Current Concepts in Compressive Neuropathies of the Upper Extremity.

The carpal and cubital tunnel syndromes are the most common compression neuropathies of the upper extremity. Although the diagnosis and management of these neuropathies have evolved over the past few decades, the ideal primary surgical treatment has not yet been established and management of recurrence remains a challenge. Revision surgery with simple repeated nerve decompression even accompanied by neurolysis does not always result in satisfactory clinical outcomes. Coverage with soft tissue or wrapping of the nerve with biologic or synthetic protective barriers can be used as an ancillary technique in the revision surgery to enhance nerve healing, preventing perineural scarring and adhesions. Future randomized larger trials combined with better understanding of nerve biology may be necessary to optimize primary and revision surgical treatment for carpal and cubital tunnel syndrome.

Scapholunate Ligament Injury: Management Strategies From Occult Injury to Arthritis.

This chapter will explore scapholunate ligament injuries with a focus on injury recognition, diagnosis, the natural history, and options for treatment. Treatment is based upon injury factors, patient factors, and surgeon preference. The classification systems in common use will be discussed, and treatment options will be explored, including nonsurgical, arthroscopic, repair, reconstruction, pain relieving measures, and salvage procedures.

Intraoperative Subluxation of the Ulnar Nerve: Use of a Triceps Sling Reconstruction Technique.

PURPOSE: To determine whether the triceps sling reconstruction technique is a safe and effective treatment of intraoperative ulnar nerve subluxation after in situ decompression. METHODS: Twelve patients who underwent a triceps sling reconstruction for intraoperative ulnar nerve subluxation after in situ release were retrospectively reviewed. The triceps sling technique consists of harvesting a small, distally based strip of triceps tendon and suturing the proximal end of the strip to the posterior aspect of the released Osborne ligament. Thus, a sling is created between the medial epicondyle and the olecranon, preventing the nerve from subluxating. Patients were clinically evaluated before and after surgery. Visual analog scale pain scores, static 2-point discrimination, strength, and Disabilities of the Arm, Shoulder, and Hand score were assessed. RESULTS: At a mean follow-up of 31 months (range, 24-38 months), there was a significant improvement in mean visual analog pain scores from 8.6 to 0.2. Static 2-point discrimination was improved from a mean of 9.1 mm before surgery to 5.7 mm afterward. Strength improved by a mean of 33% and 30% with grip and pinch, respectively. Mean Disabilities of the Arm, Shoulder, and Hand score improved from 45.9 to 3.7. No subluxation of the ulnar nerve was noted after surgery. No other complications were noted. No reoperations were required during the follow-up period. CONCLUSIONS: Triceps sling reconstruction is a safe treatment in patients with intraoperative ulnar nerve subluxation after in situ decompression. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Treatment for proximal pole scaphoid nonunion with capsular-based vascularized distal radius graft.

PURPOSE: We retrospectively reviewed the results of 89 patients with proximal pole scaphoid nonunion, 58 with avascular necrosis, treated with a capsular-based vascularized distal radius graft. METHODS: Seventy-one male and eighteen female patients with symptomatic nonunion at the proximal pole of the scaphoid were included in this study. No patient had a humpback deformity. In all patients, the vascularized bone graft was harvested from the dorsum of the distal radius and was attached to a capsular flap of the dorsal wrist capsule. After fixation of the scaphoid with a small cannulated screw, the graft was inserted press-fit into the scaphoid trough in the nonunion site. Supplementary fixation of the graft with a microsuture anchor into the scaphoid was used in 66 patients. RESULTS: At a mean time of 12.3 weeks (range 6-24) after surgery, solid union was achieved in 76 of 89 patients (49 of 58 with avascular necrosis). Eleven patients had persistent nonunion and two fibrous union as determined by CT scan. Sixty-six of the patients with solid bone union were completely pain free, and ten complained of slight pain with strenuous activities. No donor site morbidity was observed. CONCLUSIONS: The capsular-based vascularized bone graft from the distal radius is a reliable alternative technique for scaphoid nonunions. It is a simple and expedient harvesting technique without the need for a microsurgical anastomoses. The supplemental fixation with a microsuture anchor eliminates the risk of graft displacement.

Cubital Tunnel Syndrome.

Cubital tunnel syndrome is the most common cause of symptomatic ulnar neuropathy. The unique anatomic course of the ulnar nerve around the elbow makes it particularly vulnerable at a location far from its terminal destination. The natural progression of cubital tunnel syndrome allows patients who have mild symptoms to be adequately treated nonsurgically. Minor changes in activity combined with appropriate splinting may acceptably alleviate symptoms. Surgical intervention is recommended for patients who have more severe symptoms. Current data confirm that in situ ulnar nerve decompression, partial medial epicondylectomy, and anterior transposition result in equal success rates; however, more invasive techniques may increase the risk for complications. If primary surgical intervention fails, revision surgery can provide good results. Modern techniques for revision surgery incorporate the placement of a protective circumferential barrier around the pathologic nerve to mitigate cicatrix formation. Although several attractive options are currently available for the management of cubital tunnel syndrome, further research is necessary to guide treatment.

Cheilectomy for Treatment of Symptomatic Distal Interphalangeal Joint Osteoarthritis: A Review of 78 Patients.

PURPOSE: To determine whether open cheilectomy and debridement of the distal interphalangeal (DIP) joint is a safe and effective alternative to joint arthrodesis for the treatment of symptomatic osteoarthritis. METHODS: Seventy-eight patients with symptomatic DIP joint osteoarthritis and with a minimum follow-up of 24 months were retrospectively reviewed. Preoperative radiographs were graded. Open cheilectomy and debridement of the DIP joint was performed in all patients. The DIP joint was immobilized for 4 weeks after surgery. Patients were evaluated clinically and radiographically. Visual analog scale pain scores and range of motion were assessed. RESULTS: At a median final follow-up of 36 months (minimum, 24 months), there was a significant improvement in mean visual analog scale pain scores from 8 to 1. Distal interphalangeal joint flexion contracture was improved by a mean of 6° and DIP joint range of motion was improved by a mean of 20°. No postoperative infections or other complication were noted. No reoperations were required/performed during the follow-up period. CONCLUSIONS: Open DIP joint cheilectomy is a safe and effective alternative to DIP joint arthrodesis in patients with symptomatic osteoarthritis who wish to preserve joint motion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Revision of the Failed Thumb Carpometacarpal Arthroplasty.

PURPOSE: To evaluate the outcome of revision surgery for failed thumb carpometacarpal (CMC) arthroplasty. METHODS: We retrospectively analyzed 32 patients with failed thumb CMC arthroplasty. The primary reason for revision was pain caused by metacarpal subsidence. Revision surgery included soft tissue interposition and distraction pinning to address the metacarpal subsidence. Additional ligament reconstruction was performed in patients with thumb instability. Eight patients required additional metacarpophalangeal joint fusion for concomitant joint hyperextension. Eleven required additional partial excision of the trapezoid for concomitant scaphotrapezoidal joint arthritis. All patients were evaluated clinically and radiographically. RESULTS: Mean follow-up was 57 months (range, 24-121 months). Pain levels evaluated by visual analog scale were significantly reduced in all patients after revision surgery. Mean grip strength and key pinch strength significantly increased. Twenty-seven patients achieved good functional results; those for 5 patients were fair. CONCLUSIONS: This study showed that revision surgery with distraction pinning and soft tissue interposition with or without ligament reconstruction was an effective treatment for failed CMC arthroplasty of the thumb. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Release of the stiff elbow with mini-open technique.

BACKGROUND: Currently, there are many techniques used in the surgical release of elbow contracture, but no single technique has gained widespread acceptance. The purpose of this study was to report the outcomes of a lateral-column approach combined with a mini-open triceps-splitting technique for elbow contracture release. METHODS: Thirty-six patients with a mean age of 39 years were included in the study. All patients underwent a combined lateral and minimal posterior triceps-splitting open elbow contracture release. Elbow range of motion and visual analog scale pain scores were recorded. The Mayo Elbow Performance Score was used to assess functional outcome. RESULTS: The mean follow-up period was 38 months. Mean pain levels decreased from 7.59 preoperatively to 0.44 postoperatively (P < .05). The total arc of elbow motion increased from 52° preoperatively to 109° postoperatively, with an improvement of 57° (P < .05). The Mayo Elbow Performance Score improved from 44.17 preoperatively to 90.83 postoperatively (P < .05). CONCLUSION: This study shows that a combined lateral and mini-open triceps-splitting approach is a safe and effective alternative technique for the treatment of elbow contractures.

Distal biceps tendon history, updates, and controversies: from the closed American Shoulder and Elbow Surgeons meeting-2015.

Understanding of the distal biceps anatomy, mechanics, and biology during the last 75 years has greatly improved the physician's ability to advise and to treat patients with ruptured distal tendons. The goal of this paper is to review the past and current advances on complete distal biceps ruptures as well as controversies and future directions that were discussed and debated during the closed American Shoulder and Elbow Surgeons meeting in 2015.

Treatment recommendations for carpal tunnel syndrome and peripheral nerve repair.

Although open and endoscopic techniques for carpal tunnel release can provide excellent results, neither technique has demonstrated clinical superiority. A permanent nerve injury remains the most devastating complication regardless of the technique used. Symptoms in carpal tunnel syndrome recur in up to 30% of patients, usually secondary to scarring of the median nerve. Repeated nerve decompression alone does not always provide satisfactory results in patients with recalcitrant carpal tunnel syndrome. Supplementary techniques with either biologic or synthetic adhesion barriers can be used to cover the nerve, improving functional recovery and preventing recurrent scarring. Direct end-to-end repair without tension remains the gold standard treatment of peripheral nerve lacerations. When primary repair is not possible, biologic or synthetic nerve conduits and nerve allografts are an alternative to autografts. Future advances in bioengineering and better understanding of nerve biology combined with randomized, multicenter, larger studies may lead to the optimal method of peripheral nerve reconstruction.

Preliminary results of recurrent cubital tunnel syndrome treated with neurolysis and porcine extracellular matrix nerve wrap.

PURPOSE: To evaluate the clinical results of revision neurolysis and wrapping with porcine extracellular matrix (AxoGuard Nerve Protector, AxoGen Inc., Alachua, FL) for cubital tunnel syndrome after one previous surgical decompression. METHODS: Twelve patients with recurrent cubital tunnel syndrome were treated with decompression, porcine extracellular matrix nerve wrap, and minimal medial epicondylectomy (if not previously performed). The average follow-up period was 41 months (range, 24-61 mo). All patients had recurrent symptoms after having previously undergone one surgical decompression. The mean patient age was 45 years (range, 30-58 y). All patients were evaluated subjectively and objectively (pain, satisfaction, static 2-point discrimination, grip strength, and pinch strength). RESULTS: A significant improvement was demonstrated in postoperative pain levels (from 8.5 to 1.7), grip strength (from 41% to 86% of the unaffected side), and pinch strength (from 64% to 83% of the unaffected side). Static 2-point discrimination improved from an average 10.4 mm preoperatively to 7.6 mm postoperatively. Eleven of 12 patients demonstrated 2 mm or more improvement in 2-point discrimination postoperatively. There were no complications related to the use of the porcine extracellular matrix for nerve wrapping. CONCLUSIONS: This study found that secondary decompression combined with porcine extracellular matrix nerve wrapping was an effective and safe treatment for patients with recurrent cubital tunnel syndrome. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Terrible triad injuries of the elbow: does the coronoid always need to be fixed?

BACKGROUND: The "terrible triad" of the elbow is a complex injury that can lead to pain, stiffness, and posttraumatic arthritis if not appropriately treated. The primary goal of surgery for these injuries is to restore stability of the joint sufficient to permit early motion. Although most reports recommend repair and/or replacement of all coronoid and radial head fractures when possible, a recent cadaveric study demonstrated that type II coronoid fractures are stable unless the radial head is removed and not replaced. QUESTIONS/PURPOSES: The purposes of this study were to determine the (1) range of motion; (2) clinical scores using the Disabilities of the Arm, Shoulder and Hand (DASH) and the Broberg-Morrey questionnaires; and (3) rate of arthritic changes, heterotopic ossification (HO), or elbow instability postoperatively in patients whose terrible triad injuries of the elbow included Reagan-Morrey type I or II coronoid fractures that were treated without fixation. METHODS: Between April 2008 and December 2010, 14 consecutive patients were treated for acute terrible triad injuries that included two Regan-Morrey type I and 12 Regan-Morrey type II coronoid fractures. Based on the senior author's (DGS) clinical experience that coronoid fractures classified as such do not require fixation to restore intraoperative stability to the posterolaterally dislocated elbow, all injuries were treated by the senior author with a surgical protocol that included radial head repair or prosthetic replacement and repair of the lateral ulnar collateral ligament (LUCL) followed by intraoperative fluoroscopic examination through a range of 20° to 130° of elbow flexion to confirm concentric reduction of the ulnohumeral joint. Using this protocol, intraoperative stability was confirmed in all cases without any attempt at coronoid or anterior capsular repair. Repair of the medial collateral ligament or application of external fixation was not performed in any case. All patients were available for followup at a minimum of 24 months (mean, 41 months; range, 24-56 months). The mean patient age was 52 years (range, 32-58 years). At the followup all patients were evaluated clinically and radiographically by the senior author. Outcome measures included elbow range of motion, forearm rotation, elbow stability, and radiographic evidence of HO or arthritic changes using the Broberg and Morrey scale. Elbow instability was defined as clinical or radiographic evidence of recurrent ulnohumeral dislocation or subluxation at final followup. Clinical outcomes were assessed with the patient-reported DASH questionnaire and the physician-administered Broberg-Morrey elbow rating system. RESULTS: The mean arc of ulnohumeral motion at final followup was 123° (range, 75°-140°) and mean forearm rotation was 145° (range, 70°-170°). The mean Broberg and Morrey score was 90 of 100 (range, 70-100, higher scores reflecting better results) and the average DASH score was 14 of 100 (range, 0-38, higher scores reflecting poorer results). Radiographs revealed mild arthritic changes in one patient. One patient developed radiographically apparent but asymptomatic HO. None of the patients demonstrated instability postoperatively. CONCLUSIONS: These findings demonstrate that terrible triad injuries with type I and II coronoid process fractures can be effectively treated without fixation of coronoid fractures when repair or replacement of the radial head fracture and reconstruction of the LUCL complex sufficiently restores intraoperative stability of the elbow through a functional range of motion. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines to Authors for a complete description of levels of evidence.

Tendon allograft interposition for failed distal ulnar resection: 2- to 14-year follow-up.

PURPOSE: To evaluate the mid- to long-term outcome of distal radioulnar interposition arthroplasty using an Achilles allograft for salvage of painful instability after distal ulnar resection. METHODS: Twenty-six patients with an average age of 43 years were treated with Achilles tendon allograft interposition for failed distal ulnar resection. The average follow-up period was 79 months (range, 25-174 mo). Patients had an average of 2 previous procedures. All patients were evaluated clinically and radiographically. At the final follow-up, pain level, satisfaction, forearm rotation, grip strength, and Mayo Modified Wrist Score were assessed. RESULTS: All clinical parameters demonstrated statistically significant improvement at the final follow-up. Mean patient pain scores improved from 8.1 to 1.3, and patient satisfaction scores improved by an average of 6.8 points. Preoperative and postoperative forearm rotation and grip strength measurements improved by an average of 28° in pronation, 41° in supination, and 72% in grip strength. The mean Mayo Modified Wrist Score improved from 42 to 85. Postoperative radiographs showed preservation of an adequate space between the distal radius and the resected distal ulna. No postoperative infections and no foreign body reactions relating to the allograft were observed. CONCLUSIONS: Interposition arthroplasty with an Achilles allograft was an effective salvage procedure for the treatment of failed distal ulnar resection, preventing impingement of the ulnar stump on the radius. This procedure potentially provides a safe and reliable treatment, especially for patients who may not be candidates for implant arthroplasty. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Chronic Essex-Lopresti injuries: an alternative treatment method.

BACKGROUND: Currently, no technique has met general acceptance for the restoration of forearm longitudinal stability in chronic Essex-Lopresti injuries. The purpose of this study is to present an alternative treatment method for chronic Essex-Lopresti lesions by radial head replacement and ulnar shortening osteotomy. METHODS: Seven patients with a mean age of 42.4 years were included in the study. Five patients had a staged approach, and 2 underwent both procedures simultaneously. The pain level was assessed with the use of a visual analog scale. Elbow, forearm, and wrist range of motion was evaluated. The Mayo Elbow Performance Score and Mayo Wrist Score were used to assess the postoperative outcomes. RESULTS: The mean follow-up time was 33 months. The mean pain level was reduced from 8.4 points preoperatively to 3.3 points postoperatively (P < .05). The elbow arc of motion was increased on average from 79° preoperatively to 121° postoperatively (P < .05). Forearm rotation improved from 76° preoperatively to 119° postoperatively (P < .05). The wrist arc of motion improved from 94° preoperatively to 114° postoperatively (P < .05). The mean postoperative Mayo Elbow Performance Score and Mayo Wrist Score were 82 points and 71 points, respectively. The mean ulnar variance was reduced from +8 mm to +3.5 mm postoperatively. CONCLUSION: This study shows that radial head replacement in combination with ulnar shortening osteotomy can be used as an alternative reconstructive procedure in the case of a complex chronic Essex-Lopresti injury. This combination of known procedures yields predictable and satisfactory outcomes and a low complication rate. LEVEL OF EVIDENCE: Level IV, case series, treatment study.

Elbow arthritis: current concepts.

Elbow arthritis is a debilitating condition manifesting as a painful, stiff elbow. The purpose of this article is to provide an update and analyze current management, treatment options, and outcomes of treatment for elbow arthritis. This article focuses on recent developments in the treatment for elbow arthritis. Nonsurgical management may provide symptomatic relief in the majority of patients in the early stages of the disease process. Surgical treatment is guided by disease etiology and severity, patient age, and functional demands. Arthroscopic or open synovectomy, debridement arthroplasty, and interposition arthroplasty are generally recommended for the young and active patient population, whereas for low-demand and elderly patients with end-stage painful arthritis, total elbow arthroplasty is considered a more suitable surgical option. Advances in arthroscopic techniques and implant design have led to substantial improvements in the treatment of elbow arthritis.

Supplemental graft fixation for distal radius vascularized bone graft.

Vascularized bone grafts from the distal radius have been used successfully for the treatment of scaphoid nonunions. Typically, the harvested graft is secured into the scaphoid with a press-fit technique. This type of fixation may lead to graft extrusion in the early postoperative period, and thus to treatment failure. In this technical note, we describe the use of micro bone suture anchors for supplemental fixation of the vascularized bone graft into the scaphoid. It is a simple and quick technique and provides an enhanced fixation of the vascularized bone graft, which is beneficial during the early critical period of bone healing.

The contracted elbow: is ulnar nerve release necessary?

BACKGROUND: Prophylactic release of the ulnar nerve in patients undergoing capsular release for severe elbow contractures has been recommended, although there are limited data to support this recommendation. Our hypothesis was that more severely limited preoperative flexion and extension would be associated with a higher incidence of postoperative ulnar nerve symptoms in patients undergoing capsular release. MATERIALS AND METHODS: We conducted a retrospective review of 164 consecutive patients who underwent open or arthroscopic elbow capsular release for stiffness between 2003 and 2010. The ulnar nerve was decompressed if the patient had preoperative ulnar nerve symptoms or a positive Tinel test. Preoperative and postoperative range of motion and incidence of ulnar nerve symptoms were recorded. RESULTS: The mean improvement in the arc of motion of was 36.7°. New-onset postoperative ulnar nerve symptoms developed in 7 of 87 patients (8.1%) who did not undergo ulnar nerve decompression; eventually, 5 of these patients with persistent symptoms underwent ulnar nerve decompression. The rate of developing postoperative symptoms was higher if patients had preoperative flexion ≤ 100° (15.2%) compared with those with preoperative flexion >100° (3.7%). There was no association between preoperative extension or gain in motion arc and postoperative symptoms. CONCLUSIONS: The overall rate of ulnar nerve symptoms after elbow contracture release was low if ulnar nerve decompression was performed in patients with preoperative symptoms or a positive Tinel test. There was a higher rate of ulnar nerve symptoms in patients with more severe contractures (≤ 100° of preoperative flexion), which did not reach statistical significance.

Assessment of processed porcine extracellular matrix as a protective barrier in a rabbit nerve wrap model.

Nerve wrapping can improve outcomes by protecting nerves in a scarred tissue bed. Autologous tissue wraps have shown good results, but there are limitations associated with harvesting and availability. Extracellular matrix (ECM) derived from porcine small intestinal submucosa offers an attractive off-the-shelf option. This study evaluated this material as a nerve wrap. The sciatic nerves of 18 New Zealand rabbits were exposed and then wrapped, while the contralateral side served as sham control. Presence and quality of adhesions, motor conduction velocity (MCV), and histology were evaluated at 1, 2, and 6 months ( N = 6 animals per time point). The quality, extent, tenacity, and overall impression of adhesions were not different from control at any time point ( P = 0.18 to 0.99). MCV was also not statistically different from control (1 month, P = 0.35; 2 months, P = 0.20; 6 months, P = 0.83). Histology demonstrated that wrapped nerves were healthy in terms of myelination, density, and vascularity compared with controls. Vascularization and incorporation of the ECM material could be visualized at explants. All assessments supported the feasibility and safety of this material as a nerve wrap. Its ability to function as a protective barrier has strong implications for clinical use in trauma and/or recurrent compression neuropathies.

Dorsal capsular-based vascularized distal radius graft for proximal pole scaphoid nonunion with avascular necrosis.

BACKGROUND: Scaphoid nonunion involving the proximal pole with the presence of avascular necrosis is difficult to reconstruct. We aimed to determine the efficacy of surgical treatment of proximal pole scaphoid nonunion with avascular necrosis using a dorsal capsular-based vascularized distal radius graft. METHODS: Between 2000 and 2018, 64 patients with established proximal pole scaphoid nonunion with avascular necrosis were treated using a dorsal capsular-based vascularized distal radius graft. This graft was harvested from the dorsal aspect of the distal radius with its dorsal wrist capsule attachment. Fixation of the scaphoid nonunion was performed with a small cannulated screw, followed by insertion of the vascularized graft into the dorsal trough at the scaphoid nonunion site. In the last 47 patients of this series, a micro suture anchor was placed into the scaphoid to augment graft fixation. RESULTS: Union rate was 86% (55 of 64 scaphoid nonunions with avascular necrosis) at a mean time of 12 weeks. Persistent non-union was noted in eight patients and fibrous union in one patient. No patients developed donor site morbidity. No graft dislodgment was noted. There was significant improvement of the wrist functional outcomes at the final follow up. CONCLUSIONS: The dorsal capsular-based vascularized distal radius graft is a safe and effective treatment in patients with scaphoid nonunion with avascular necrosis of the proximal pole. This pedicle vascularized bone graft is derived from a location that can easily reach the proximal third of the scaphoid avoiding microsurgical dissection or anastomosis.

Vein wrapping at cubital tunnel for ulnar nerve problems.

BACKGROUND: Recurrent compression of the ulnar nerve in the cubital tunnel is a difficult problem and many solutions have been tried with variable success. Autologous vein graft wrapping is an alternative technique and it is recommended for the treatment of recalcitrant ulnar nerve compression in which 2 or more previous surgical procedures have failed to resolve the problem. METHODS: Seventeen patients with recurrent cubital tunnel syndrome were treated with autologous saphenous vein wrapping. These patients had previously undergone simple decompression, decompression combined with medial epicondylectomy, anterior submuscular, or intramuscular transposition with internal neurolysis and had persistence of symptoms. Each patient underwent both subjective and objective evaluation. RESULTS: Our clinical results on 17 patients have been encouraging. All patients reported significant pain relief, while improvements in grip strength and 2-point discrimination were also observed. There were no complications, other than transient leg swelling secondary to harvesting the saphenous vein graft from the leg. CONCLUSION: This technique is not technically demanding, has low donor site morbidity, and leads to pain relief and high patient satisfaction.