Survival and Long-Term Outcomes of Thumb Metacarpal Extension Osteotomy for Symptomatic Carpometacarpal Laxity and Early Basal Joint Arthritis.

PURPOSE: To evaluate the survival and long-term outcomes of thumb metacarpal extension osteotomy for early carpometacarpal (CMC) arthritis. METHODS: Patients who underwent a thumb extension osteotomy between years 2000 and 2011 were identified. Patient demographics, complications, and reoperations were recorded. The Kaplan-Meier survival analysis was used with subsequent CMC surgery defined as failure. Patients who had undergone surgery 10 years or more before the study date underwent radiographic assessment, grip and pinch strength testing, and completed the Patient Rated Wrist/Hand Evaluation (PRWHE) and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaires. RESULTS: Thirty-two procedures in 7 males and 21 females were performed (mean age, 44.8 y). There were no cases of nonunion. Nine of 32 thumbs developed pin site erythema and were treated with oral antibiotics. Two thumbs developed osteomyelitis. Seven of 32 thumbs (22%) required reoperation. The Kaplan-Meier analysis indicated a 70% probability that patients who have this procedure will not require additional CMC surgery up to 14 years. Seven patients with a mean follow-up of 12.3 years (minimum 10 y) returned for clinical evaluation. The mean PRWHE and QuickDASH scores were 32.1 and 27.7, respectively. Examination revealed 124% pinch and 98% grip strength relative to the preoperative values. One thumb did not progress from stage II disease; 2 thumbs progressed from stage I to stage II; 1 thumb progressed from stage II to stage III; 1 thumb progressed from stage II to stage IV; 1 thumb did not have disease progression at the CMC joint, but developed scaphotrapeziotrapezoidal arthritis. CONCLUSIONS: Although reoperation rates and superficial infections with the described method of fixation were relatively high, thumb metacarpal osteotomy provides some degree of pain relief and improvement of function. This procedure may have utility as a temporizing measure in younger patients as it does not compromise future reconstructive procedures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Efficacy of 3 therapeutic taping configurations for children with brachial plexus birth palsy.

STUDY DESIGN: Cross-sectional clinical measurement study. INTRODUCTION: Scapular winging is a frequent complaint among children with brachial plexus birth palsy (BPBP). Therapeutic taping for scapular stabilization has been reported to decrease scapular winging. PURPOSE OF THE STUDY: This study aimed to determine which therapeutic taping construct was most effective for children with BPBP. METHODS: Twenty-eight children with BPBP participated in motion capture assessment with 4 taping conditions: (1) no tape, (2) facilitation of rhomboid major and rhomboid minor, (3) facilitation of middle and lower trapezius, and (4) facilitation of rhomboid major, rhomboid minor, and middle and lower trapezius (combination of both 2 and 3, referred to as combined taping). The participants held their arms in 4 positions: (1) neutral with arms by their sides, (2) hand to mouth, (3) hand to belly, and (4) maximum crossbody adduction (CBA). The scapulothoracic, glenohumeral and humerothoracic (HT) joint angles and joint angular displacements were compared using multivariate analyses of variance with Bonferroni corrections. RESULTS: Scapular winging was significantly decreased in both the trapezius and combined taping conditions in all positions compared with no tape. Rhomboids taping had no effect. Combined taping reduced HT CBA in the CBA position. CONCLUSIONS: Rhomboid taping cannot be recommended for treatment of children with BPBP. Both trapezius and combined taping approaches reduced scapular winging, but HT CBA was limited with combined taping. Therefore, therapeutic taping of middle and lower trapezius was the most effective configuration for scapular stabilization in children with BPBP. Resting posture improved, but performance of the positions was not significantly improved. LEVEL OF EVIDENCE: Level II.

Does a Weekly Didactic Conference Improve Resident Performance on the Pediatric Domain of the Orthopaedic In-Training Examination?

BACKGROUND: Performance on the Orthopaedic In-training Examination (OITE) has been correlated with performance on the written portion of the American Board of Orthopaedic Surgery examination. Herein we sought to discover whether adding a regular pediatric didactic lecture improved residents' performance on the OITE's pediatric domain. METHODS: In 2012, a didactic lecture series was started in the University of Pittsburgh Medical Center (UPMC) Hamot Orthopaedic Residency Program (Hamot). This includes all topics in pediatric orthopaedic surgery and has teaching faculty present, and occurs weekly with all residents attending. A neighboring program [UMPC Pittsburgh (Pitt)] shares in these conferences, but only during their pediatric rotation. We sought to determine the effectiveness of the conference by comparing the historic scores from each program on the pediatric domain of the OITE examination to scores after the institution of the conference, and by comparing the 2 programs' scores. RESULTS: Both programs demonstrated improvement in OITE scores. In 2008, the mean examination score was 19.6±4.3 (11.0 to 30.0), and the mean percentile was 57.7±12.6 (32.0 to 88.0); in 2014, the mean examination score was 23.5±4.2 (14.0 to 33.0) and the mean percentile was 67.1±12.1 (40.0 to 94.0). OITE scores and percentiles improved with post graduate year (P<0.0001). Compared with the preconference years, Hamot residents answered 3.99 more questions correctly (P<0.0001) and Pitt residents answered 2.93 more questions correctly (P<0.0001). Before the conference, site was not a predictor of OITE score (P=0.06) or percentile (P=0.08); there was no significant difference found between the mean scores per program. However, in the postconference years, site did predict OITE scores. Controlling for year in training, Hamot residents scored higher on the OITE (2.3 points higher, P=0.003) and had higher percentiles (0.07 higher, P=0.004) than Pitt residents during the postconference years. CONCLUSIONS: This study suggests that adding a didactic pediatric lecture improved residents' scores on the OITE and indirectly suggests that more frequent attendance is associated with better scores. LEVEL OF EVIDENCE: Level III-retrospective case-control study.

A systematic review of postoperative hand therapy management of basal joint arthritis.

BACKGROUND: There are a variety of postoperative immobilization and therapy options for patients with basal joint arthritis. Although prior systematic reviews have compared surgical procedures used to treat basal joint arthritis, none to our knowledge compares therapy protocols for this condition, which are considered an important part of the treatment. QUESTIONS/PURPOSES: (1) We sought to determine whether differences in the length and type of postoperative immobilization affect clinical results after basal joint arthritis surgery. (2) We also compared specific therapy protocols that were prescribed. (3) Finally, we evaluated published protocols to determine when patients were released to full activity to see whether these appeared to affect clinical results. METHODS: A systematic review of English-language studies in the PubMed and Cochrane databases was performed. Studies were then reviewed to determine what postoperative immobilization and therapy protocols the authors used and when patients were released to full activities. A total of 19 studies were identified using the search criteria. RESULTS: All but one of the studies included a postoperative period of immobilization in either a cast or splint. Immobilization time varied depending on whether Kirschner wires were used for the surgery and whether an implant was placed. Postoperative therapy protocols also varied but followed three general patterns. Some therapy protocols involved teaching patients a home exercise program only, whereas some authors described routine referral to a therapist. The third group consisted of studies in which patients were only referred for therapy if the physicians determined it was necessary during followup. Many studies did not give a specific time for full return to activity and instead described a gradual transition to full activity after immobilization was discontinued. Because of the variability and small numbers, no conclusive recommendations could be made on any of the three study questions. CONCLUSIONS: Comparative, multicenter studies comparing different immobilization and therapy protocols after the surgical treatment of basal joint arthritis would be helpful for both surgeons and therapists looking to refine their treatment protocols.

Use of bone morphogenetic protein-2 (rh-BMP-2) in treatment of wrist and hand nonunion with comparison to historical control groups.

The purpose of this study is to report the percentage of patients achieving union, time to union, and complications with the use of bone morphogenetic protein-2 (rh-BMP-2) in surgical repair of established nonunion in the hand and wrist. Twenty-seven patients with nonunion of the hand and wrist were treated between 2005 and 2011 with surgical repair and augmentation using 4.2 mg of rh-BMP-2. Sites of nonunion included the phalanx (seven), carpus (nine), distal radius (five), and distal ulna (six). Radiographic union and complications were the primary and secondary outcomes, respectively. Eighty-nine percent (24/27) of patients achieved union within an average of 4.3 ± 2.8 months of surgery. There were no direct complications from administration of rh-BMP-2. Radiographic union was consistent with published rates for nonunion repair of scaphoid, phalanx, and distal radius fractures. Rh-BMP-2 did not produce superior rates of union in the patients with wrist and hand nonunion.

Necrotizing soft tissue infections of the upper extremity: a case series.

Four cases of necrotizing soft tissue infections of the upper extremity are presented. Each involved minor wounds to the hand that gradually progressed to fulminant infection. Two of the patients reported a history of alcohol abuse. One patient had psychiatric illness that led to delay in recognizing the infection and seeking intervention. The causative organism in all cases was group A beta hemolytic streptococcus. Fortunately, none of the patients suffered loss of the affected extremity, although long-term function is limited. The necrotizing soft tissue infection encountered in these cases represents a less severe presentation than classic necrotizing fasciitis. Necrotizing soft tissue infections are properly recognized as a spectrum of disease and can, as in these cases, follow a prolonged progression with limited systemic involvement. The current literature regarding diagnosis and treatment of necrotizing soft tissue infections is reviewed.

Clinical Outcomes of Lunocapitate Arthrodesis: A Retrograde Single-Screw Approach.

BACKGROUND: A single-site retrospective study was designed to evaluate the clinical outcomes of single-screw lunocapitate arthrodesis (LCA) using a retrograde approach for the treatment of scapholunate advanced collapse (SLAC) wrist. METHODS: We retrospectively identified 31 patients (33 cases) between September 2010 and December 2019 with SLAC wrist changes who were treated with single-screw LCA. Objective outcomes included time to fusion, union rate, range of motion, and grip and pinch strength recovery. Subjective outcomes included Disabilities of the Arm, Shoulder, and Hand (DASH) scores. RESULTS: We report on 33 cases (7 female), mean age 58.4 years (range: 41-85), with SLAC wrist who underwent LCA. Our cohort reported a 94% union rate and a 90-day mean time to fusion. Final active wrist range of motion was 38° dorsiflexion, 35° volarflexion, 17° radial deviation, 17° ulnar deviation, 82° pronation, and 83° supination (mean: 450.8 days). Final grip and pinch strengths recovered was 75% gross grip, 84% lateral pinch, and 75% precision pinch (mean: 379.0 days) compared with the contralateral side. The mean postoperative DASH score was 27 (mean: 1203.9 days). Two nonunions were observed. Two hardware complications occurred: one symptomatic screw and one screw fatigue fracture. CONCLUSIONS: We found retrograde single-screw LCA to be an effective salvage procedure for SLAC wrist. LCA is a less-taxing procedure, requires shorter operating time, and produces range of motion and grip and pinch strength recovery comparable to those of 4-corner arthrodesis. Furthermore, the viability of single-screw fixation may reduce hardware-related operative costs without compromising union rates.

Fingertip Injuries in Athletes, Musicians, and Other Special Cases.

Management of fingertip injuries in athletes is optimized by consideration of the sport, the playing position, the timing within the season, the level of competition, and the patient's goals. Mallet and jersey fingers are common injuries in athletes and may be treated in several different ways, based on the nature of the injury and the timing of presentation, as well as the athlete's demands. Management of fingertip injuries in musicians is optimized by consideration of how the musician handles his or her instrument and the specific requirements of the injured digit in the context of musical performance.

Pseudoarthrosis in a hypertrophic nonunion of the humerus: a case report.

Nonunion of humerus fractures is an extensively reviewed topic in orthopedic literature. The current case describes the successful outcome of a hypertrophic nonunion in a patient who chose not to undergo any intervention when the nonunion was identified and the treatment options were discussed with him. Hence this case report is a good example of the transition of the medical world to the concept of patient-centered decision making having a successful outcome.

A review of mallet finger and jersey finger injuries in the athlete.

PURPOSE OF REVIEW: The purposes of this review are to discuss the diagnosis and management of mallet and jersey finger injuries in athletes and to highlight how treatment impacts return to play. RECENT FINDINGS: Mallet finger: although numerous non-operative and operative techniques have been described, there continues to be little consensus regarding the optimal procedure. Jersey finger: ultrasound appears to be a cost-effective imaging modality that may be useful for preoperative planning. Wide-awake surgery offers optimal intraoperative assessment of the tendon repair. Tendon repair with volar plate augmentation has been shown to improve the strength of the repair in the laboratory, and early clinical results are encouraging. Most mallet finger injuries will heal with non-operative treatment over a period of 8-12 weeks, even when treatment is delayed up to 3-4 months. An acute diagnosis of jersey finger requires surgical treatment and generally means 8-12 weeks of inability to compete in most contact sports.

Treating Unstable Distal Radius Fractures With a Nonspanning External Fixation Device: Comparison With Volar Locking Plates in Historical Control Group.

We conducted a study to compare functional and radiographic outcomes of unstable comminuted intra-articular distal radius fractures (DRFs) treated with a nonspanning external fixation device and outcomes achieved with volar locking plates in a historical control group. Clinical and radiographic data from 25 patients with these fractures, treated with the external fixation device, were compared with outcomes data from historical control matched patients with fracture patterns treated with volar locking plates. There was no statistically significant difference in the measured outcomes for wrist flexion and extension, radial deviation, pronation and supination, volar tilt, radial height, radial inclination, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores between the 2 groups. The external fixator group had significantly more postoperative ulnar deviation than the historical control group. Complications included pin-tract infection and fracture in 1 patient who fell 2 weeks after fixator removal. Nonspanning external fixation is an alternative treatment option for unstable comminuted DRFs. It is minimally invasive and has functional and radiographic results similar to those achieved with volar locking plates in matched patients in historical control studies.

Elbow deformities after fracture.

Nonunion of the lateral humeral condyle,cubitus varus, cubitus valgus, and fishtail deformity represent particularly challenging problems to the upper extremity surgeon. Although closed or open reduction and pinning of supracondylar fractures of the distal humerus can restore anatomic alignment and avoid anatomic deformities in most cases, closed reduction is still a common form of treatment. In those hopefully few cases in which reduction is less than optimal, or when a good reduction is performed but subsequently lost between follow-up visits, the aforementioned deformities of the distal humerus can develop. Even when anatomic reduction is obtained and held, avascular necrosis of the trochlea may develop, leading to the so-called fishtail deformity. Although not recognized for several years, and when initially recognized, not necessarily taken seriously, fishtail deformity may be one of the more devastating deformities in that it is not correctable by traditional methods of osteotomy. Flexion contracture when present may be treated by standard release; however, when a bony block exists as a result of the shape of the fishtail, nonsurgical options exist and the patient often is left with a permanent loss of motion.

Enchondroma of the Hand: Evaluation and Management.

Enchondroma is the most common primary bone tumor of the hand. This benign, cartilaginous tumor often presents as a pathologic fracture. When hand enchondroma is suspected, less common conditions, such as multiple enchondromatosis syndromes and benign and malignant lesions, should be ruled out. Surgical management with curettage is the standard of care for symptomatic lesions. However, controversy surrounds the timing of surgery for pathologic fractures and the use of surgical adjuncts and postcurettage void management. Microscopically distinguishing hand enchondroma from low-grade hand chondrosarcoma is a diagnostic challenge for pathologists, but the primary surgical treatment for both conditions is curettage because the latter has a low metastatic potential. Postoperative complications are typically joint stiffness and soft-tissue[FIGURE DASH]related deformities, whereas recurrence and malignant degeneration of solitary lesions are much less common. Most patients return to full function after surgery.

Hand Surgeon Reporting of Tendon Rupture Following Distal Radius Volar Plating.

Background: Volar plate fixation with locked screws has become the preferred treatment of displaced distal radius fractures that cannot be managed nonoperatively. This treatment, however, is not without complication. The purpose of this study was to determine what percentage of hand surgeons, over a 12-month period, have experienced a tendon complication when using volar plates for the treatment of distal radius fractures. Methods: A total of 3022 hand surgeons were e-mailed a link to an online questionnaire regarding their observation and treatment of tendon injuries associated with volar plating of distal radius fractures. Responses were reported using descriptive statistics. Results: Of the 596 (20%) respondents, 199 (33%) surgeons reported encountering at least one flexor tendon injury after distal radius volar plating over the past year of practice. The flexor pollicis longus was the most commonly reported tendon injury (254, 75%). Palmaris longus grafting (118, 37%) and tendon transfer (114, 36%) were the most often reported treatments following this complication. A total of 216 respondents (36%) also encountered 324 cases of extensor tendon rupture after volar plating of distal radius fractures, with tendon transfer (88%) being the preferred treatment option. Conclusions: Both flexor and extensor tendon ruptures can be seen after volar plating of distal radius fractures. Surgeons should be aware of these complications. Critical assessment of hardware position at the time of index procedure is recommended to avoid complications. Long-term studies are needed to standardize approaches to managing tendon rupture following volar plating of distal radius fractures.

Risk factors, treatment, and outcomes associated with nonunion of the midshaft humerus fracture.

Charts of 28 patients with a diagnosis of delayed union or nonunion were reviewed. There were four delayed unions and 25 nonunions. Comorbidities, risk factors, treatments, and outcomes were evaluated. Comorbidities were common and included cardiovascular, pulmonary, and renal compromise, as well as endocrinopathies and rheumatologic disease. Consensus risk factors included: unstable fractures (comminuted or short oblique, 83% (24/29); advanced age, 57% (16/28); obesity, 35% (9/28); daily tobacco use, 38% (10/28); and multiple long bone fractures, 21% (6/29). Sixty-nine percent (20/29) of the fractures united; 21% (6/29) failed to heal. Healing outcome for 11% (3/29) could not be determined because of death or loss to follow-up. Patients presenting for primary treatment with any of the aforementioned risk factors should be cautioned regarding possible nonunion.

Patient-related factors influencing ulnar-shortening osteotomy outcomes using the trimed dynamic compression plate.

Ulnocarpal impingement can be surgically managed with various shortening osteotomy techniques. The purpose of this study was to retrospectively examine the outcomes of the ulnar-shortening osteotomy technique using the Trimed dynamic compression plate (Valencia, California) and to determine whether results vary among patient-related factors, including smoking status, occupation, preoperative diagnosis, and workers' compensation status. Twenty-seven patients (28 wrists) operated by a single surgeon underwent ulnar shortening over a 4-year span. Radiographic analysis was obtained preoperatively and at an average 24-month follow-up. A subset of 12 patients completed the Disabilities of the Arm, Shoulder and Hand (DASH) inventory; the Patient-Rated Wrist Evaluation (PRWE); and the visual analog scale for pain and underwent clinical evaluation for range of motion and strength. Ulnar variance improved in all cases between pre- and postoperative imaging (P<.05). Grip strength and range of motion were found to be 79% and 90% of the contralateral extremity, respectively. Among the examined patient-related factors, patients involved in a workers' compensation claim demonstrated significantly different DASH (average, 56.8 claim vs 26.8 no claim; P=.037) and PRWE (average, 66.0 claim vs 32.8 no claim; P=.008) scores while also showing a trend toward nonunion (3/10 claim vs 1/18 no claim; P=.105). Results of ulnar-shortening osteotomy using the Trimed system at 2-year follow-up show consistent objective improvements in radiographic ulnar variance. Workers' compensation claims may negatively influence outcomes of ulnar shortening, and this factor should be considered in preoperative patient selection and counseling.