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.

Dynamic analysis of the ulnar nerve and cubital tunnel morphology using ultrasonography: a cadaveric study.

BACKGROUND: The causes of ulnar neuropathy at the elbow are unclear. The authors hypothesized that the humeral trochlea protrudes into the cubital tunnel during elbow flexion and causes a dynamic morphologic change of the ulnar nerve in the cubital tunnel. METHODS: An ultrasonic probe was fixed to the ulnar shafts of 10 fresh cadavers with an external fixator, and dynamic morphology of the cubital tunnel and ulnar nerve was observed. The distance from the Osborne band to the trochlea (OTD), distance from ulnar nerve center to the trochlea (UTD), and the short- and long-axis diameters of the nerve at 30°, 60°, 90°, and 120° of elbow flexion were recorded. We compared the OTD, UTD, and the flattening of the ulnar nerve at the different angles of flexion using single-factor analysis of variance. Correlation between the ulnar nerve flattering, OTD, and UTD was examined using Spearman correlation coefficient. A P value less than .05 was used to denote statistical significance. RESULTS: Flattening of the ulnar nerve progressed with increasing elbow flexion and was significantly different between 0° and 60°, 90°, and 120° (P = .03 at 60°, P < .01 at 90° and 120°). OTD decreased with elbow flexion, and there was a significant difference at all elbow flexion angles (all P < .01). UTD decreased significantly from 0° flexion to 90° flexion (P = .03). Flattening of the nerve was significantly correlated with the OTD (r = 0.66, P < .01). CONCLUSIONS: A positive correlation was found between the protrusion of the humeral trochlea into the cubital tunnel during elbow flexion and ulnar nerve flattening using cadaveric elbow and ultrasonography.

Treatment of painful median nerve neuroma using pedicled vascularized lateral antebrachial cutaneous nerve with adipofascial flap: a cadaveric study and exploration of clinical application.

The most common procedure for the treatment of painful median nerve neuroma is coverage with vascularized soft tissue following external neurolysis. However, the ideal treatment should include reconnecting the proximal and distal stumps of the damaged nerve to allow the growth of regenerating axons to their proper targets for a functional recovery. We developed a useful technique employing radial artery perforator adipofascial flap including the lateral antebrachial cutaneous nerve (LABCN) to repair the median nerve by vascularized nerve grafting and to achieve coverage of the nerve with vascularized soft tissue. In an anatomical study of 10 fresh-frozen cadaver upper extremities, LABCN was constantly bifurcated into two branches at the proximal forearm (mean: 8.2 cm distal to the elbow) and two branches that run in a parallel manner toward the wrist. The mean length of the LABCN branches between the bifurcating point and the wrist was 18.2 cm, which enabled inclusion of adequate length of the LABCN branches into the radial artery perforator adipofascial flap. The diameters of the LABCN branches (mean: 1.7 mm) were considered suitable to bridge the funiculus of the median nerve defect after microsurgical internal neurolysis. In all cadaver upper extremities, the 3-cm median nerve defect at the wrist level could be repaired using the LABCN branches and covered with the radial artery perforator adipofascial flap. On the basis of this anatomical study, the median nerve neuroma was successfully treated with radial artery perforator adipofascial flap including vascularized LABCN branches.

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.

Vascularized pedicled bone graft from the distal radius supplied by the anterior interosseous artery for treatment of ulnar shaft nonunion: An anatomical study of cadavers and a case report.

BACKGROUND: A vascularized distal radius graft can be a reliable solution for the treatment of refractory ulnar nonunion. The aim of this study is to establish the anatomical basis of a vascularized bone graft pedicled by the anterior interosseous artery and report its clinical application, using cadaveric studies and a case report. METHODS: Fourteen fresh frozen cadaveric upper limbs were used. The branches of the anterior interosseous artery (the 2, 3 intercompartmental supraretinacular artery and the fourth extensor compartment artery) were measured at the bifurcation site. The anatomical relationship between the anterior interosseous artery and motor branches of the posterior interosseous nerve was investigated. An anterior interosseous artery pedicled bone flap was used in a 48-year-old woman with refractory ulnar nonunion. RESULTS: There were two variations depending on whether the 2,3 intercompartmental supraretinacular artery branched off distally or proximally from the terminal motor branch of the posterior interosseous nerve. The proximal border of the graft was located at an average of 10.5 cm (range, 6.5-12.5 cm) from the distal end of the ulnar head in the distal type (57%) and 17.5 cm (range, 9.5-21.5 cm) in the proximal type (43%). In the clinical application, successfully consolidation was achieved 4 months post-surgery. The patient had not developed any postoperative complications until the 2-year postoperative follow-up. CONCLUSIONS: The anterior interosseous artery-pedicled, vascularized distal radius bone graft would be a reliable alternative solution for the treatment of an ulnar nonunion located within the distal one-third of the ulna.

Reverse vascularized bone graft of the lateral distal humerus for non-union of the radial neck fracture: anatomical study and case report.

A few treatment options for radial neck non-union have been reported, including radial head excision, radial head replacement, and internal fixation with a bone graft. We describe a new treatment for radial neck non-union using a reverse vascularized bone graft of the lateral distal humerus. In the anatomical study, the posterior radial collateral artery (PRCA) was dissected in eight fresh-frozen cadaver arms. The number of branches from the PRCA to the humerus was determined, and the distances from these branches to the lateral epicondyle of the humerus were measured. We then used this information to create a reverse vascularizedhumeral bone graft, which was used to treat non-union of a radial neck fracture in a 73-year-old female. There were two to four PRCA branches (mean: 3.3) entering the bone. The distance from the branches to the lateral epicondyle of the humerus ranged from 2.5 to 10.8 cm. The mean distances from the most proximal and distal PRCA branches to the lateral epicondyle of the humerus were 7.6 cm and 3.4 cm, respectively. The case of non-union of a radial neck fracture was successfully treated with a reverse vascularized humeral bone graft. There were no major complications, and radiographs showed bony union at 8 weeks postoperatively. This procedure may become a new option for the treatment of non-union of fractures of the radial head and neck, as it enables preservation of the radial head, which is an important structure in the elbow and proximal radioulnar joints.

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.

Anatomical Study of the Popliteal Artery Perforator-Based Propeller Flap and Its Clinical Application.

There is lack of anatomical information regarding the cutaneous perforator of the popliteal artery and its connections with the descending branch of the inferior gluteal and profunda femoris arteries. The authors aimed to evaluate the anatomical basis of the popliteal artery perforator-based propeller flap from the posterior thigh region and to demonstrate their experience using this flap. Ten fresh cadaveric lower extremities were dissected following injection of a silicone compound into the femoral artery. The authors investigated the number, location, length, and diameter of cutaneous perforators of the popliteal artery. Based on the results, the authors treated three cases with a large soft-tissue defect around the knee using a popliteal artery perforator-based propeller flap. The authors found a mean of 1.9 cutaneous perforators arising from the popliteal artery, with a mean pedicle length of 6 cm and a mean arterial internal diameter of 0.9 mm, which were located at an average of 4 cm proximal to the bicondylar line. The most distal perforator consistently arose along the small saphenous vein and connected proximally with the concomitant artery of the posterior femoral cutaneous nerve, forming a connection with perforating arteries of the profunda femoris artery. A mean of 4.5 cutaneous perforators branched from the arterial connection sites. All clinical cases healed without any complications. The popliteal artery perforator-based propeller flap is reliable for reconstruction of soft-tissue defects around the knee. The flap should include the deep fascia and concomitant artery along with the posterior femoral cutaneous nerve for maintaining the blood supply.

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.

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.

Biceps femoris musculocutaneous flap for reconstruction of refractory ulceration at the popliteal fossa.

BACKGROUND: There is a lack of information about the possibility of transfer of the long head of the biceps femoris (LHBF) musculocutaneous flap to the knee area. We discuss the use of the LHBF musculocutaneous flap to treat refractory ulceration at the popliteal fossa and the results of a preliminary study investigating the anatomical possibility of transferring this flap to the popliteal region. METHODS: Five lower extremities of 5 fresh cadaveric specimens were dissected following injection of a silicone compound into the deep femoral artery. We investigated the number, location, and diameter of nutrient branches to the LHBF originating from the deep femoral artery. Based on these results, we treated a 76-year-old woman with a refractory postradiation ulcer at the popliteal fossa associated with popliteal artery obstruction using a 25 × 7 cm LHBF musculocutaneous flap. RESULTS: The mean number of nutrient branches to the LHBF muscle was 3.6, with a mean diameter of 1.9 mm. One to two branches consistently arose from the distal aspect of the posterior thigh. Most branches followed an intramuscular route, giving rise to fine cutaneous branches. The distal border reached by the musculocutaneous flap was located 6.7 cm distal to the bicondylar line. The flap survived completely without complications, and the patient was able to walk with a walking frame postoperatively. CONCLUSIONS: The LHBF musculocutaneous flap may offer a reliable treatment option for soft-tissue defects of the popliteal fossa, especially in patients with significant damage to the popliteal artery from trauma or radiation therapy.

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.

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.

Microsurgical second toe-metatarsal bone transfer for reconstructing congenital radial deficiency with hypoplastic thumb.

This study describes a consecutive series of 11 children who received a microsurgical second toe-metatarsal bone transfer for reconstructing a hypoplastic thumb associated with radial club hand, between 1996 and 2000. The parents refused pollicization in all cases for aesthetic and cultural reasons. Surgery was intended to improve hand function and cosmetic appearance. The average patient age was 3 years, and the average follow-up period was 4 years. Average surgery time for the second toe-metatarsal bone transplantation was 8 hr. The primary success rate was 90.9 percent, with one patient requiring repeat surgery owing to venous occlusion. The surgical outcomes reveal a normal growth of the transferred toe, an acceptable range of motion, and satisfactory recovery of sensation. All children achieved both small and large grasp functions. The parents were satisfied with the reconstruction procedures. Based on the preliminary results, second toe-metatarsal bone transfer appears an acceptable alternative for reconstructing radial deficiency with hypoplastic thumb.