Suture Materials, Needles, and Methods of Skin Closure: What Every Hand Surgeon Should Know.

Sutures are used ubiquitously in surgery and are the most implanted materials in hand surgery. However, surgical training does not routinely include formal education on stitching materials or needles. Rather, suture familiarity is passed down by common use throughout training. We focus on a brief history and evolution of suture materials and suture needles, their material and mechanical properties, hand surgery-specific applications, other methods of skin closure (staples, skin glue, and adhesive strips), a cost analysis, and advances in musculoskeletal suturing, with a look toward the future. Equipped with a fundamental knowledge of suture needles and suture materials, hand surgeons will be better prepared to select the most appropriate, situation-specific tools.

Secondary Management of Nonnail Perionychial Deformities: Restoring Aesthetic and Functional Subunits.

Delayed finger and thumb tip reconstruction should try to optimally reconstruct perioncyhial aesthetic and functional units by replacing tissue as closely resembling the original loss as possible. Avoid thinking in terms of a "reconstructive ladder" but rather going directly to the reconstructive choice that seems most suited to the task. Some reconstructive choices may seem more attractive because of their simplicity, but may not necessarily give the best functional and aesthetic result. Free flaps and the newer advancements with vascular island flaps give many more and versatile reconstructive options.

Why you should wear your seatbelt on an airplane: Burst fracture of the atlas (jefferson fracture) due to in-flight turbulence.

The Jefferson fracture is a burst-type fracture to the atlas first described in 1919, characterized by anterior and posterior fractures of the weak C1 ring caused by a sudden axial load to the vertex of the skull. Here we report a Jefferson fracture caused by head trauma due to mid-flight turbulence in an unrestrained 56-year-old male airline passenger. Imaging revealed a comminuted burst fracture of the atlas with an avulsion fracture of the transverse atlantal ligament. The patient was treated conservatively in a Miami-J collar with close clinical and radiographic follow-up. Lateral flexion-extension radiographs demonstrated fracture stability, and clinically the patient lacked pain or neurologic symptoms at 12 weeks from injury. To our knowledge this is the first report of a Jefferson fracture caused by axial compression attributable to in-flight turbulence. Traditionally associated with automobile crashes and diving headfirst into shallow pools, the axial load results in a compressive force to the atlas and subsequent lateral separation of the two halves of the C1 vertebral ring. The purpose of this case study is to alert providers, aircraft personnel, and passengers of the inherent risk of air travel and the importance of wearing a seatbelt at all times, describe the signs and symptoms of this often-overlooked fracture, and provide general treatment guidelines based on radiographic assessments of fracture stability.

Fuzzy Functional Dependencies as a Method of Choice for Fusion of AIS and OTHR Data.

Maritime situational awareness at over-the-horizon (OTH) distances in exclusive economic zones can be achieved by deploying networks of high-frequency OTH radars (HF-OTHR) in coastal countries along with exploiting automatic identification system (AIS) data. In some regions the reception of AIS messages can be unreliable and with high latency. This leads to difficulties in properly associating AIS data to OTHR tracks. Long history records about the previous whereabouts of vessels based on both OTHR tracks and AIS data can be maintained in order to increase the chances of fusion. If the quantity of data increases significantly, data cleaning can be done in order to minimize system requirements. This process is performed prior to fusing AIS data and observed OTHR tracks. In this paper, we use fuzzy functional dependencies (FFDs) in the context of data fusion from AIS and OTHR sources. The fuzzy logic approach has been shown to be a promising tool for handling data uncertainty from different sensors. The proposed method is experimentally evaluated for fusing AIS data and the target tracks provided by the OTHR installed in the Gulf of Guinea.

Maritime over the Horizon Sensor Integration: High Frequency Surface-Wave-Radar and Automatic Identification System Data Integration Algorithm.

To obtain the complete operational picture of the maritime situation in the Exclusive Economic Zone (EEZ) which lies over the horizon (OTH) requires the integration of data obtained from various sensors. These sensors include: high frequency surface-wave-radar (HFSWR), satellite automatic identification system (SAIS) and land automatic identification system (LAIS). The algorithm proposed in this paper utilizes radar tracks obtained from the network of HFSWRs, which are already processed by a multi-target tracking algorithm and associates SAIS and LAIS data to the corresponding radar tracks, thus forming an integrated data pair. During the integration process, all HFSWR targets in the vicinity of AIS data are evaluated and the one which has the highest matching factor is used for data association. On the other hand, if there is multiple AIS data in the vicinity of a single HFSWR track, the algorithm still makes only one data pair which consists of AIS and HFSWR data with the highest mutual matching factor. During the design and testing, special attention is given to the latency of AIS data, which could be very high in the EEZs of developing countries. The algorithm is designed, implemented and tested in a real working environment. The testing environment is located in the Gulf of Guinea and includes a network of HFSWRs consisting of two HFSWRs, several coastal sites with LAIS receivers and SAIS data provided by provider of SAIS data.

A Prospective Study on the Effect of Corticosteroid Injection Dosage for Hand Disorders in Non-Insulin Dependent Diabetics.

Local administration of corticosteroids is an effective yet potentially dangerous intervention in the treatment of hand disorders in diabetics. Prolonged exposure to hyperglycemia contributes to non-enzymatic glycosylation of various organ systems, which may cause detrimental health effects such as blindness, renal failure, and peripheral neuropathy, contributing to the high cost of health care. The purpose of this study is to determine the effects of corticosteroid dosage on serum glucose levels when used to treat common hand disorders in diabetic patients. Twenty-one patients with non-insulin-dependent diabetes mellitus treated with a corticosteroid injection were prospectively enrolled. Either triamcinolone 10 mg (T-10 group, N = 11) or 40 mg (T-40 group, N = 10) was administered with a local anesthetic. Fasting morning serum glucose, QuickDASH scores, and visual analog scale (VAS) pain scores were recorded prior to injection. Post-prandial serum glucose was recorded the evening of the injection, and the fasting serum glucose was recorded each morning. Clinical outcomes were recorded at 6 weeks and again at an average of 26 months. Patients in both cohorts, on average, had improvements in their Quick- DASH and VAS scores after the injection without significant variation. There was a significant elevation in serum glucose in both groups. T-10 had an average glucose increase of 53 mg/dL (41%), which returned to baseline at 21 hours. T-40 had a maximum glucose increase of 50 mg/dL (40%), which returned to baseline in 58 hours. The difference in time to return to baseline was statistically significance. Both T-10 and T-40 are effective in relieving painful symptoms and improving patient functionality after injection. A lower dosage triamcinolone is associated with a quicker return of serum glucose to baseline and may be a safer alternative to higher dosages when considering prolonged hyperglycemia and its known detrimental effects of non-enzymatic glycosylation on various organ systems.

Mycobacterium longobardum Infection in the Hand.

Mycobacterium longobardum is a slow-growing, nontuberculous mycobacterium that was first characterized in 2012. We report a case of M. longobardum infection in the right middle finger of a diabetic man. He underwent surgery for a presumed diagnosis of an epidermal inclusion cyst. Molecular diagnosis of the surgical specimens demonstrated M. longobardum through RNA polymerase ß-subunit encoding gene sequencing. After surgery, the patient was treated with antibiotics and eventually cured of the infection. To the best of our knowledge, this is only the second reported case of a pathogenic M. longobardum infection worldwide and the first such case in the hand. The purposes of this case study are to alert treating providers to consider nontuberculous mycobacterium infection when an inflammatory process persists, discuss signs and symptoms of the disease, and provide general treatment guidelines.

Machete injuries to the upper extremity.

PURPOSE: We intend to describe and analyze the spectrum of upper extremity injuries that arises from both accidental and intentional machete injuries with a focus on associated complications and comorbidities. This review is the first from a United States institution, and the only from a designated level 1 trauma center. METHODS: A retrospective review of machete related upper extremity injuries admitted to a level 1 trauma center from 2008 to 2016. The following data was collected on admitted patients: demographics, mechanism of injury, surgical management, and complications. We assessed the data with Pearson Chi square analysis. RESULTS: This cohort consisted of 48 patients (mean = 42 ± 13 years old); the majority were men (96%) involved in an assault (81%). These patients had a high rate of documented psychiatric history, substance and tobacco abuse, and being underinsured. Patient follow-up was extremely variable: 75% of patients presented for follow-up care (mean = 149 ± 344 days; range 8-1846 days). 44% had complications (i.e., infection, tendon rupture, nerve palsy). We identified no associations when examining follow-up rates or complication rates regarding patient comorbidities, insurance status, mechanism of injury, or the need for a nerve, artery, or tendon repair. Patients with current tobacco use did have an increased risk for infection. The majority (52%) of injuries occurred on the ulnar side of the forearm and to the non-dominant extremity (66%). Patients assaulted by machetes are significantly more likely to have a history of psychiatric illness, substance abuse, tobacco use, and are more likely to be underinsured compared to those with accidental machete injuries. CONCLUSIONS: While machete injuries may be uncommon in most areas of the United States, physicians should give special attention to the patient comorbidities as many of these patients have complex medical and social issues which could complicate attempts of appropriate treatment. LEVEL OF EVIDENCE: IV; Prognostic Study.

The effect of two different trochanteric nail lag-screw designs on fixation stability of four-part intertrochanteric fractures: a clinical and biomechanical study.

OBJECTIVES: To compare lag-screw sliding characteristics and fixation stability of two cephalomedullary nails (CMN) with different lag-screw designs (solid and telescopic), we conducted a biomechanical study and an analysis of clinical results. METHODS: Six pairs of cadaver femurs with simulated intertrochanteric fractures were randomly assigned to one of two CMN fixations. Femur constructs were statically then cyclically loaded on an MTS machine. Lag-screw sliding and inferior and lateral femoral head displacements were measured, following which failure strength of the construct was determined. Forty-five patients with intertrochanteric fractures treated with these CMN were identified. Medical records and radiographs were reviewed and analyzed using Fisher's exact test and Student's t test to determine lag-screw sliding. RESULTS: No difference was seen with cycling in inferior femoral head displacement between the two screw designs. The solid screw had an average inferior head displacement of 1.75 mm compared with 1.59 mm for the telescoping screw (p = 0.772). The solid lag screws slid an average of 2.79 mm lateral from the nail, whereas the telescoping screws slid an average of 0.27 mm (p = 0.003). In our clinical review, the average lateral sliding of the telescoping screw was 0.5 mm and of the solid screw was 3.7 mm (p < 0.001). Despite differences in lateral sliding, there were no reoperations for prominent or painful hardware in either group. CONCLUSIONS: Both designs are acceptable devices for stabilization of intertrochanteric fractures. Clinical and biomechanical data demonstrate greater lateral sliding in the solid lag-screw group, making for greater potential for lateral-sided hip pain in CMNs with solid lag screws as opposed to telescoping lag screws.

Vascular smooth muscle cell optimization of vasculogenesis within naturally derived, biodegradable, hybrid hydrogel scaffolds.

BACKGROUND: As vascularization represents the rate-limiting step in permanent incorporation of hydrogel-based tissue-regeneration templates, the authors sought to identify the material chemistry that would optimize endothelial cell adhesion and invasion into custom hydrogel constructs. The authors further investigated induction of endothelial tubule formation by growth factor supplementation and paracrine stimulation. METHODS: Hydrogel scaffolds consisting of combinations of alginate, collagen type I, and chitosan were seeded with human umbilical vein endothelial cells and maintained under standard conditions for 14 days. Cell density and invasion were then evaluated. Tubule formation was evaluated following basic fibroblast growth factor addition or co-culture with human aortic smooth muscle cells. RESULTS: Human umbilical vein endothelial cells demonstrated greatest cell-surface density and invasion volumes with alginate and collagen (10:1 weight/weight) scaffolds (p < 0.05). Supplementation with basic fibroblast growth factor increased surface density but neither invasion nor tubule formation. A significant increase in tubule content/organization was observed with increasing human aortic smooth muscle cell-to-human umbilical vein endothelial cell ratio co-culture. CONCLUSIONS: Alginate and collagen 10:1 scaffolds allow for maximal cellularization compared with other combinations studied. Growth factor supplementation did not affect human umbilical vein endothelial cell invasion or morphology. Paracrine signaling by means of co-culture with human umbilical vein endothelial cells stimulated endothelial tubule formation and vascular protonetwork organization. These findings serve to guide future endeavors toward fabrication of prevascularized tissue constructs.

The effects of pronator quadratus repair on outcomes after volar plating of distal radius fractures.

OBJECTIVES: The purpose of this study was to evaluate forearm rotation after volar plating of the distal radius fractures with and without pronator quadratus repair. DESIGN: This was an institutional review board-approved retrospective review of prospectively collected data. SETTING: The study was conducted at an Academic Medical Center. PATIENTS: Over a 5-year period, 606 patients with distal radius fractures (OTA classifications 23-A through 23-C) were enrolled in an institutional review board-approved, prospectively collected, distal radius database. One hundred and seventy-five patients underwent open reduction and internal fixation with volar plating. Of these, 112 patients had complete 1-year follow-up (6 weeks, 3, 6, and 12 months) and were included in this study. INTERVENTION: Volar plating of the distal radius was performed with pronator quadratus repair (group A), versus volar plating without pronator quadratus repair (group B). Surgeries in group A were performed by a fellowship trained hand surgeon utilizing volar plates from Depuy Orthopedics (Warsaw, IN), whereas the surgeries in group B were performed by a fellowship trained orthopedic trauma surgeon utilizing volar plates from Stryker (Mahwah, NJ). MAIN OUTCOME MEASUREMENTS: Primary outcomes include forearm range of motion. Secondary outcomes include grip strength, pain levels, functional outcomes (DASH scores), radiographs, and complications. RESULTS: Baseline and demographic characteristics of the patients were similar between the 2 groups. There was no difference in mean pronation (P = 0.08) at 1 year. Among secondary analyses, radial deviation was significantly different (P = 0.03); however, pain (P = 0.13) and DASH scores (P = 0.14) were not. The only patient that requested plate removal had the pronator repaired (group A). CONCLUSIONS: We conclude that there is no advantage in repairing the pronator quadratus during volar plating of distal radius fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes after knee joint extensor mechanism disruptions: is it better to fracture the patella or rupture the tendon?

OBJECTIVES: The purpose of this study was to compare the outcome after the operative treatment of patella fractures (PFs) as compared with those of quadriceps tendon and patella tendon (PT) ruptures. DESIGN: This pertains to a retrospective case control. SETTING: The setting was in academic teaching hospitals. PATIENTS: Ninety-four patients with 99 extensor mechanism disruptions were treated operatively. Of these, 50 (50%) were PFs; 36 (37%) were quadriceps ruptures; and 13 (13%) were PT ruptures. MAIN OUTCOME MEASURES: The patients were evaluated at 6 and 12 months and were tested for range of motion, quadriceps circumference and strength, SF36, Lysholm, and Tegner outcome scores by independent observers. Radiographs of the knee were obtained to assess bony healing, posttraumatic arthritis, and heterotopic ossification. RESULTS: A minimum of 12-month follow-up (range 12-81 months) was available for 76 patients (77%). PFs were seen more commonly in women (P < 0.001) and PT ruptures tended to occur in younger males (P < 0.001), with no difference in the body mass index. Thigh circumference was significantly smaller than normal in PFs at 1 year as compared with tendon injuries. At latest follow-up, there were no significant differences noted with respect to knee range of motion, radiographic arthritis, Tegner, Lysholm, or SF36 scores. CONCLUSIONS: There were no significant differences with regard to outcome in patients sustaining these injuries. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Treatment of two-part proximal humerus fractures: intramedullary nail compared to locked plating.

BACKGROUND: Two-part proximal humerus fractures are common orthopedic injuries for which surgical intervention is often indicated. Choosing a fixation device remains a topic of debate. PURPOSE: The purpose of this study is to compare two methods of fixation for two-part proximal humerus fractures, locking plate (LP) with screws versus intramedullary nailing (IMN), with respect to alignment, healing, patient outcomes, and complications. To our knowledge, a direct comparison of these two devices in treating two-part proximal humerus fractures has never before been studied. We hope that our results will help surgeons assess the utility of LP versus IMN. METHODS: A retrospective chart review was performed on 24 cases of displaced two-part surgical neck fractures of the humerus. Twelve shoulders were treated using IMN fixation and 12 others were fixated with LP. Data collected included sociodemographic, operative details, and postoperative care and function. RESULTS: Radiographic comparison of fixation demonstrated an average neck-shaft angle of 124° and 120° in the IMN group and LP group, respectively. Adjusted postoperative 6-month follow-up range of motion was 134° of forward elevation in the IMN group and 141 in the LP group. The differences in range of motion and in complication rates were not found to be significant. CONCLUSIONS: Our results suggest that either LP fixation or IMN fixation for a two-part proximal humerus fracture provides acceptable fixation and results in a similar range of shoulder motion. Although complication rates were low and insignificant between the two groups, a trend toward increased complications in the IMN group is noted.

Future practice plans of orthodontic residents in the United States.

INTRODUCTION: The purpose of this study was to investigate the future clinical practice plans of orthodontic residents in the United States. METHODS: All program chairs and directors of the 65 US orthodontic residency programs were contacted by e-mail and telephone and asked for permission to e-mail their residents and invite them to take part in an anonymous 57-item questionnaire online. A total of 335 e-mails from 37 programs were obtained, and the survey was sent in May 2007. Basic statistics including chi-square comparative analyses were performed by sex, age, and year of program. RESULTS: A total of 63.04% of orthodontic residents plan to use self-ligating brackets; 84.06% plan to use Invisalign (Align Technology, Santa Clara, Calif); 92.03% plan to use temporary anchorage devices, and 72.26% plan on placing them themselves; 28.26% plan to use cone-beam computerized tomography; 92.75% plan to use a digital imaging program; 45.65% plan to use indirect bonding; and 10.87% plan to use lingual orthodontics. A total of 70.07% plan to use 2-phase treatment, and 61.59% said they will use functional appliances. A total of 81.16% plan to become certified by the American Board of Orthodontics, but only 18.12% thought certification should be mandatory for licensure; 36.50% indicated that a master of science degree should be required in their program, and 77.94% believe that a 24- to 30-month program adequately prepares them for future orthodontic practice. CONCLUSIONS: Newer orthodontic technologies such as self-ligating brackets, temporary anchorage devices, and Invisalign as well as functional appliances are expected to grow in popularity in the United States because of projected future use by orthodontic residents. Two-phase orthodontic treatment with functional appliance mechanics will continue to be used. Most orthodontic residents will become certified by the American Board of Orthodontics but do not believe it should be necessary for licensure. Orthodontic residents in the United States believe that a 2-year program adequately prepares them for private practice.