Revision Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament Reconstruction With Autograft and Button Suspension.

Recurrent instability following thumb ulnar collateral ligament repair or reconstruction may result in pain and poor function. The use of certain suture anchors during the index procedure may predispose patients to the development of osteolysis and subsequent fixation failure. In this article, we describe an effective surgical technique for revision reconstruction of ulnar collateral ligament injuries using autograft and suture suspensionplasty. This technique restores joint stability and allows functional recovery with minimal postoperative complications.

Complex Elbow Fracture-Dislocations: An Algorithmic Approach to Treatment.

Elbow stability arises from a combination of bony congruity, static ligamentous and capsular restraints, and dynamic muscular activation. Elbow trauma can disrupt these static and dynamic stabilizers leading to predictable patterns of instability; these patterns are dependent on the mechanism of injury and a progressive failure of anatomic structures. An algorithmic approach to the diagnosis and treatment of complex elbow fracture-dislocation injuries can improve the diagnostic assessment and reconstruction of the bony and ligamentous restraints to restore a stable and functional elbow. Achieving optimal outcomes requires a comprehensive understanding of pertinent local and regional anatomy, the altered mechanics associated with elbow injury, versatility in surgical approaches and fixation methods, and a strategic rehabilitation plan.

Urinary bladder matrix versus dermal regeneration template for lower extremity wound coverage.

PURPOSE: To compare dermal regenerative template (DRT), with and without split-thickness skin-grafting (STSG), and urinary bladder matrix (UBM) for coverage of lower extremity wounds. METHODS: A retrospective review of 56 lower extremity wounds treated with either DRT and STSG (DRT-S) (n = 18), DRT only (n = 17), or UBM only (n = 21). Patient characteristics, comorbidities, American Society of Anesthesiology (ASA) classification, injury characteristics, wound characteristics, use of negative pressure wound therapy, surgical details, postoperative care, and failure of primary wound coverage procedure were documented. RESULTS: The DRT group, compared to the DRT-S group, was older [median difference (MD) 17.4 years, 95% confidence interval (CI) 9.1-25.7; p = 0.0008], more diabetic (proportional difference (PD) 54.2%, CI 21.2-76.1%; p = 0.002), had smaller wounds (MD - 91.0 cm2, CI - 125.0 to - 38.0; p = 0.0008), more infected wounds (PD 49.0%, CI 16.1-71.7%; p = 0.009), a shorter length of stay after coverage (MD - 5.0 days, CI - 29.0 to - 1.0; p = 0.005), and no difference in primary wound coverage failure (41.2% vs. 55.6%; p = 0.50). The UBM group, compared to the DRT group, was younger (MD - 6.8 years; CI - 13.5 to - 0.1; p = 0.04), had fewer patients with an ASA > 2 (PD - 35.0%, CI - 55.2% to - 7.0%; p = 0.02), diabetes (PD - 49.2%, CI - 72.4% to - 17.6%; p = 0.003), and had no difference in primary wound coverage failure (36.4% vs. 41.2%; p = 1.0). Failure of primary wound coverage was found to only be associated with larger wound surface areas (MD 22.0 cm2, CI 4.0-90.0; p = 0.01). CONCLUSIONS: DRT and UBM coverage had similar rates of primary wound coverage failure for lower extremity wounds. LEVEL OF EVIDENCE: Diagnostic, Level III.

Radiocapitellar and Ulnotrochlear Pressures Increase in a Radial Head Fracture Model: A Cadaveric Biomechanical Analysis.

BACKGROUND: Changes in intra-articular pressure have not been previously described in relation to the management of radial head fractures. We hypothesized that pressure within the radiocapitellar and ulnotrochlear joints would increase with progressive radial head resection, mimicking a displaced radial head fracture, in a cadaveric model. METHODS: Ten cadaveric specimens were tested. Intra-articular pressure sensors were used to measure pressure within the radiocapitellar and ulnotrochlear joints with the forearm in full supination. The elbow was loaded to 100 N in extension, 45° of flexion, and 90° of flexion under the following conditions: (1) intact radial head, (2) 20% radial head resection, (3) 40% radial head resection, and (4) 100% radial head resection. RESULTS: The distribution of pressure between the radiocapitellar and ulnotrochlear joints did not change with sequential, partial resection of the radial head (radiocapitellar joint, between 48.92% and 53.79%; ulnotrochlear joint, between 46.21% and 51.08%). After 20% resection, radiocapitellar peak contact pressure (PCP) increased by 22% (from 1,410 to 1,721.5 kPa) and ulnotrochlear PCP increased by 36% (from 1,319 to 1,797.5 kPa). After 40% resection, radiocapitellar PCP increased by 123% (from 1,410 to 3,145 kPa; p = 0.0003) and ulnotrochlear PCP increased by 105% (from 1,319 to 2,702 kPa; p = 0.007). Ulnotrochlear PCP increased by a total of 159% after complete radial head resection (from 1,319 to 3,415.5 kPa; p = 0.003). CONCLUSIONS: Pressures in the radiocapitellar and ulnotrochlear joints were equally distributed with an intact radial head and after partial resection. Radiocapitellar and ulnotrochlear pressures increased with increasing radial head resection, significantly exceeding 100% of normal after radial head resection of 40% of the anterolateral diameter. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Posterolateral Rotatory Instability Develops Following the Modified Kocher Approach and Does Not Resolve Following Interval Repair.

BACKGROUND: The modified Kocher and extensor digitorum communis (EDC)-splitting intervals are commonly utilized to approach the lateral elbow. Iatrogenic injury to the lateral ulnar collateral ligament may result in posterolateral rotatory instability (PLRI). in the present cadaveric study, we (1) evaluated lateral elbow stability following the use of these approaches and (2) assessed the accuracy of static lateral elbow radiographs as a diagnostic tool for PLRI. METHODS: Ten matched-pair cadaveric upper-extremity specimens (n = 20) were randomly assigned to Kocher or EDC-splitting approaches. Specimens underwent evaluation pre-dissection, post-dissection, and following repair of the surgical interval. Clinical evaluation of lateral elbow stability was performed with the lateral pivot-shift maneuver. Radiographic radiocapitellar displacement was evaluated with the fully extended hanging arm test and on lateral elbow 30° flexion radiographs. Paired Wilcoxon signed-rank tests with Bonferroni correction were utilized to compare groups. RESULTS: All Kocher group specimens (10 of 10) developed PLRI on the pivot-shift maneuver following dissection. No EDC-splitting group specimens (0 of 10) developed instability with pivot-shift testing. The fully extended hanging arm test showed no difference in radiocapitellar displacement between groups (p > 0.008). Lateral elbow 30° flexion radiographs in the Kocher group showed an increased radiocapitellar displacement difference (mean, 8.46 mm) following dissection compared with the pre-dissection baseline (p < 0.008). Following repair of the Kocher interval, the radiocapitellar displacement (mean, 6.43 mm) remained greater than pre-dissection (mean, 2.26 mm; p < 0.008). In the EDC-splitting group, no differences were detected in radiocapitellar displacement on lateral elbow radiographs with either the fully extended hanging arm or lateral elbow 30° flexion positions. CONCLUSIONS: The Kocher approach produced PLRI that did not return to baseline conditions following repair of the surgical interval. The EDC-splitting approach did not cause elbow instability clinically or radiographically. The hanging arm test was not reliable for the detection of PLRI. CLINICAL RELEVANCE: The Kocher interval for lateral elbow exposure results in iatrogenic PLRI that is not detectable on the hanging arm test and that does not return to baseline stability following repair of the surgical interval.

Is self-inflicted amputation to the upper extremity a contraindication to replantation?

PURPOSE: Contraindications to replantation include severe medical or psychiatric comorbidities. Recently, authors have suggested that due to the improving therapeutic options for patients with psychiatric decompensation, this should no longer be listed as a contraindication to replantation. Despite this, authors continue to list severe psychiatric comorbidities as a contraindication to replantation. This case series and review of the literature discusses this complex topic and provides recommendations regarding the management of patients following upper extremity self-inflicted amputations. METHODS: The authors present two cases of self-inflicted upper extremity amputations. The cases depict the acute management and the outcomes of these patients. The authors also reviewed the literature to present the available literature on this topic. RESULTS: The first case is a 64-year-old male who deliberately amputated his left hand with a table saw while suffering postictal psychosis. He underwent replantation. The patient was co-managed by the surgical and psychiatric team postoperatively. The patient expressed gratitude for his replantation after being treated for his psychoneurological condition. The second case is that of a 25-year-old male who deliberately amputated his left forearm using a Samurai sword. The patient's limb was successfully replanted. In the post-anesthesia care unit, the patient experienced extreme agitation, and during this event, he reinjured the left forearm. He was again taken urgently to the operating room to revise the replantation. Once psychiatrically stabilized, the patient was thankful for the care he received. CONCLUSION: The management of upper extremity self-inflicted amputations is controversial and difficult to establish as this presentation is rare. We present two cases which illustrate some of the nuances in the care of these patients. Our review suggests that psychiatric diagnosis be viewed as a comorbidity and not a contraindication to replantation. Thus, an informed consent discussion should be performed with the patients and, as needed, a member of the psychiatric team in order to decide whether to replant or not.

Evidence-based postoperative replantation protocols.

Postoperative care is essential to upper extremity replantation success and includes careful and frequent monitoring of the replanted part. During this period, pharmacologic agents such as antithrombotic and anticoagulants may prevent complications such as arterial thrombosis and venous congestion. Dressings and therapy can also impact short- and long-term outcomes following replantation. This article reviews the literature to provide guidance for postoperative protocols following upper extremity replantation.

Management of Self-Inflicted Nonaccidental Amputations of the Upper Extremity: Systematic Review.

PURPOSE: Clinicians assessing patients with deliberate self-inflicted amputations face a problem of whether or not to replant. The objective of this study was to summarize the literature on this topic and provide recommendations regarding the acute management of patients following self-inflicted amputations in the upper extremity. METHODS: Two reviewers searched four databases using the keywords "Upper extremity," "Amputation," and "Self-Inflicted." The reviewers systematically screened and collected data on publications reporting cases of self-inflicted upper-extremity amputations. The findings then were summarized in a narrative fashion. RESULTS: Twenty-four studies were included. Twenty-nine cases of self-inflicted upper-extremity amputations were reported. There were 25 unilateral and four bilateral extremity amputations. Amputations were most commonly at the hand/wrist (18 patients) and forearm level (6 patients). The amputations were most commonly performed with a saw (9 patients) or a knife (8 patients). Reasons for amputation included psychosis (10 cases), suicide attempt (7 cases), depression (5 cases), and body integrity identity disorder (four cases). Fifteen replantations were performed; all were successful. Reasons for not pursuing replantation were related to injury factors (ie, multilevel injury, prolonged ischemia, damaged part) rather than patient-level factors. Two patients with replantable extremities declined replantation, both of whom had body integrity identity disorder. Of the patients who underwent replantation, none expressed regret. CONCLUSIONS: The literature shows that patients experiencing psychosis or depression committed self-harm during an acute psychiatric decompensation, and once medically and psychiatrically stabilized, expressed satisfaction with their replanted limb. Surgeons should not consider psychiatric decompensation a contraindication to replantation and should be aware of patients with body integrity identity disorder who consciously may elect to undergo revision amputation. When presented with patients experiencing psychiatric decompensation who refuse replantation/are not competent, surgeons should seek emergency assistance from the psychiatry team to determine the best management of a self-inflicted amputation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapy/Prevention/Etiology/Harm V.

Proximal Hamate Reconstruction of Proximal Pole Scaphoid Nonunion: A Case Series and Analysis of Clinical Outcomes.

BACKGROUND: Small proximal pole scaphoid nonunions present a clinical challenge influenced by fragment size, vascular compromise, deforming forces exerted through the scapholunate interosseous ligament (SLIL), and potential articular fragmentation. Osteochondral autograft options for proximal pole reconstruction include the medial femoral trochlea, costochondral rib, or proximal hamate. This study reports the clinical outcomes of patients treated with proximal hamate osteochondral autograft reconstruction. METHODS: A retrospective review identified patients treated with this surgery from 2 institutions with a minimum 6-month follow-up. Clinical outcomes included the Visual Analog Dcale pain score, 12-item Short-Form survey, abbreviated Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, wrist and forearm range of motion (ROM), radiographic assessment, and complications. We reviewed and compared these outcomes with those of the current published literature. RESULTS: Four patients (mean age: 24 years, 75% men) with a 12.8-month average follow-up (range: 6-20 months) were included. Radiographic union was identified in all cases by 12 weeks (range, 10-12). The average wrist ROM was 67.5% flexion/extension and 100% pronation/supination compared with the contralateral side at the final follow-up. The mean QuickDASH score was 17.6 (SD, 13). No complications were identified. CONCLUSIONS: Proximal pole scaphoid nonunion reconstruction using autologous proximal hamate osteochondral graft demonstrated encouraging clinical and radiographic outcomes. Proximal hamate harvest involves minimal donor site morbidity without a distant operative site, uses an osteochondral graft with similar morphology to the proximal scaphoid, requires no microsurgical technique, and permits reconstruction of the SLIL using the volar capitohamate ligament.

The Iatrogenic Injury Potential of Self-adherent Elastic Bandages in Finger Injuries.

BACKGROUND: The use of a self-adherent, elastic bandage is a practical way to dress finger injuries. Multiple reports describe iatrogenic injuries from elastic bandages, ranging from skin necrosis to finger gangrene, necessitating amputations. This study investigated whether elastic bandages can compromise digital perfusion by occluding arterial blood flow in healthy volunteers and evaluated the utility of pulse oximetry as a monitoring tool for digital perfusion. A technique for safe bandage application is proposed. METHODS: A commercially available elastic bandage was wrapped around the index finger of 20 healthy volunteers at varying degrees of stretch. Digital perfusion measurements were carried out using photoelectric pulse transduction, laser Doppler flowmetry, and pulse oximetry. Intracompartmental pressure measurements were recorded using a separate in vitro experimental model. RESULTS: Elastic bandages applied at maximum stretch did not change digital brachial index or pulse oximetry values, suggesting arterial blood flow was preserved distal to the bandage. Intracompartmental pressure measurements at maximum stretch remained below the systolic digital pressure. In contrast, superficial dermal perfusion fell to 32% of normal as measured by laser Doppler flow, at 100% bandage stretch. CONCLUSION: This study suggests a risk for iatrogenic injury when using elastic bandages for finger dressings. While arterial inflow was never compromised, pressures were high enough to occlude superficial venous outflow, which may begin at 20% bandage stretch. Pulse oximetry failed to detect changes distal to applied dressings, and we do not recommend it to detect digital vascular compromise in this setting.

The safety and accuracy of various carpal tunnel injection techniques.

PURPOSE: Carpal tunnel (CT) syndrome continues to be a commonly treated hand pathology. We aimed to evaluate several CT injection techniques for (1) spatial accuracy within the CT and (2) risk of median nerve (MN) injury. Our purpose was to evaluate for any significant differences in accuracy of needle placement within the carpal tunnel and final distance between the needle tip and the MN with each technique. METHODS: Fifteen fresh frozen cadaveric arms were used for this study. Six different injection techniques for CT injection were performed on each specimen, including palmaris longus, ulnar to flexor carpi radialis, trans-flexor carpi radialis, volar radial, volar ulnar, and direct through the palm techniques. After needle placement, a standard open CT release was performed to assess for accuracy of placement within the CT and measure needle position in relation to the MN and other anatomic structures. RESULTS: Accurate intra-CT needle placement was seen in 91% of injections. While there was no significant difference between injection techniques for distance to nearest tendon (p = 0.1531), the trans-flexor carpi radialis (tFCR), volar radial (VR), and volar ulnar (VU) techniques consistently provided the greatest intra-CT distance from needle tip to median nerve (p = 0.0019). The least incidence of intraneural needle placement was found with the tFCR and VR approaches. CONCLUSION: All six injection techniques reliably enter the CT space. The lowest risk to the MN was found with tFCR and VR techniques, and we recommend these techniques for safe and effective needle placement to avoid iatrogenic intraneural injection. LEVEL OF EVIDENCE: Level V: Cadaveric Study.

Initial Displacement of Humeral Shaft Fractures Is Associated With Failure of Nonoperative Management.

OBJECTIVES: To determine whether the initial radiographic displacement of humeral shaft fractures is associated with failure of nonoperative management. DESIGN: Retrospective cohort study. SETTING: Urban level 1 trauma center. PATIENTS/PARTICIPANTS: 106 patients with humeral shaft fractures (OTA/AO 12) initially managed nonoperatively. INTERVENTION: Functional bracing. MAIN OUTCOME MEASUREMENTS: Failure of nonoperative management, defined as conversion to surgery, malunion, and delayed union/nonunion. RESULTS: Nonoperative management failed in 33 (31%) of 106 included patients with 27 patients (25%) requiring surgery. On multivariate analysis, female sex [odds ratio (OR): 3.50, 95% confidence interval (CI): 1.09 to 11.21], American Society of Anesthesiologist classification >1 (OR: 7.16, CI: 1.95 to 26.29), initial fracture medial/lateral (ML) translation (OR: 1.09, CI: 1.01 to 1.17, per unit change), and initial fracture anterior-posterior (AP) angulation (OR: 1.09, CI: 1.02 to 1.15, per unit change) were independently associated with failure of nonoperative management. Initial fracture displacement values that maximized the sensitivity (SN) and specificity (SP) for failure included an AP angulation >11 degrees (SN 75%, SP 64%) and ML translation >12 mm (SN 55%, SP 75%). The failure rate in patients with none, 1, or both of these fracture parameters was 3.1% (1/32), 35.6% (20/56), and 66.6% (12/18), respectively. CONCLUSIONS: Nearly one-third of patients experienced failure of initial nonoperative management. Failure was found to be associated with greater initial fracture AP angulation and ML translation. Fracture displacement cut-off values were established that may be used by surgeons to counsel patients with these injuries. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical Outcomes of Severely Angulated Fifth Metacarpal Neck Fractures Treated Nonsurgically.

BACKGROUND: Reasonable functional outcomes for nonoperative management of isolated, closed fifth metacarpal neck fractures with up to 70° angulation have been reported; however, reported outcomes for fractures with greater than 70° angulation are limited. This study describes clinical outcomes of nonsurgically treated fifth metacarpal neck fractures with angulation of greater than 70°. METHODS: A retrospective review of patients treated between May 1, 2016, and May 1, 2020, included: (1) patients aged 18 years and above with an isolated, closed, fifth metacarpal neck fracture; (2) nonsurgical treatment; (3) healed fractures with angulation greater than 70° measured on oblique radiographs; and (4) minimum 6-month follow-up after injury. Photographic hand motion and patient-rated outcomes (Functional Hand Scale, Quick Disabilities of the Arm, Shoulder, and Hand [QuickDASH], 12-item Short-Form Health Survey [SF-12]) were collected and reported. RESULTS: A total of 364 fractures were identified; 11% (40/364) demonstrated angulation of greater than 70° (range: 71°-82°); and 15 patients (inclusion rate: 38%, 15/40) with mean fracture angulation of 73° (range: 71°-77°) participated in the study. Mean follow-up was 32 months (range: 8-120 months), the dominant hand was injured in 87% (13/15) of patients, and 47% (7/15) of patients worked in manual labor. All patients scored the highest rating of "very good" (range: 26-30 of 30 points) on the functional hand scale. A QuickDASH score of zero (no morbidity) was reported in 80% (12/15) of patients. About 87% (13/15) of patients had average or above-average scores on the SF-12 (mean = 109, range: 84-115). CONCLUSIONS: Patients with healed, isolated, closed fifth metacarpal neck malunions with severe angulation greater than 70° demonstrated acceptable functional outcomes based on patient-rated outcomes scoring.

Lunate Revascularization With Temporary Internal Radiocarpal Spanning Fixation for Kienböck Disease.

BACKGROUND: The goal in the treatment of stages II and III Kienböck disease is to restore lunate vascularity and halt the progression of avascular necrosis. METHODS: We report the outcomes for patients with stages II and III Kienböck disease treated with fourth extensor compartment artery vascularized bone grafting and temporary radiocarpal spanning internal fixation. Nine patients with a mean age of 28.8 years were included. Mean clinical and radiographic follow-up were 4.9 and 1.9 years, respectively. RESULTS: Six patients had no change in Lichtman stage, 2 patients regressed 1 stage, and 1 patient progressed 1 stage. Mean postoperative quick disabilities of the arm, shoulder, and hand (QuickDASH) was 17.4. Mean postoperative visual analogue pain scale (VAS) was 1.8. Patients under age 25 trended toward improved clinical outcomes compared with patients over age 25. Two patients, aged 33 and 65, underwent proximal row carpectomy at a mean 30.5 months postoperatively. CONCLUSIONS: In conclusion, the use of local vascularized bone graft with temporary internal radiocarpal spanning fixation provides a treatment option with outcomes comparable to existing literature with benefits inherent to internal immobilization.

Classification and Radiographic Characterization of Kienböck Disease.

Robert Kienböck described radiographic changes associated with idiopathic lunate osteonecrosis in 1910. The radiographic progression of this eponymous condition has been well-described to progress from normal radiographs, to lunate sclerosis, lunate collapse, proximal capitate migration, scaphoid flexion, and pancarpal arthritis. Diagnosing early stages of the disease without radiographic changes presented a challenge. As imaging modalities have evolved, diagnosis has become possible with MRI. Although numerous classification systems exist, the Lichtman classification and the Bain arthroscopic grading system have become widely used. This article outlines the available classification systems and aims to highlight when each may be useful in patient management.

Ligament-Sparing Volar Radiocarpal Arthrotomy During Distal Radius Fracture Repair: Anatomical Description and Quantification of Articular Surface Area Visualized in a Cadaveric Model.

PURPOSE: Distal radius (DR) fracture repair using the volar locked plating technique typically involves indirect fracture reduction, assessed using fluoroscopy, without direct visualization of the articular surface. This method of fracture repair may be guided by the rationale that volar radiocarpal ligament disruption may cause radiocarpal instability, although direct articular visualization may facilitate improved fracture reduction. This study investigated anatomical feasibility and articular surface visualization using volar ligament-sparing radiocarpal arthrotomy pertinent to DR fracture repair. METHODS: Ten fresh-frozen cadaveric specimens of the upper extremity underwent volar arthrotomy via the standard flexor carpi radialis approach with partial longitudinal sectioning of the long radiolunate and partial transverse sectioning of the short radiolunate ligaments to visualize the articular surface of the DR. Following arthrotomy, the visible surface of the DR was analyzed using digital photography. The wrist was disarticulated, and the fully exposed articular surface was photographed. The visible area of the articular surface was quantified using digital imaging software by calculating the ratio of the surface area visualized using the arthrotomy to the total articular surface area. RESULTS: The percentage of the articular surface area of the DR visualized using the volar arthrotomy was 76% ± 7.6% (range, 69%-90%), including both the scaphoid facet, lunate facet, and scapholunate ridge. CONCLUSIONS: Volar radiocarpal arthrotomy allows clinically relevant visualization of the articular surface of the DR, including the scaphoid and lunate facets. CLINICAL RELEVANCE: Radiocarpal arthrotomy may facilitate improved articular reduction during DR fracture repair via the volar approach.

Orthopaedic Injuries After Introduction of Electric Scooters to Denver, Colorado.

INTRODUCTION: Cost and efficiency have made electric scooters (e-scooters) popular in urban areas, but many orthopaedic injuries are associated with their use. METHODS: A retrospective review of e-scooter-related injuries at a level one trauma center identified injury patterns and hospital-associated costs before and after widespread commercial introduction of e-scooters. RESULTS: Twenty-three and 197 patients were included in preimplementation and postimplementation groups, respectively. Hospital admission increased from 11% to 62% after commercial introduction. Cost of care increased from $1.8 million to $7.6 million, and 61% of orthopaedic injuries required surgery. The most common orthopaedic injuries were distal radius fractures. Seventy-three percent of the patients tested were intoxicated at the time of injury. DISCUSSION: This study categorizes injury patterns and highlights increased hospital-related admissions and surgeries associated with e-scooters. The high rate of intoxicated rider injuries emphasizes the need for laws guiding operation of e-scooters.