Biomechanical Analysis of Headless Compression Screw Versus Tension Band Wiring for Proximal Interphalangeal Joint Arthrodesis.

PURPOSE: Proximal interphalangeal (PIP) joint arthrodesis is a procedure employed to address arthritis, instability, and deformity. Multiple fixation methods are available to maintain stability across the arthrodesis interval, including headless compression screws (HCSs), tension band wiring (TBW), plating, and Kirschner wire constructs. The purpose of this study was to compare the biomechanical properties of the HCS and TBW techniques. METHODS: Thirty-two nonthumb digits from the paired upper limbs of four fresh frozen cadavers were divided into pairs, matching contralateral digits from the same specimen. One PIP joint of each pair was fused with an antegrade 3.5 mm HCS, and the second was fused with TBW using 0.035 in. Kirschner wires with 24-gauge dental wire. Each construct was then stressed to 10 N in the radial deviation, ulnar deviation, flexion, and extension planes, and stiffness (N/mm) was calculated. The fingers were stressed to failure in extension with the ultimate load and mode of failure recorded. RESULTS: When stressed in extension, the HCS construct had a significantly greater mean stiffness than the TBW construct (16.4 N/mm vs 10.8 N/mm). The stiffness in all other planes of motion were similar between the two constructs. The mean ultimate load to failure in extension was 91.4 N for the HCS and 41.9 N for the TBW. The most common mode of failure was fracture of the dorsal lip of the proximal phalanx (13/16) for the HCS and bending of the K-wires (15/16) for TBW. CONCLUSIONS: Arthrodesis of the PIP joint using a HCS resulted in a construct that was significantly stiffer in extension with greater than double the load to failure compared to TBW. CLINICAL RELEVANCE: Although the stiffness required to achieve successful PIP joint arthrodesis has not been well quantified, the HCS proved to be the most favorable construct with respect to initial strength and stability.

Fractional Lengthening of Forearm Flexor Tendons: A Cadaveric Biomechanical Analysis.

PURPOSE: Multiple procedures have been described for wrist and finger flexion contractures and spasticity. Fractional lengthening of forearm flexor tendons involves making parallel transverse tenotomies at the musculotendinous junction to elongate the muscle. Currently, there is limited literature to define the biomechanical consequences of this lengthening technique. METHODS: Forty-eight flexor tendons were harvested from eight paired upper limbs including flexor carpi radialis, flexor carpi ulnaris, flexor pollicis longus, and flexor digitorum superficialis tendons. Each tendon that was lengthened was paired with the contralateral tendon as a control. A pair of transverse tenotomies were completed for the fractional lengthening. The first tenotomy was performed at the musculotendinous junction where the tendon narrowed to 75% of its maximal width. The second tenotomy was made 1 cm distal to the first. Tendon length was measured before and after fractional lengthening at a constant resting tension of 1 N. The maximum load at failure of each tendon and the mechanism of failure were each measured and compared with the contralateral side. RESULTS: After fractional lengthening, the mean increase in resting tendon length was 4 mm. When loaded to failure, the mean maximum load of fractionally lengthened tendons was 42% of the mean maximum load of intact tendons. All lengthened tendons failed at the distal tenotomy site. CONCLUSIONS: Fractional lengthening resulted in an increase of 3-6 mm (mean: 4 mm) in tendon length at resting tension. There was a significant loss in tensile strength and load to failure following fractional lengthening compared with an intact musculotendinous unit. CLINICAL RELEVANCE: The reduction in tensile strength following fractional lengthening results in loads at failure that are, in some cases, lower than the estimated forces required to perform basic tasks. Caution during the healing and rehabilitation period is warranted.

Accuracy of Visual Estimates of Partial Flexor Tendon Lacerations.

PURPOSE: To determine whether hand surgeons could accurately and consistently estimate the size of partial flexor tendon lacerations. MATERIALS AND METHODS: Thirty-two partial flexor tendon lacerations were made in the flexor digitorum profundus tendons of a fresh-frozen cadaveric hand. Four hand surgeons and 5 residents estimated the size of the lacerations. Estimates were repeated 3 days later. Magnified images of the laceration cross-section were used to calculate the true size of each laceration. Inter- and intrarater reliability were calculated using the intraclass correlation coefficient. Accuracy was measured with the mean bias error and the mean absolute error. RESULTS: Interrater and intrarater reliabilities were both high. There was a high level of consistency for both surgeons and residents. In terms of accuracy, there was a 3% bias toward underestimation. The mean absolute error was 11%. There was no statistically significant difference between the accuracy of attending hand surgeons and that of residents. Participants were less accurate when estimating lacerations close to a 60% laceration threshold for surgical repair (lacerations in the 50%-70% range). For lacerations within this range, an incorrect management decision would have been made 17% of the time, compared with 7% of the time for lacerations outside that range. CONCLUSIONS: The accuracy and reliability of surgeon estimates of partial flexor tendon laceration size were high for surgeons and residents. Accuracy was lower for lacerations close to the threshold for repair. CLINICAL RELEVANCE: Visual estimation is acceptable for evaluating partial flexor tendon lacerations, but it may be less reliable for lacerations near the threshold for repair. Therefore, surgeons should be cautious when deciding whether or not to repair partial lacerations in the borderline range.

The effect of barbed suture tendon repair on work of flexion.

PURPOSE: To compare the work of flexion, ultimate strength, and gap resistance of a conventional 4-strand tendon repair to a knotless barbed-suture 4-strand tendon repair. METHODS: Tendon repairs were performed on 16 cadaver flexor digitorum profundus tendons using either a 4-strand double Kessler repair or a similar but knotless 4-strand repair with a unidirectional barbed suture. Work of flexion, gap resistance during cyclical loading, and ultimate strength of both techniques were determined and their means compared. RESULTS: There was no difference in mean maximum load and gap formation between the 2 techniques. Work of flexion was higher for the barbed-suture repair group compared with the traditional repair group (39 N·mm vs 31 N·mm). CONCLUSIONS: The higher work of flexion in the barbed-suture group suggests that barbed suture may negatively affect tendon gliding within the flexor tendon sheath. CLINICAL RELEVANCE: Knotless barbed-suture tendon repair leads to increased work of flexion compared with traditional flexor tendon repairs, which may result in an increased rupture incidence.

Advances in the healing of flexor tendon injuries.

The intrasynovial flexor tendons of the hand are critical for normal hand function. Injury to these tendons can result in absent finger flexion, and a subsequent loss of overall hand function. The surgical techniques used to repair these tendons have improved in the past few decades, as have the postoperative rehabilitation protocols. In spite of these advances, intrasynovial flexor tendon repairs continue to be plagued by postoperative scar formation, which limits tendon gliding and prevents a full functional recovery. This paper describes the current challenges of flexor tendon repair, and evaluates the most recent advances and strategies for achieving an excellent functional outcome.

Tenodesis for restoration of distal interphalangeal joint flexion in unrepairable flexor digitorum profundus injuries.

PURPOSE: To describe in a cadaveric model a tenodesis procedure for restoring distal interphalangeal joint flexion in patients with unrepairable isolated flexor digitorum profundus (FDP) injuries. METHODS: In 16 fresh-frozen cadaveric fingers, the FDP tendon was transected 1 cm proximal to its insertion to simulate an isolated zone I laceration. The injury was reconstructed using a palmaris longus tendon graft to create a mechanical linkage between the interphalangeal joints, which restored coordinated interphalangeal joint flexion. Joint motion and the force required to flex and extend the fingers were tested before and after the tenodesis. RESULTS: After FDP zone I laceration, distal interphalangeal joint flexion with load applied to the flexor digitorum superficialis tendon averaged 2°. The FDP flexion increased to a mean of 57° after the tenodesis. The sum of metacarpophalangeal, proximal interphalangeal and distal interphalangeal joint flexion averaged 186° before the tenodesis and increased to 233° after the tenodesis. The force required to achieve fingertip to palm contact and the force required to fully extend the proximal interphalangeal joint were not altered. CONCLUSIONS: In this cadaveric model, this tenodesis successfully restored coordinated interphalangeal joint flexion after a simulated zone I FDP laceration with improvements in distal interphalangeal joint flexion and composite finger flexion. Critical factors such as the effects of inflammation, edema, soft tissue healing, and scar formation could not be evaluated and would likely affect the outcomes of this procedure. The in vivo results of this procedure are not known. CLINICAL RELEVANCE: The potential use of this tenodesis for treating unrepairable isolated zone I FDP injuries was demonstrated in a cadaveric model. Further investigation of the outcomes and complications in vivo would be required before routine clinical use.

Complications related to harvest of the proximal end of the fibula: a systematic review.

BACKGROUND: The fibula is a common source of bone graft used in skeletal reconstruction. Although in most cases only the diaphysis of the fibula is used, there are clinical scenarios in which the proximal end of the fibula and fibular head are harvested for use in articular reconstruction. The purpose of this systematic review is to determine the incidence of knee instability and peroneal nerve motor dysfunction associated with removal of the proximal end of the fibula and fibular head. METHODS: A systematic search was performed using the PubMed, Ovid MEDLINE, and cochrane databases. Studies accepted for review included those that clearly reported donor site morbidity (instability or peroneal nerve motor dysfunction) after proximal fibula resection. All studies in which the proximal fibula was resected for bone graft or for marginal resection of tumor were included. RESULTS: Fifteen studies reporting a total of 337 patients were included. The rate of symptomatic knee instability after proximal fibula resection was 3.9%. The incidence of instability that was detectible on physical examination or stress radiographs was higher. Although transient motor dysfunction was not uncommon, the incidence of persistent peroneal nerve motor dysfunction was 2.6%. CONCLUSION: Although asymptomatic laxity is common, the incidence of symptomatic knee instability after resection of the proximal fibula is relatively low. The incidence of persistent peroneal nerve motor dysfunction is also low when the nerve is intentionally protected during surgery.

The association between glomus tumors and neurofibromatosis.

PURPOSE: To determine whether an epidemiologic association exists between glomus tumors and neurofibromatosis. METHODS: Using a pathology database, we established a study cohort consisting of all patients who had undergone excision of a glomus tumor of the hand between 1995 and 2010. We created a control cohort by randomly selecting 200 patients who had undergone excision of a ganglion cyst over the same period. We reviewed medical records for each cohort to identify patients with a diagnosis of neurofibromatosis. We calculated the odds ratio was calculated and performed Fisher's exact test to determine the significance of the association. RESULTS: We identified 21 patients with glomus tumors of the hand. Six of these patients carried the diagnosis of neurofibromatosis (29%). In contrast, no patients in the control group carried the diagnosis of neurofibromatosis. The odds ratio for a diagnosis of neurofibromatosis in association with a glomus tumor compared with controls was 168:1. CONCLUSIONS: This study provides evidence of a strong epidemiologic association between glomus tumors and neurofibromatosis. Glomus tumor should be included in the differential diagnosis in neurofibromatosis patients who present with a painful lesion of the hand or finger. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

Use of Biologic Agents in Extremity Reconstruction.

Skin and soft tissue defects of the lower extremity present a unique challenge for the reconstructive surgeon. Successful repair of the lower extremity relies not only on strong anatomical knowledge and surgical expertise, but also on careful consideration of the numerous preoperative factors and indications that may alter the patient's response to operative management. While many of these injuries result from burns, avulsive trauma, diabetes, or vascular insufficiencies, a significant portion can be associated with resection of neoplastic pathologies. This review outlines the uses, indications, and considerations for biologic wound agents in reconstructing skin and soft tissue defects of the lower extremity following Mohs micrographic surgery.

Arthrodesis as a salvage for failed proximal interphalangeal joint arthroplasty.

PURPOSE: To review the rate of fusion, complications, and subjective outcome measures of proximal interphalangeal joint arthrodesis after failed implant arthroplasty. METHODS: We conducted a retrospective review identifying patients from 1990 to 2009 who underwent proximal interphalangeal joint arthrodesis for implant arthroplasty failure. All types of implants were included. We reviewed clinical notes and radiographs identifying patient history, implant type, revisions before arthrodesis, method of arthrodesis, rate of union, time to union, and complications. We used the Michigan Hand Outcomes Questionnaire to assess patients' function and perceived clinical outcome. RESULTS: A total of 13 joints in 8 patients (6 female, 2 male) identified with an average clinical follow-up of 6.5 years (range, 1.0-12.3 y) were available for study. The average time from joint replacement to salvage for all implant types was 9.3 years (range, 1.6-32.2 y). Eight of the 13 fingers achieved union. The average time to union was 5.8 months (range, 1-11 mo). Eight of 13 fingers underwent removal of K-wires, tension band, or both. Excluding hardware-related problems, there were 4 additional complications in 4 patients. CONCLUSIONS: Salvage of failed proximal interphalangeal joint arthroplasty remains a challenging clinical problem. Although achieving solid fusion with arthrodesis is not completely reliable or without complication, patients' subjective and functional outcomes demonstrate fair to good results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Rodeo Thumb: To Replant or Not.

BACKGROUND: This study investigated patient-reported outcomes after surgical treatment of rodeo thumb amputation to guide clinical decision-making. METHODS: A retrospective review was performed for rodeo thumb amputations from 2009 to 2019. Patient-reported outcomes were collected and compared by injury level, age, and treatment. Two-sided t test was used to compare continuous variables, and Pearson chi-square test was used to compare categorical data. RESULTS: The study included 37 patients. Patients with interphalangeal injuries treated with replantation had Quick Disabilities of the Arm, Shoulder and Hand questionnaire scores similar to those treated with amputation (1 versus 8; p = 0.07). There was no significant difference in percentage of patients with similar or better roping ability after treatment (40 percent versus 79 percent; p = 0.26), and similar percentages were satisfied (80 percent versus 71 percent; p = 1.00). Patients with metacarpophalangeal injuries treated with replantation and those treated with amputation had similar questionnaire scores (7 versus 10; p = 0.47). Both groups had similar roping ability after treatment (67 percent versus 56 percent; p = 1.00), and there was no statistically significant difference in satisfaction (79 percent versus 44 percent; p = 0.34). Pediatric patients had questionnaire scores similar to those of adults (6 versus 8; p = 0.42). A significantly higher percentage of pediatric patients had similar roping ability following injury than adults (100 percent versus 54 percent; p = 0.02). Most patients in both groups were satisfied (89 percent versus 61 percent; p = 0.22). CONCLUSIONS: For both interphalangeal and metacarpophalangeal injuries, patient-reported outcomes were similar regardless of treatment. Children were able to return to roping and perform at a similar or higher level at a greater rate than adults, but had similar questionnaire scores and satisfaction.

Description and outcomes of a new technique for thumb Basal joint arthroplasty.

PURPOSE: Many surgeries have been described for thumb basal joint arthroplasty, but none is clearly superior to the others. The purposes of this study were to describe a simple technique for trapeziectomy and ligament reconstruction, and to determine its objective and subjective outcomes. METHODS: The surgical technique involves trapeziectomy, interposition of tissue, and abductor pollicis longus ligament reconstruction around the extensor carpi radialis longus tendon through a single incision. A retrospective chart review was performed on 48 patients who had undergone this surgery over an 11-year period by a single surgeon. RESULTS: At a minimum of 8 months' follow-up, grip had improved from 71% of contralateral strength to 93% of contralateral strength (p = .02), an increase of 32%. Appositional pinch had improved from 66% of contralateral strength to 98% of contralateral strength (p = .03), an increase of 49%. Radial abduction did not change to a statistically significant degree. Trapezial space ratio measured 0.44 preoperatively and 0.31 postoperatively (p < .01), a decrease of 30%. Of 42 patients, 27 had little or no pain and an additional 11 had improved pain postoperatively. Of 41 patients, 26 were very or extremely satisfied and 13 were satisfied with the outcome of the surgery. CONCLUSIONS: The described technique for trapeziectomy and ligament reconstruction is easy to perform, has a number of potential advantages over other arthroplasty techniques, and has similar short-term outcomes compared with ligament reconstruction and tendon interposition.

Oral Antibiotics Are Effective for the Treatment of Hand Osteomyelitis in Children.

Background: Acute osteomyelitis of the hand is common in the pediatric population. Treatment with intravenous antibiotics is expensive and is associated with catheter-site infection and thrombosis. The purpose of this study is to investigate the efficacy of managing osteomyelitis of the hand in children with oral antibiotics. Methods: A retrospective review of cases of acute osteomyelitis of the hand at a single pediatric institution over a 4.5-year period was performed. Demographic and clinical data were reviewed, and treatment courses and outcomes were analyzed. Results: In total, 21 patients with acute osteomyelitis of the hand were included in the study. Of the 21 patients, 17 were initiated on a 6-week course of oral antibiotics upon diagnosis. Thirteen were successfully treated with oral antibiotics alone, 3 required subsequent surgical debridement, and 3 required conversion to intravenous antibiotics. Of the 21 patients, 4 were treated with surgical debridement upon diagnosis due to gross purulent drainage and then initiated on a 6-week course of oral antibiotics. All patients who underwent debridement were treated successfully with postoperative oral antibiotics. Conclusions: Most cases of osteomyelitis of the hand in children can be treated with oral antibiotics, either as the primary treatment or as postoperative therapy. Surgical debridement is indicated when purulence is present at the time of initial diagnosis or if the infection progresses during treatment with oral antibiotics. The use of oral antibiotics for treating acute osteomyelitis of the hand in children may result in decreased cost and fewer catheter-associated complications.

Comparison of Fracture Location and Extent of Comminution in Isolated Scaphoid Fractures Versus Transscaphoid Fracture-Dislocations.

Background: Isolated scaphoid fractures (ISFs) are common, whereas transscaphoid fracture-dislocations (TSFDs) are not. Scaphoid fracture location and the extent of comminution are factors that affect treatment and outcome. The purpose of this study is to compare the radiographic characteristics of ISFs with TSFDs associated with greater arc injury. Methods: This study is a retrospective review of all ISFs and TSFDs that presented to our institution during a 5-year period. Fracture location (along the long axis of the scaphoid) was calculated by dividing the distance from the proximal pole to the fracture by the entire length of the scaphoid. The extent of comminution was measured in millimeters along the mid-axis of the scaphoid and divided by the entire length of the scaphoid. Results: One-hundred thirty-eight scaphoid fractures in 137 patients were identified. One-hundred twelve fractures (81%) were ISFs, and 26 (19%) were associated with a TSFD. The mean fracture location was more proximal in TSFDs than in ISFs. However, fractures occurred in the distal third of the scaphoid in 12% of ISFs compared with 0% of TSFDs. Nine percent of ISFs demonstrated comminution as compared with 12% of TSFDs. Extent of comminution was 16% and 28% for ISFs and TSFDs, respectively. Conclusion: Scaphoid fractures associated with greater arc injuries are located more proximally and are more comminuted than ISFs, and distal pole fractures rarely occur in the setting of TSFDs. The increased incidence and extent of comminution in TSFDs may be suggestive of a higher energy injury mechanism.

Vascularized medial femoral condyle graft for thumb metacarpal reconstruction: case report.

The vascularized medial femoral condyle bone graft has many clinical applications. It can be harvested as a thin, pliable, corticoperiosteal graft and wrapped around recalcitrant nonunions in long bones to achieve osseous union. It can also be harvested as a small, structural, corticocancellous graft and used to treat small defects such as scaphoid avascular nonunion. We present a case of thumb metacarpal osteomyelitis resulting in a large segmental osseous defect. Reconstruction was performed using a large, structural, vascularized bone graft from the medial femoral condyle.

The effect of ulnar styloid fractures on patient-rated outcomes after volar locking plating of distal radius fractures.

PURPOSE: Ulnar styloid fractures commonly occur with distal radius fractures (DRFs). Ulnar styloid fractures that involve the insertion of the radioulnar ligaments can cause distal radioulnar joint (DRUJ) instability, and the literature suggests that these fractures should be treated with open reduction internal fixation (ORIF). However, in the absence of DRUJ instability, the effects of ulnar styloid fractures are unknown. The purpose of this study is to evaluate the outcome of ulnar styloid fractures without DRUJ instability on patient-rated outcomes after DRF ORIF. METHODS: Between 2003 and 2008, a cohort of DRF patients treated with volar plating was enrolled. Patients with DRUJ instability treated at the time of distal radius ORIF were excluded. Radiographs were evaluated to identify and characterize ulnar styloid fractures. Patient-rated outcomes were measured at 6 weeks, 3 months, 6 months, and 12 months postoperatively using the Michigan Hand Outcomes Questionnaire (MHQ). Regression analysis was performed to determine whether the presence of an ulnar styloid fracture, the size or displacement of the fracture, or the healing status of the fracture was predictive of MHQ scores. RESULTS: One-hundred and forty-four patients were enrolled; 88 patients had ulnar styloid fractures. During the collection period, DRUJ instability was found intraoperatively in 3 patients; these patients had ulnar styloid ORIF and were not enrolled. The 144 patients with a stable DRUJ after DRF ORIF maintained DRUJ stability after surgery. In these patients, the presence of an ulnar styloid fracture did not affect MHQ scores. Furthermore, the size of the ulnar styloid fracture, the degree of displacement, and the healing status of the ulnar styloid did not affect MHQ scores. CONCLUSIONS: In patients with a stable DRUJ after DRF ORIF ulnar styloid fractures did not affect subjective outcomes as measured by the MHQ. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.

Arthroscopic Ganglionectomy in the Pediatric Population.

BACKGROUND: Arthroscopic dorsal wrist ganglionectomy is an established alternative to open excision in the adult population. The purpose of this study was to retrospectively compare outcomes of arthroscopic and open dorsal wrist ganglionectomy in the pediatric population. METHODS: All patients who underwent arthroscopic or open dorsal wrist ganglionectomy at a single pediatric institution between 2011 and 2014 were retrospectively evaluated by chart review and telephone interview. The primary outcome variable was whether or not the cyst had recurred. Other outcome measures included the incidence of complications, and patient-rated outcome measures such as satisfaction, pain, function, and aesthetics. RESULTS: There were eight cases of arthroscopic and 19 cases of open ganglionectomy, with a mean age of 14 years. At an average follow-up of 2 years, the recurrence rate was one of eight for the arthroscopic group and two of 19 for the open group. No patients in the arthroscopic group reported functional limitations, compared with three patients in the open group. On a 10-point scar appearance scale, with 1 being not satisfied at all and 10 being highly satisfied, the median score in the arthroscopic group was 9.5, compared with 8 in the open group. No patients in the arthroscopic group had residual pain at the surgical site, compared with nine patients in the open group, a finding that was statistically significant. All patients in the arthroscopic group reported that they would undergo surgery again, whereas two patients in the open group would not undergo surgery again. CONCLUSION: Arthroscopic dorsal wrist ganglionectomy compares favorably with open ganglionectomy in the pediatric population.

Brachial Artery Aneurysm in a 7-Month-Old Infant: Case Report and Literature Review.

Congenital upper extremity aneurysms are very rare and can be challenging to diagnose and treat. Although they can present as an isolated finding, they are often associated with other systemic conditions. We present a rare case of brachial artery aneurysm in a 7-month-old boy. The patient was evaluated with ultrasound, magnetic resonance angiography, and vein mapping before surgical reconstruction. After excision of the aneurysm, the brachial artery was reconstructed with an interposition saphenous vein graft. Because of potentially associated diagnoses and the possibility of concurrent aneurysms, this condition requires multidisciplinary management.

Management of complications with flap procedures and replantation.

Replantation and flap procedures employ microvascular techniques to salvage or reconstruct a severely damaged limb or digit. The most devastating complications include complete or partial flap loss, or replantation failure due to vascular complications. Often, these complications can be prevented by appropriate patient selection, careful surgical planning, meticulous technique, and proper postoperative management. This article discusses complications related to replantation and flap procedures in the upper limb, focusing on preventing and managing these complications.

Salvage Operations for Wrist Ligament Injuries with Secondary Arthrosis.

Wrist ligamentous injuries can be challenging to treat successfully. In some cases the ligament repair or reconstruction fails, resulting in instability and progressive degenerative changes. In other cases the original injury is missed, and the patient presents for the first time with established wrist arthritis. Multiple operations have been devised to treat patients with arthrosis secondary to wrist ligament injuries. This article discusses definitive salvage operations such as intercarpal arthrodeses and proximal row carpectomy, as well as other alternatives such as wrist denervation and radial styloidectomy.