supported conditions compared with the self-supported trials. The addition of wrist stabilization had no significant effect compared with elbow stabilization alone. CONCLUSIONS: A strong ECRB has adequate strength to extend the wrist, even after multiple transfers that contribute an additional flexion moment from strong activation of donor muscles. Anatomical and functional differences between the wrist and elbow musculature are important determinants for self-stabilizing joints proximal to the tendon transfer. The ability to increase Br activation and resulting pinch force may be determined, in part, by the individual's ability to develop new coordination strategies.