Mapping Origins of Tendons on the Medial Epicondyle to Improve Treatment of Medial Epicondylitis: Anatomical Study.

PURPOSE: Medial epicondylitis is a tendinosis found commonly in throwing and golfing athletes. Although there are choices for nonsurgical treatments, when these fail, surgical intervention can be considered. When surgical treatment is performed, the objective is to debride the diseased tissue from the epicondyle. The purpose of this study was to clarify the locations and size of the common flexor tendons and medial collateral ligament (MCL) relative to each other and to the posterior ridge of the medial epicondyle. METHODS: The common flexor tendons and MCL were dissected and reflected their origin on the medial epicondyle in six cadaver elbows. Measurements were taken from the posterior and distal ridges of the medial epicondyle with respect to the humerus. Each origin was also measured for its height and width. RESULTS: The flexor carpi ulnaris origin starts at a mean of 4.2 mm from the posterior ridge of the medial epicondyle and extends anteriorly an average of 4.8 mm. The flexor carpi radialis starts at a mean of 4.2 mm from the posterior ridge and extends anteriorly an average of 7.4 mm. The pronator teres begins at a mean of 4.6 mm from the posterior ridge and extends an average of 5.7 mm anteriorly. The MCL starts at an average of 10.4 mm from the posterior ridge and extends 5.2 mm anteriorly. CONCLUSIONS: The measurements found have allowed the creation of a map of the specific common flexor tendon origins and their sizes on the medial epicondyle, as well as their position relative to the MCL. CLINICAL RELEVANCE: A surgeon may debride 1 cm anteriorly from the posterior ridge of the medial epicondyle to safely address the affected tissues and ensure the safety and integrity of the MCL.

A Multicenter Prospective Randomized Comparison of Conduits Versus Decellularized Nerve Allograft for Digital Nerve Repairs.

PURPOSE: While there are advantages and disadvantages to both processed nerve allografts (PNA) and conduits, a large, well-controlled prospective study is needed to compare the efficacy and to delineate how each of these repair tools can be best applied to digital nerve injuries. We hypothesized that PNA digital nerve repairs would achieve superior functional recovery for longer length gaps compared with conduit-based repairs. METHODS: Patients (aged 18-69 years) presenting with suspected acute or subacute (less than 24 weeks old) digital nerve injuries were recruited to prticipate at 20 medical centers across the United States. After stratification to short (5-14 mm) and long (15-25 mm) gap subgroups, the patients were randomized (1:1) to repair with either a commercially available PNA or collagen conduit. Baseline and outcomes assessments were obtained either before or immediately after surgery and planned at 3-, 6-, 9-, and 12-months after surgery. All assessors and patients were blinded to the treatment arm. RESULTS: In total, 220 patients were enrolled, and 183 patients completed an acceptable last evaluable visit (at least 6 months and not more than 15 months postrepair). At last follow-up, for the short gap repair groups, average static two-point discrimination was 7.3 ± 2.8 mm for PNA and 7.5 ± 3.1 mm for conduit repairs. For the long gap group, average static two-point discrimination was significantly lower at 6.1 ± 3.3 mm for PNA compared with 7.5 ± 2.4 mm for conduit repairs. Normal sensation (American Society for Surgery of the Hand scale) was achieved in 40% of PNA long gap repairs, which was significantly more than the 18% observed in long conduit patients. Long gap conduits had more clinical failures (lack of protective sensation) than short gap conduits. CONCLUSIONS: Although supporting similar levels of nerve regeneration for short gap length digital nerve repairs, PNA was clinically superior to conduits for long gap reconstructions. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Occult Amyloid Deposition in Older Patients Presenting With Bilateral Carpal Tunnel Syndrome or Multiple Trigger Digits.

PURPOSE: The diagnosis of amyloidosis is important for early intervention, disease monitoring, and prevention of complications and progression. Carpal tunnel syndrome (CTS) and trigger digit (TD) are two common conditions associated with early disease. The purpose of this study was to define disease prevalence among patients with bilateral CTS and multiple TDs and assess for an increased rate of diagnosis in the presence of both. METHODS: Men older than 50 years and women older than 60 years of age diagnosed with bilateral CTS, multiple TDs, or a combination of the 2 were prospectively enrolled in our study. Tenosynovial biopsy samples taken at the time of surgery were tested for the presence of amyloid using Congo red staining. Demographic and medical covariates were also collected and analyzed for differences between amyloid-positive and -negative patients. RESULTS: Fifty-six patients were enrolled in the study, and nine patients tested positive for amyloid deposition. The demographics and medical comorbidities were similar between amyloid-positive and -negative patients. Thirty patients with bilateral CTS were enrolled, and four tested positive for amyloid. For patients with multiple TDs, a total of 17 patients were enrolled, and 4 tested positive for amyloid. Among patients with multiple TDs, only men tested positive for amyloid and were, on average, younger than those who tested negative (61 and 73 years, respectively). Patients presenting with a combination of CTS and TD did not exhibit increased amyloid discovery. CONCLUSIONS: Hand surgeons should consider tenosynovial biopsy in men older than 50 years and women older than 60 years presenting with either bilateral CTS or multiple TDs. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Reconstruction of the Thumb Metacarpophalangeal Ulnar Collateral Ligament With an Adductor Pollicis Slip: An Anatomic Evaluation.

PURPOSE: Reconstruction of the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal joint is commonly performed for chronic injuries. This study evaluates the anatomic feasibility of using a part of the adductor pollicis tendon to reconstruct UCL. METHODS: Ten cadaveric arms were dissected to evaluate the relationship between the insertions of UCL and the adductor pollicis. A slip of the adductor pollicis was divided from the tendon and transposed dorsally. The dissected tendon was deemed sufficient for reconstruction if it could be reflected to the footprint of the UCL origin. The size of the adductor pollicis slip was then compared with that of UCL. RESULTS: The dissected slip of the adductor pollicis could be fully reflected proximally to the UCL origin in all the specimens, and the insertion was also found to be closely approximated to the UCL insertion, averaging 2 mm distally and 0.6 mm dorsally. CONCLUSIONS: A sufficiently sized partial adductor pollicis tendon can be obtained to reconstruct UCL of the thumb metacarpophalangeal joint, and the location of the adductor pollicis insertion closely approximates that of the UCL insertion. CLINICAL RELEVANCE: The anatomic relationship evaluated in this study relates to a recently described method of the reconstruction of UCL of the thumb metacarpophalangeal joint that does not require free tendon harvest. This study shows that the technique is anatomically feasible.

Efficacy of a single, image-guided corticosteroid injection for glenohumeral arthritis.

BACKGROUND: Limited data are available on the efficacy of cortisone injections for glenohumeral osteoarthritis (GHOA). The amount and longevity of pain relief provided by a single cortisone injection are unclear. Additionally, it remains uncertain how the severity of radiographic GHOA and patient-reported function and pain levels impact the efficacy of an injection. Therefore, we sought to describe the relief provided by a single, image-guided glenohumeral injection in patients with GHOA. We hypothesized that patients with more severe radiographic GHOA and poorer baseline shoulder function would require earlier secondary intervention. METHODS: Patients with symptomatic GHOA who elected to receive a corticosteroid injection for pain relief were prospectively enrolled. A phone interview was conducted to record the baseline Oxford Shoulder Score (OSS) and visual analog scale (VAS) score prior to the injection, as well as the OSS and VAS score at months 1, 2, 3, 4, 6, 9, and 12 after the injection. The endpoint of the study occurred when patients required a second injection, progressed to surgery, or reached month 12. Patients were grouped by their respective baseline OSS (mild vs. moderate or severe) and Samilson-Prieto radiographic classification (mild, moderate, or severe) for analysis. RESULTS: We analyzed 30 shoulders (29 patients). Of the patients, 52% were men. The average age was 66.1 years. No significant difference in overall survival (defined as no additional intervention) was seen between groups based on either the OSS or Samilson-Prieto grade. Additionally, the OSS and VAS score at each follow-up were compared with baseline values. For the entire cohort, a clinically significant difference was seen between baseline and months 1-4 for the OSS and between baseline and months 1-4, 6, 9, and 12 for the VAS score. DISCUSSION: This study aimed to determine the efficacy of corticosteroid injections for GHOA. There were no differences in the need for secondary intervention in this population based on the severity of either the OSS or the Samilson-Prieto radiographic classification. However, patients with more severe shoulder dysfunction based on the OSS did experience statistically significantly greater symptomatic relief than patients with milder dysfunction. Additionally, following a single injection, patients in this cohort experienced statistically and clinically relevant improvements in shoulder function and pain up to 4 months after injection.

Maintenance of pronation function after pronator teres to flexor pollicis longus tendon transfer: a cadaver study.

STUDY DESIGN: Mechanistic cadaver study. OBJECTIVES: Patients in groups 4 and 5 of the International Classification for Surgery of the Hand in Tetraplegia have a few options for tendon transfer donors, but in general the needs for reestablishing motor power exceed the donor options, such that any increase in the number of potential transfers can enhance function. Although transfer of brachioradialis (BR) in these patients is well-established, pronator teres (PT) may also be a suitable donor due to its strength and excursion. It has not been extensively studied in this role, possibly because of concerns about its expendability as the major agonist of forearm pronation. The purpose of this study is to quantify forearm pronation capability pre- and post-tendon transfer of PT to flexor pollicis longus (FPL) in a cadaver model. SETTING: Surgery center in Indianapolis, USA. METHODS: Five cadaver arms were evaluated for pronation capability against gravity before and after PT to FPL tendon transfer. In both stages, the arms were also assessed for the pronation forces produced at the wrist when pulling PT with 25, 50, and 75 N of force. With each force, the arms were tested in full supination and neutral position. RESULTS: All five arms were capable of pronating against gravity before and after the PT to FPL tendon transfer. Following the transfer, pronation force at the wrist decreased by 1-5 N, but the change was not statistically significant. CONCLUSIONS: PT to FPL tendon transfer produces thumb flexion while retaining the forearm's ability to pronate and would likely retain good clinical function, freeing up BR to recreate active finger flexion or extension.

The Use of a Vascularized Distal Ulna Autograft for Complex Distal Radius Fracture Nonunions.

In patients with segmental nonunion of the distal radius, the distal ulna and distal radioulnar joint may not be salvageable. As an alternative to a vascularized free fibula, a pedicled distal ulna vascularized graft is a useful salvage technique. The procedure relies on the vascular bundle of the pronator quadratus and the dorsal oblique arterial anastomosis between the anterior and posterior interosseous arteries running along the interosseous membrane as the pedicle. We present 3 patients who received a distal ulna vascularized graft with concomitant wrist arthrodesis for distal radius segmental nonunion after complex distal radius fracture. This technique provides a local pedicled graft that may be a simpler, more reliable, and less technically demanding alternative.

Testing of Direct Neurorrhaphy Strain.

PURPOSE: To investigate the ideal suture material to test strain at nerve repair sites. Based on nerve strain tolerance, we aimed to determine which suture reliably failed by an average of 5% and a maximum of 8% strain when loaded to failure. METHODS: The median nerve of 19 cadavers was exposed in the distal forearm, transected proximally, and attached to a spring gauge. It was marked 5 cm on either side of its midpoint to measure strain. A laceration was created at its midpoint. We performed a tension-free end-to-end repair with a single epineural suture. Load to failure of the repair site was recorded. We recorded strain at failure and mode of failure (pullout vs breakage). Eight different sutures were tested: 6-0, 8-0, 9-0, and 10-0 nylon; and 6-0, 7-0, 8-0, and 10-0 polypropylene. RESULTS: Average strain at failure of 9-0 nylon most closely approximated 5% (4.9%). Moreover, 8-0 polypropylene and 10-0 nylon and polypropylene failed with average strains less than 5% and a maximum strain of failure less than 8%. Regardless of type, 6-0 to 8-0 caliber suture failed primarily by pullout of the suture from the epineurium whereas 9-0 and 10-0 nylon and polypropylene failed by suture breakage. Decreased precision through increased variability was seen when testing sutures failing via pullout. CONCLUSIONS: Nylon suture size 8-0 has been advocated as the suggested intraoperative aid to test strain at nerve repair sites. Our study suggests that 9-0 nylon may be a more appropriate testing suture because of its more predictable failure via breakage and its failure by a threshold of 5% to 8% strain. Although 8-0 nylon and polypropylene may also represent reasonable testing sutures, 8-0 nylon failed on average above 5% strain, with strains exceeding 8%, and both failed via the mechanism of pullout. CLINICAL RELEVANCE: This study's findings provide information for surgeons attempting to decide during surgery whether to perform direct nerve repair.

A Pediatric Medial Epicondyle Fracture Cadaveric Study Comparing Standard AP Radiographic View With the Distal Humerus Axial View.

BACKGROUND: Controversy exists with regard to the amount of fracture displacement that warrants surgical fixation of medial epicondyle fractures. Inaccurate determination of degree of displacement on plain radiographs may account for the disputed management. Recently, a novel distal humerus axial radiograph technique has been developed to improve the accuracy of radiographs. The purposes of the study are 2-fold; to identify the anatomic orientation of the medial elbow epicondyle physis in children and to compare the accuracy of determining fracture displacement between axial radiographs and standard anterior-posterior (AP) radiographs in a cadaveric medial epicondyle fracture model. METHODS: Twelve pediatric elbow computed tomographic scans and 19 pediatric elbow magnetic resonance imaging scans were analyzed for the orientation of the medial elbow physis. After determining the correct orientation, 15 adult cadaveric medial epicondyle fracture models were created at displacements of 2, 5, 10 mm, and maximum displacement with elbow at 90 degrees of flexion. A linear mixed model regression analysis was used to compare displacement based on the axial versus the AP radiographic methods. RESULTS: The medial epicondyle physis was found to be a posterior structure angled distally at ~36 degrees (range, 10.7 to 49.6) and angled posteriorly at 45 degrees (range, 32.2 to 59). The AP radiograph significantly underestimated displacement relative to the axial radiograph at 5 mm [mean difference, -1.6; 95% confidence interval (CI), -2.9 to -0.3], at 10 mm (mean difference, -4.5; 95% CI, -5.8 to -3.2 mm), and at maximal displacement (mean, 15 mm; range, 13 to 20 mm) (mean difference, -7.1; 95% CI, -8.3 to -5.8). CONCLUSIONS: The medial epicondyle physis of the distal humerus is a posterior structure angled distally and posteriorly. When displacement was >5 mm, the distal humerus axial radiograph technique was significantly more accurate than the AP radiograph technique at determining actual fracture displacement in our adult cadaveric fracture models. Therefore, we recommend clinicians to include the axial radiograph view during the evaluation of patients with medial epicondyle fractures. CLINICAL RELEVANCE: This study provides further insight into the location and orientation of the medial humeral epicondyle physis, and further supports the improved accuracy of the distal humerus axial radiograph at detecting displacement in medial epicondyle fractures.

Distal Biceps Brachii Tendon Transfer for Re-establishing Extrinsic Finger Function: Feasibility Study in Cadavers.

PURPOSE: To determine the anatomic feasibility of transferring the biceps brachii tendon into either the extensor digitorum communis (EDC) or flexor digitorum profundus (FDP), determine the excursion imparted to EDC and FDP tendons after transfer, and compare the work capacity of the cadaver biceps to previously published data on the biceps as well as the recipient muscles by calculating the physiologic cross-sectional area (PCSA). METHODS: Four fresh-frozen cadaver shoulder-elbow-wrist specimens were used to measure tendon excursion that can be obtained with transfer of the distal biceps tendon into either the EDC or FDP. Two cadavers had distal biceps-to-EDC transfer performed, and the other 2 had distal biceps-to-FDP performed. Passive ranging of each elbow from flexion to extension and active loading at 90° of elbow flexion were then performed on each specimen to determine tendon excursion. An analysis of the PCSA of the biceps muscle was performed on each specimen. RESULTS: Distal biceps-to-EDC transfer resulted in an average of 24 mm of tendon excursion with passive loading, and 24 mm of tendon excursion with active loading. Distal biceps-to-FDP transfer resulted in an average of 24 mm of tendon excursion with passive loading, and 24 mm of tendon excursion with active loading. The average PCSA was 3.6 cm2. CONCLUSIONS: Transfer of the distal biceps tendon into the EDC or FDP is anatomically feasible and provides roughly 24 mm of tendon excursion to the tendon units. The PCSA in the specimens used is slightly lower than other published data; it closely approximates the PCSA of the EDC, but is only half of the PCSA of the FDP in previously published data. CLINICAL RELEVANCE: The findings suggest potentially novel transfer options for restoring finger flexion and extension in patients lacking FDP or EDC function.

Progression of Authorship of Scientific Articles in The Journal of Hand Surgery, 1985-2015.

PURPOSE: For scientists, authorship is academic currency. Authorship characteristics have been studied in a subset of the surgical and medical literature, but trends in the specialty of hand surgery have not yet been investigated. Specifically, a longitudinal analysis of number, educational training, sex, and geographical origin of authors has not been conducted. We explored the progression of authorship of scientific articles in a leading hand surgery journal. METHODS: We recorded number of authors, number of references, degrees, and sex of the first and senior authors as well as geographical origin of the corresponding author in The Journal of Hand Surgery in 1985, 1995, 2005, and 2015. All original work was analyzed. RESULTS: A total of 892 articles were reviewed. The mean number of authors per article increased significantly from 2.6 in 1985 to 3.9 in 2015 and the number of references increased significantly from 13.7 in 1985 to 22.6 in 2015. There was a significant increase in the proportion of first authors with an MD/PhD, PhD, master's or bachelor's degree since 1985. During that same time period, a decrease in the proportion of first authors who held solely an MD was seen. There was a significant increase in proportion of the number of last authors with an MD/PhD, PhD or Master's degree in that same time period. There has been significant growth in publications originating from the "Far East" and "Other" regions, with 4.2% and 5.0% of publications, respectively, in 1985 having increased to 10.3% and 7.4% of publications, respectively, in 2015. Female first authorship significantly increased over the study period from 7.9% in 1985 to 22.1% of publications in 2015. CONCLUSIONS: There has been a significant increase in number of authors per article in The Journal of Hand Surgery. Similar to other studies, we noted shifts in the degrees most commonly held by authors, an increase in references per article, and a greater representation of international authors in the hand surgery. In addition, the proportion of manuscripts written by female authors has increased in the past 30 years, with the largest increase occurring between 2005 and 2015. CLINICAL RELEVANCE: This manuscript strives to provide further insight into the changing characteristics of authors contributing to the hand surgery literature. With increased pressure to publish in academia, it is important to understand how publishing author characteristics have evolved over time. In addition, the published literature of a field could be considered one repository of the insights and advancements of the field. One would hope that the authors contributing to that literature are a deep and wide reflection of the people working in that field. Analyzing authorship is one way to assess the breadth and depth of contributions from the profession.

The Effect of Progressive Extensor Retinaculum Excision on Wrist Biomechanics and Bowstringing.

PURPOSE: To quantify the effect of the extensor retinaculum in preventing bowstringing and extensor lag. METHODS: The extensor carpi radialis brevis (ECRB) and extensor digitorum communis (EDC) tendons to the middle finger were isolated in 6 human cadaveric specimens. Extensor tendon excursion and bowstringing were measured as the extensor retinaculum was serially excised. RESULTS: For the second dorsal compartment, extensor lag averaged 7° when the entire retinaculum over the ECRB was excised. Bowstringing did increase with sequential resections and was greater for distal resections than for proximal resections. When the entire retinaculum over the ECRB was removed, bowstringing averaged 12 mm. For the fourth dorsal compartment, excision of the distal retinaculum resulted in more bowstringing and extensor lag than excision of the proximal retinaculum. When the proximal two-thirds was excised, EDC extensor lag averaged 12° and bowstringing averaged 9 mm; with the distal two-thirds excised, extensor lag averaged 18° and bowstringing averaged 14 mm. Complete retinaculum excision resulted in EDC bowstringing of about 61 mm and extensor lag of 80°. CONCLUSIONS: Resection of the entire extensor retinaculum over the second dorsal compartment results in minimal extensor lag and minimal bowstringing. Resection of the entire retinaculum over the fourth dorsal compartment results in massive extensor lag and bowstringing and should be avoided. The distal portion of the retinaculum is most important in preventing extensor lag and bowstringing for the fourth compartment. CLINICAL RELEVANCE: The findings inform the surgeon's handling of the extensor retinaculum during procedures on the dorsum of the wrist, especially when portions are to be excised, transposed, or repaired.

Paraumbilical perforator flap for soft tissue reconstruction of the forearm.

Numerous flaps exist for coverage of injuries to the upper extremity, ranging from local, to regional, to free tissue transfer. The choice of flap is dependent on a variety of factors, including patient, functional needs, and depth of injury. The paraumbilical perforator (PUP) flap for upper extremity coverage can offer the benefits and versatility of pedicled and free flaps while avoiding some of the donor-site morbidity and risks of free tissue transfer. We report the indications and management of two clinical cases that exemplify PUP flap application. Technical points of flap harvest, inset, timing of pedicle division, and pertinent anatomy are discussed.

Flexor tendon repairs: techniques, eponyms, and evidence.

The evolution in surgical technique and suture technology has provided an abundance of options for flexor tendon repairs. Multiple biomechanical studies have attempted to identify the best surgical technique based on suture properties, technical modifications, and repair configurations. However, the burgeoning amount of research on flexor tendon repairs has made it difficult to follow, and no gold standard has been determined for the optimal repair algorithm. Therefore, it seems that repairs are usually chosen based on a combination of familiarity from training, popularity, and technical difficulty. We will discuss the advantages, disadvantages, and technical aspects of some of the most common core flexor tendon repairs in the literature. We will also highlight the nomenclature carried through the years, drawings of the repairs referred to by that nomenclature, and the data that support those repairs.

Return to Sports and Recreational Activities Following Arthroplasty of the Basal Joint of the Thumb: A Retrospective Review.

Purpose: Arthroplasty of the basal, or carpometacarpal, joint of the thumb has been shown to decrease pain, improve strength, improve range of motion, and allow return to work. This study sought to assess whether basal joint arthroplasty also allows for a return to sports and recreational activities. Methods: A survey assessing participation in sports and recreational activities, timing of return to play after surgery, enjoyment, and the presence of pain and limitations was mailed to patients who had undergone an arthroplasty of the basal joint of the thumb over a 3-year period. Results: Of the 333 patients who underwent thumb carpometacarpal arthroplasty, met the criteria, and responded, 73% were able to successfully return to sports and recreational activities, with decreased pain and at the same or increased level of play, frequency of participation, and level of enjoyment for their sport or recreational activity. Patients were more likely to successfully return to sports and recreational activities if they had undergone surgery on their nondominant hand, did not stop their sport or recreational activity before surgery, were able to return within 9 months of surgery, and reported no postoperative limitations. Successful return to sports and recreational activities was not related to age, sex, surgeon, level of play, or the type of sport or recreational activity. Conclusions: Most patients who replied to our survey reported successful return to sports and recreational activities after arthroplasty of the basal joint of the thumb. Type of study/level of evidence: Prognostic IV.

The ipsilateral olecranon tip is a suitable anatomic autograft for unrepairable coronoid fractures: A comparative three-dimensional mapping analysis.

Background: Perform computed tomography (CT) three-dimensional (3D) mapping analysis of the ipsilateral olecranon tip to determine its suitability as an autograft for unrepairable coronoid fractures. Methods: CT was evaluated using Mimics 13.0 and 3-matic software (Materialise, Inc., Leuven, Belgium). Coronoid fracture fragment was measured from the medial sublime tubercle to the halfway point of the proximal radioulnar joint. Ipsilateral olecranon tip graft was measured at the equivalent height of the coronoid fragment and the angle of graft "cut" necessary to match the coronoid fragment was measured. The overall width of each graft site was measured in thirds and the congruity of surface geometry was measured by overlapping both fragments. The ipsilateral olecranon tip lateral facet which rotates to become the coronoid medial facet was also measured. Results: The olecranon tip and coronoid fragments were similar in average maximum height and width. The average angle of graft cut needed to match the coronoid fragment was 86°. The average difference between the medial facet of the coronoid and lateral facet of the olecranon was <2 mm. Discussion: The ipsilateral olecranon tip can be harvested through the same surgical incision and function as a local autograft during reconstruction of unrepairable coronoid fractures.

Long-term results of bone-retinaculum-bone autograft for scapholunate instability.

PURPOSE: To report long-term follow-up of scapholunate interosseous ligament reconstruction with bone-retinaculum-bone autograft in patients with dynamic scapholunate instability. METHODS: Of the 14 patients from the previously reported cohort who had bone-retinaculum-bone autograft for dynamic instability, 6 returned for clinical examination and radiographs, 3 were reached by telephone, and 2 were lost to follow-up. The remaining 3 had salvage procedures (2 total wrist arthrodeses and 1 proximal row carpectomy) between the prior report and the current study and thus reached an endpoint, at 2 to 4 years. For the 6 who returned, outcome measurements included scapholunate angle and gap, radiographic evidence of secondary arthritis, wrist extension and flexion, grip strength, and Mayo wrist score. RESULTS: Follow-up averaged 11.9 years (range, 10.7-14.1 y). Clinical and radiographic outcomes deteriorated moderately from the prior report. Mayo wrist score averaged 83. There were 3 failures, resulting in 1 proximal row carpectomy and 2 total wrist arthrodeses. Findings at repeat surgery in the failed group included an intact graft without any apparent abnormalities, a partially ruptured graft (after a subsequent re-injury), and a completely resorbed graft. CONCLUSIONS: Bone-retinaculum-bone autograft reconstruction is a viable treatment option for dynamic scapholunate instability in which the scaphoid and lunate can be reduced. Results may deteriorate but are similar to those reported previously from other techniques. Problems with graft strength or stiffness may necessitate further surgery.

Use of an Abductor Pollicis Brevis Tendon Slip for Reconstruction of the Radial Collateral Ligament of the Thumb Metacarpophalangeal Joint: An Anatomical Investigation.

BACKGROUND: Reconstruction of the radial collateral ligament (RCL) of the thumb metacarpophalangeal (MP) joint is commonly performed for chronic injuries. This study aims to evaluate the anatomical feasibility and reliability of using the abductor pollicis brevis (APB) tendon to reconstruct the RCL. METHODS: Ten cadaver arms were dissected to evaluate the relationship between insertions of the RCL and APB. A slip of the APB was divided from tendon and reflected proximally. The dissected tendon was deemed sufficient for reconstruction if it could be reflected to the footprint of the RCL origin. The size of the dissected APB slip was then compared with that of the RCL. RESULTS: The dissected slip of the APB could be fully reflected proximally to the RCL origin in all specimens. The APB insertion was also found to be closely approximated to the RCL insertion, averaging 2.1 mm distal and 1.8 mm dorsal. Significant differences existed between the lengths (P < .001) of the APB slip and RCL, with no significant difference in widths (P = .051). CONCLUSIONS: A sufficient APB tendon slip can be obtained to reliably reconstruct the RCL of the thumb MP. The location of the APB insertion closely approximates the RCL insertion.

A Cadaveric Comparison of Approaches for Exposure of the Volar Distal Radius: Is There a Utilitarian Approach?

BACKGROUND: It remains unclear whether exposure for planned fixation of distal radius fractrues is superior with any given approach, and whether a single utilitarian approach exists that permits reliable complete exposure of the volar distal radius. METHODS: A cadaveric study was performed using 10 matched specimens. Group 1 consisted of 3 radially based approaches (standard flexor carpi radialis [FCR], standard FCR with radial retraction of FCR and flexor pollicis longus [FPL] tendons, extended FCR). Group 2 consisted of 2 ulnarly based approaches (volar ulnar, extended carpal tunnel). The primary outcome was total width of exposed distal radius at the watershed line. Mann-Whitney U and Wilcoxon rank testing was used to identify differences. RESULTS: The standard FCR approach exposed 29 mm (90%), leaving on average 3 mm (10%) of the ulnar corner unexposed. Retracting the FCR and FPL tendons radially allows for an extra 1 mm of volar ulnar corner exposure. Finally, converting to an extended FCR approach provided 100% exposure in all specimens. The volar ulnar exposure however provided exposure to only 9 mm (37%), leaving 20 mm (62.5%) left unexposed radially. The extended carpal tunnel provided exposure to 21 mm (65%), leaving 11 mm (35%) radially unexposed. Differences between each group were statistically significant (P < .05). CONCLUSIONS: The extended FCR approach exposed 100% of the volar distal radius in our study and may serve as a utilitarian volar surgical approach for exposure and fixation of distal radius fractures. Additional knowledge of the limitations of alternative approaches can be helpful in surgical planning.

Flexor tendon repair with a knotless barbed suture: a comparative biomechanical study.

PURPOSE: To test the hypothesis that a flexor tendon repair with only a knotless barbed suture technique provides a repair with a greater maximal load to failure and 2-mm gapping resistance than a traditional technique using a 4-strand core plus a running-locking epitendinous suture. METHODS: We assigned 41 fresh-frozen cadaveric flexor digitorum profundus tendons for repair by either a traditional technique using a 4-strand core (Tajima and horizontal mattress) plus a running-locking epitendinous suture (n = 20) or a bidirectional barbed suture technique using a knotless, 4-strand core secured with 3 transverse passes (n = 21). A biomechanical study was performed on each tendon-suture construct and the tendons were linearly distracted to failure at 100 mm/min. The maximal tensile load to failure, 2-mm gapping tensile load, and mode of failure were determined and statistically compared. RESULTS: The average maximal load to failure was not significantly different between the traditional repair (48 ± 12 N) and the barbed suture repair (50 ± 14 N). The average 2-mm gapping load was also insignificantly different between the traditional repair (42 ± 12 N) and the barbed suture repair (32 ± 9 N). The traditional repair failed by knot unraveling and suture rupture 35% and 65% of the time, respectively. The barbed suture repair failed by suture pull-out and rupture 67% and 33% of the time, respectively. The average load to failure by suture rupture was insignificantly different between the traditional repair (51 ± 13 N) and the barbed suture repair (63 ± 16 N). The average load to failure by knot unraveling using the traditional repair was 43 ± 11 N, whereas the average load to failure by suture pull-out using the barbed suture repair was 43 ± 8 N. CONCLUSIONS: The barbed suture repair did not demonstrate a significant difference in maximal load to failure and 2-mm gapping resistance compared with the traditional method of repair. CLINICAL RELEVANCE: This study examines the biomechanical differences between 2 types of flexor-tendon repair, which can help guide the surgical management for these injuries.