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.

Epidemiology of and Risk Factors for Table Saw Injuries of the Hands and Fingers.

Purpose: The purpose of this study was to evaluate circumstances surrounding power saw injuries. We hypothesized that power saw injuries are caused by either inexperienced or inappropriate usage of saws. Methods: A retrospective review of patients at our level 1 trauma center from January 2011 to April 2022 was conducted. Patients were screened using surgical billing records based on Current Procedural Terminology codes. Codes associated with revascularization; amputation of digits; and repair of tendon, nerve, and open metacarpal and phalanx fractures were queried. Patients who sustained power saw injuries were identified. They were then contacted by phone, and a standardized questionnaire was administered. Verbal consent was included in the standardized script, which was approved by the institutional review board. Results: One hundred eleven patients were identified who underwent surgical treatment for power saw injuries of the hands. Of them, we were able to contact 44 patients, who consented to and completed the questionnaire. Of all of the contacted patients, 40 (91%) were men, with an average age of 55 years (range, 27-80 years). No patients were intoxicated when the injury occurred. Thirty-two (73%) patients had used the same saw for more than 25 times. Sixteen (36%) patients had not received formal training regarding safe use of their saw, and 7 (16%) had removed a safety mechanism prior to the injury. Thirteen (30%) patients had used the saw on an unstable surface, and 17 (39%) reported not having changed the saw blade regularly. Conclusions: Power saw injuries occur for a multitude of reasons. Contrary to our hypothesis, more experience with the use of saws does not necessarily protect one from saw injuries. These findings highlight the need for formal training among new saw users and continuing education for the more experienced to help reduce the incidence of saw injuries that require surgical intervention. Type of study/level of evidence: Prognostic IV.

Outcomes Following Repeat Collagenase Treatment of Dupuytren Contracture.

PURPOSE: Injectable collagenase Clostridium histolyticum has been an effective and well-tolerated nonsurgical treatment option for the management of Dupuytren contracture of the hand. The purpose of this study was to determine the efficacy of collagenase injection and adverse event rate in patients who had undergone previous collagenase treatment. METHODS: A retrospective chart review was performed on 332 patients treated with collagenase injection for Dupuytren contracture by three fellowship-trained hand surgeons at a single institution from 2009 to 2019. Fifty-nine joints in 45 patients underwent repeat collagenase therapy for recurrent contracture in the same digit. Pretreatment and posttreatment total metacarpophalangeal and proximal interphalangeal joint flexion contractures were recorded, with complete correction defined as <5° residual digital flexion contracture. Postmanipulation skin tears and adverse events were recorded. A comparison was made between average contracture improvement after initial collagenase injection and that after repeat injection. RESULTS: Forty-five patients with an average duration of 30 months (range, 6-73 months) between initial and repeat collagenase therapies were identified. The mean improvement after first collagenase injection was 45° ± 24° (39° for metacarpophalangeal joint and 50° for proximal interphalangeal joint) compared with a mean improvement of 43° ± 23° (41° for metacarpophalangeal joint and 44° for proximal interphalangeal joint) after second injection. Although similar complete correction rates and skin tear rates (32.2 % for initial and 30.5% for repeat) were observed between initial (80%) and repeat injections (73%), the occurrence of adverse events was 3 times higher (3.4% for initial and 10.2% for repeat) in the latter group. CONCLUSIONS: Collagenase treatment of Dupuytren contracture yields effective total flexion contracture correction. Repeat collagenase treatment of previously treated digits yields similar deformity correction and complete correction rates but a higher incidence of adverse events. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Intramedullary Headless Screw Fixation for Phalanx Fractures: Technique and Review of Current Literature.

Fractures of the phalanges can often be managed nonoperatively, but displaced phalangeal fracture patterns, including malrotation, are more amenable to operative treatment. There are several described methods for surgical management of phalanx fractures, but there remains no consensus on a clearly superior method of fixation. Percutaneous Kirschner wires, interfragmentary screws, plate and screw constructs, intramedullary nails, and cannulated intramedullary headless screws are all utilized in the treatment of these fractures. Intramedullary headless screws for phalanx fractures may provide suitable fixation allowing early motion and recovery. Here, we describe a technique for antegrade and retrograde intramedullary headless screw fixation for phalanx fractures.

ORIF of Distal Humerus Fractures with Modern Pre-contoured Implants is Still Associated with a High Rate of Complications.

BACKGROUND: The purpose of this study was to identify complications after operative treatment of distal humerus fractures with anatomic, pre-contoured, locking distal humeral plates. We hypothesized that these fractures have high complication rates despite the use of these modern implants. MATERIALS AND METHODS: Between 2010 and 2018, 43 adult patients with a distal humerus fracture underwent open reduction and internal fixation (ORIF) at a Level I trauma center. Pre-operative variables, including medical comorbidities, mechanism of injury, open or closed fracture, AO/OTA fracture classification (Type A, B, or C), and nerve palsy, were recorded. Intra-operative variables including surgical approach, ulnar nerve transposition, and plate configuration were recorded. Anatomic, pre-contoured, locking distal humeral plates were used in all patients. Various plating systems were used based on surgeon preference and fracture pattern. Post-operative complications including infection, nonunion, malunion, painful implants, nerve palsy, heterotopic ossification, stiffness, and post-traumatic arthritis were recorded. RESULTS: Most fractures were Type C (53%). The posterior olecranon osteotomy approach (51%) and parallel plate configuration (42%) were used in most cases. At a mean follow-up of 15 months, the complication rate was 61% (26/43 patients). Among all patients, 49% (21/43 patients) required a reoperation. Elbow stiffness (19%) was the most common complication followed by nerve palsy (16%). There were four fracture nonunions (9%), deep infections (9%), painful implants (9%), post-traumatic arthritis (9%), and heterotopic ossification (9%). CONCLUSIONS: Distal humerus fractures treated with ORIF utilizing anatomic, pre-contoured, locking distal humeral plates have a high complication rate, with many requiring reoperation. LEVEL OF EVIDENCE: Therapeutic Level IV.

Intramedullary Headless Screw Fixation for Metacarpal Fractures.

Multiple techniques have been proposed for metacarpal fracture fixation, including percutaneous Kirschner-wires, interfragmentary screws, plate and screw constructs, intramedullary (IM) nails, and cannulated IM headless screws. Each of these treatment options has its proposed advantages and disadvantages, and there remains no consensus on the optimal mode of treatment. We describe a technique of retrograde IM headless screw fixation for extra-articular metacarpal fractures.

Peripheral nerve repair throughout the body with processed nerve allografts: Results from a large multicenter study.

BACKGROUND: Peripheral nerve damage resulting in pain, loss of sensation, or motor function may necessitate a reconstruction with a bridging material. The RANGER® Registry was designed to evaluate outcomes following nerve repair with processed nerve allograft (Avance® Nerve Graft; Axogen; Alachua, FL). Here we report on the results from the largest peripheral nerve registry to-date. METHODS: This multicenter IRB-approved registry study collected data from patients repaired with processed nerve allograft (PNA). Sites followed their own standard of care for patient treatment and follow-up. Data were assessed for meaningful recovery, defined as ≥S3/M3 to remain consistent with previously published results, and comparisons were made to reference literature. RESULTS: The study included 385 subjects and 624 nerve repairs. Overall, 82% meaningful recovery (MR) was achieved across sensory, mixed, and motor nerve repairs up to gaps of 70 mm. No related adverse events were reported. There were no significant differences in MR across the nerve type, age, time-to-repair, and smoking status subgroups in the upper extremity (p > .05). Significant differences were noted by the mechanism of injury subgroups between complex injures (74%) as compared to lacerations (85%) or neuroma resections (94%) (p = .03) and by gap length between the <15 mm and 50-70 mm gap subgroups, 91 and 69% MR, respectively (p = .01). Results were comparable to historical literature for nerve autograft and exceed that of conduit. CONCLUSIONS: These findings provide clinical evidence to support the continued use of PNA up to 70 mm in sensory, mixed and motor nerve repair throughout the body and across a broad patient population.

Drains Are Not Beneficial in Primary Shoulder Arthroplasty.

The purpose of this study was to determine if clinical differences exist between closed drainage use in primary shoulder arthroplasty and postoperative complications. A retrospective review was performed of all primary total shoulder and reverse total shoulder arthroplasty procedures at the authors' institution during a 2-year period. A total of 378 of 636 shoulder arthroplasty patients met inclusion criteria. Drains were used in 111 patients. The authors did not identify a significant relationship between drain use and postoperative complications. When complications were stratified just by the presence or absence of risk factors, irrespective of whether a drain was used, no significant relationship was identified. This study does not support the routine use of closed drainage systems in primary shoulder arthroplasty, including for patients with risk factors for potentially developing postoperative complications. [Orthopedics. 2019; 42(1):e29-e31.].

Intraarticular Distal Radius Fracture Open Reduction Internal Fixation.

PURPOSE: Intraarticular distal radius fractures are often treated with open reduction and internal fixation (ORIF) through a volar approach. This common approach, however, is technically demanding to restore the articular surface of the radiocarpal joint while respecting soft tissue integrity. The purpose of this video is to demonstrate the surgical technique of volar plate fixation of an intraarticular distal radius fracture. METHODS: A 32-year-old patient who sustained multiple injuries including an intraarticular distal radius fracture was treated with ORIF by a volar approach. RESULTS: Exposure is performed through a standard flexor carpi radialis approach. The intraarticular fracture of the distal radius is reduced, and a volar plate is applied. Careful measurement of screw length is described in detail to minimize postoperative tendon irritation. Closure of the soft tissues is completed and early postoperative rehabilitation is emphasized. DISCUSSION: Multiple, varied techniques for fixation of intraarticular distal radius fractures are described in the literature. As demonstrated in this video of ORIF with a volar plate, attention to articular reduction, soft-tissue protection, and postoperative rehabilitation are key components used to achieve good clinical outcomes.

Retrograde headless intramedullary screw fixation for displaced fifth metacarpal neck and shaft fractures: short term results.

BACKGROUND: This study aimed to evaluate the early clinical outcomes of retrograde headless intramedullary screw fixation for displaced fifth metacarpal neck and shaft fractures. METHODS: We retrospectively reviewed nine patients treated with retrograde intramedullary screw fixation of fifth metacarpal neck and shaft fractures between 2011 and 2013. Patient demographics and outcomes including hand dominance, age, sex, type of injury, injury and postoperative radiographs, return to work, time to fracture union radiographically, complications, visual analog score, disabilities of the arm, shoulder, and hand scores, postoperative metacarpophalangeal joint range of motion, and grip strength were recorded. RESULTS: Nine fractures in nine patients with a mean age of 32 years (19-54) were included. There were seven metacarpal neck and two metacarpal shaft fractures. All patients sustained injury by direct impact of fist against an object. No case involved worker's compensation. Patients had a mean follow-up of 36 weeks (6-57 weeks) and at the time of latest follow-up had no pain. Mean radiographic healing was 49 days (28-85 days). Mean return to work was 6 weeks (4-10 weeks). Mean metacarpalphalangeal joint motion was 0° extension and 90° flexion. Mean disabilities of the arm, shoulder, and hand scores pre- and postoperatively improved from 43 to 0.7, respectively. The mean postoperative grip strength was measured of the injured hand (40 kg) and un-injured hand (41 kg). CONCLUSIONS: Retrograde headless intramedullary screw fixation of fifth metacarpal neck and shaft fractures has overall favorable early outcomes and offers the benefit of stable fixation, early motion without cast immobilization, and the ability for early return to work. This technique is a viable surgical option for these fractures and may be considered in the appropriate patient population.

Basal joint osteoarthritis of the thumb: comparison of suture button versus abductor pollicis longus suspensionplasty.

BACKGROUND: Our purpose was to compare the outcomes of patients with severe basilar thumb osteoarthritis treated with trapeziectomy and suspensionplasty using abductor pollicis longus (APL) tendon versus a suture button device. METHODS: A retrospective study was performed for patients undergoing trapeziectomy and suspensionplasty with APL tendon or suture button fixation. Outcome measures included disabilities of the arm, shoulder, and hand (DASH); visual analog score (VAS); grip strength; key pinch; tip pinch; and thumb opposition. Radiographic measurements, surgical times, and complications were recorded. RESULTS: Thirty-three patients in the APL tendon group and 27 patients in the suture button group had a minimum 6-month follow-up. VAS, DASH, and functional measurements improved after surgery for both groups. Mean operative time was 68 min for the APL tendon group and 48 min for the suture button group. Complications were similar between groups. CONCLUSIONS: The use of suture button fixation when compared to APL tendon suspensionplasty offers similar clinical outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

A comparison of percutaneous needle fasciotomy and collagenase injection for dupuytren disease.

PURPOSE: To compare percutaneous needle fasciotomy (PNF) with collagenase injection in the treatment of Dupuytren contracture. METHODS: A retrospective review was performed for patients with Dupuytren disease treated with PNF or collagenase. Range of motion, patient satisfaction, and complications were recorded. RESULTS: There were 29 patients in the collagenase group with mean baseline contractures of 40° for 22 affected metacarpophalangeal joints and 50° for 12 affected proximal interphalangeal joints. The PNF group was composed of 30 patients with mean baseline contractures of 37° for 32 affected metacarpophalangeal joints and 41° for 18 affected proximal interphalangeal joints. All patients were observed for a minimum of 3 months. Clinical success (reduction of contracture within 0° to 5° of normal) was accomplished in 35 of 50 joints (67%) in the PNF group and in 19 of 34 joints (56%) in the collagenase group. Patient satisfaction was similar between groups. Only minor complications were observed, including skin tears, ecchymosis, edema, pruritus, and lymphadenopathy. CONCLUSIONS: In the short term, both PNF and collagenase have similar clinical outcomes and patient satisfaction. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Clinical outcomes of arthrodesis and arthroplasty for the treatment of posttraumatic wrist arthritis.

PURPOSE: To compare clinical outcomes of wrist arthrodesis and total wrist arthroplasty in the treatment of pancarpal posttraumatic arthritis. We hypothesized that arthroplasty would demonstrate better clinical outcomes than wrist arthrodesis. METHODS: We performed a retrospective review of 22 patients treated (15 arthrodeses and 7 arthroplasties) for pancarpal posttraumatic arthritis. We measured clinical outcomes with the visual analog pain scale; Disabilities of the Arm, Shoulder, and Hand questionnaire; the Patient-Rated Wrist Evaluation; and a study-specific questionnaire. Postoperative complications were recorded from chart review. RESULTS: Mean follow-up was 68 months for arthrodesis and 56 months for arthroplasty. The mean visual analog scale pain score was 2 for each group. The mean Disabilities of the Arm, Shoulder, and Hand score was 38 for the arthrodesis group and 29 for the arthroplasty group. The mean Patient-Rated Wrist Evaluation was 73 for the arthrodesis group and 31 for the arthroplasty group. The results from the study-specific questionnaire revealed that the majority of patients in both groups were satisfied. Complication rates were similar in both groups. CONCLUSIONS: Total wrist arthroplasty as an alternative to arthrodesis for the treatment of pancarpal posttraumatic arthritis may offer improved functional outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Complications following distal biceps repair.

PURPOSE: Distal biceps rupture is a relatively uncommon injury. Surgical repair is performed in patients who seek increased flexion and supination strength over that which results from nonoperative treatment. The purpose of this study was to evaluate complications associated with surgical repair of the distal biceps tendon in a large series of patients. METHODS: We retrospectively reviewed 198 consecutive patients with distal biceps ruptures treated with surgical repair, and evaluated time from injury to repair, surgical technique, and complications. RESULTS: A total of 72 patients (36%) developed complications; 6 patients underwent additional surgery. Minor complications included lateral antebrachial cutaneous nerve paresthesia (26%), radial sensory nerve paresthesia (6%), and superficial infection (2%). Major complications included posterior interosseous nerve injury (4%), symptomatic heterotropic ossification (3%), and re-rupture (2%). CONCLUSIONS: Minor complications were common after distal biceps tendon repair; however, most were sensory nerve injuries that resolved with time. Major complications were infrequent, and few patients required revision surgery. Complications were more common after distal biceps tendon repair performed more than 28 days after rupture. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Incidence and clinical outcomes of tendon rupture following distal radius fracture.

PURPOSE: To evaluate the incidence of tendon rupture after nonoperative and operative management of distal radius fractures, report clinical outcomes after tendon repair or transfer, and examine volar plate and dorsal screw prominence as a predictor of tendon rupture. METHODS: We performed a retrospective chart review on patients treated for tendon rupture after distal radius fracture. We evaluated active range of motion, Disabilities of Arm, Shoulder, and Hand score, grip strength, and pain score, and performed radiographic evaluation of volar plate and dorsal screw prominence in both the study group and a matched control group. RESULTS: There were 6 tendon ruptures in 1,359 patients (0.4%) treated nonoperatively and 8 tendon ruptures in 999 patients (0.8%) treated with volar plate fixation. At the time of final follow-up, regardless of treatment, we noted that patients had minimal pain and excellent motion and grip strength. Mean Disabilities of the Shoulder, Arm, and Hand scores were 6 for patients treated nonoperatively and 4 for those treated with volar plating. CONCLUSIONS: We were unable to verify volar plate or dorsal screw prominence as independent risk factors for tendon rupture after distal radius fractures. However, we recommend continued follow-up and plate removal for symptomatic patients who have volar plate prominence or dorsal screw prominence. In the event of tendon rupture, we report excellent clinical outcomes after tendon repair or tendon transfer. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Clinical outcomes of total wrist arthroplasty.

PURPOSE: Current indications for total wrist arthroplasty include patients with symptomatic end stage posttraumatic wrist arthritis, rheumatoid arthritis, and Kienböck disease, as an alternative to wrist arthrodesis. Arthroplasty may have advantage over arthrodesis because of the ability to retain motion. The purpose of this study was to evaluate the short-term clinical outcomes and complications of the Maestro Total Wrist System. METHODS: We report the results of a retrospective review of 23 total wrist prostheses implanted in 22 patients. We administered the visual analog pain scale and Mayo wrist and Disabilities of the Arm, Shoulder, and Hand questionnaires. We reviewed wrist motion, grip strength, radiographs, and complications. RESULTS: At a mean follow-up of 28 months (range, 4-55 mo), the Disabilities of the Arm, Shoulder, and Hand score and Mayo wrist score were 31 and 54, respectively. Mean pain scores improved from 8.0 to 2.2. The mean wrist flexion-extension arc was 90°. Radiographs revealed no evidence of prosthetic loosening. Grip strength averaged 60% of the strength of the opposite hand. Complications occurred in 7 of 23 patients. One failure occurred as a result of deep infection in a patient with prior intercarpal fusion, and was successfully converted to a wrist fusion. CONCLUSIONS: Total wrist arthroplasty performed for pancarpal arthritis as an alternative to wrist arthrodesis can yield successful outcomes with low short-term failure rates. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The use of clopidogrel (Plavix) in patients undergoing nonelective orthopaedic surgery.

OBJECTIVE: To assess the effects of Plavix on patients requiring nonelective orthopaedic surgery. DESIGN: Retrospective cohort study. SETTING: University-affiliated teaching institutions. PATIENTS AND PARTICIPANTS: The orthopaedic trauma registry was used to retrospectively identify all patients taking clopidogrel (Plavix; Bristol-Myers Squibb/Sanofi Pharmaceuticals, Bridgewater, NJ) who required nonelective orthopaedic surgery from 2004 to 2008. Twenty-nine patients were identified on Plavix (PG) and 32 matched patients in the control group not taking Plavix (NPG). The Plavix group was separated into those with a surgical delay less than 5 days of the last dose (PG < 5) (n = 28) and a delay greater than 5 days (PG > 5) (n = 1). A randomized age- and injury-matched control group not on Plavix was separated with surgical delay less than 5 days (NPG < 5) (n = 29) and delay greater than 5 days (NPG > 5) (n = 3). INTERVENTION: A retrospective review was performed comparing pre- and postoperative hemoglobin, blood transfusion requirements, surgical delay, 30-day mortality, and postoperative complications. MAIN OUTCOME MEASUREMENTS: Statistical analyses were performed using the Student t test and chi square test to identify differences between the groups. RESULTS: : The mean preoperative hemoglobin of the PG and the NPG was 11.2 g/dL and 12.3 g/dL (P = 0.03). Transfusion rates were similar with 18 of 28 in the PG compared with 13 of 29 in the NPG (P = 0.22). The mean surgical delay between the PG and NPG was 1.88 and 1.68 days (P = 0.64). Overall complications between the PG and NPG was nine of 28 and nine of 29 (P = 0.92). In both groups, two patients had postoperative wound drainage, which resolved without intervention. One patient in each group required revision surgery for nonunion. The 30-day mortality in the Plavix group was zero of 28 (0%) compared with one of 29 (3%) in the control group (cardiac arrest) (P = 0.32). CONCLUSIONS: In this study, there were no serious complications or increased transfusion requirements in the Plavix group. Avoiding surgical delay for patients on Plavix requiring nonelective orthopaedic surgery appears to be safe. The goal should be early operative intervention to decrease the morbidity and mortality of surgical delay. This is especially true for patients with hip fractures, which was the most common nonelective orthopaedic surgery required of patients on Plavix in this study.