Midcarpal Instability.

Midcarpal instability (MCI) of the wrist represents multiple distinct clinical entities that all have in common abnormal force transmission across the midcarpal joint. This can be asymptomatic but can also result in painful wrist motion, a characteristic catch-up clunk, and symptoms of instability. The carpus is stabilized by numerous extrinsic and intrinsic ligaments. Dynamic joint reactive forces between the proximal and distal carpal rows help create reciprocal motion, which results in smooth, physiologic wrist mechanics. Diagnosis of MCI requires a thorough history, physical examination, and adequate imaging. MCI can be managed nonsurgically with activity modification, physical therapy, specialized orthotics, medications, and corticosteroid injections. A variety of surgical treatment options exists to treat symptomatic MCI. These include arthroscopic thermal capsulorrhaphy, ligament repair or reconstruction, radial osteotomies, and limited radiocarpal or intercarpal fusions. Capsulorrhaphy or ligament repair is favored for mild to moderate cases; osteotomies can be used for the correction of bony deformities contributing to instability, whereas partial wrist arthrodesis is indicated for severe or recurrent instability and fixed deformities.

Primary Resection of the Ulnar Slip of Flexor Digitorum Superficialis in the Persistently Triggering Patient After A1 Pulley Release.

BACKGROUND: The purpose of this study was to determine the occurrence of patients undergoing primary trigger finger release (TFR) that underwent ulnar superficialis slip resection (USSR) for decompression and to determine which digit was most commonly affected. METHODS: A retrospective chart review was conducted of all cases of open TFR performed by a single surgeon. The following data were obtained: age, sex, laterality, affected digit, and consideration for USSR. All patients failed nonoperative treatment of at least 1 steroid injection. The occurrence of patients who underwent TFR and USSR and which digit(s) most commonly underwent USSR were determined. The average patient age that underwent USSR, frequency by sex, and relative occurrence of USSR in each digit were computed. Statistical calculations were conducted using χ2 analysis (P < .05). RESULTS: A total of 911 primary open TFRs were performed in 631 patients over a 16-year period. A total of 20 TFRs in 20 patients underwent USSR (2.2%). The long finger was the most commonly affected digit (40%) that required simple decompression. Within all USSR cases, the long finger was the most commonly affected digit. The index finger was the second most affected (30%), and there were no cases in the small finger. CONCLUSIONS: This study determined the occurrence of primary TFR cases that underwent USSR, with the long finger being the most commonly affected digit. Surgeons may consider this additional procedure to perform a larger decompression than simple A1 pulley release alone.

Nerve Transfers for Restoration of Elbow Flexion in Patients With Acute Flaccid Myelitis.

PURPOSE: The purpose of this study was to evaluate short- to midterm outcomes of patients with acute flaccid myelitis who underwent nerve transfers for restoration of elbow flexion. METHODS: Patients with a minimum of 10 months of follow up after undergoing nerve transfers to restore elbow flexion were clinically assessed using the Active Movement Scale (AMS). They were evaluated for any postoperative complications, particularly weakness in the distribution of the donor nerve(s). Fifteen of 25 consecutive patients who were treated using this surgical technique were included in the final analysis. RESULTS: All patients exhibited poor elbow flexion preoperatively (AMS 0 to 3). At a mean follow up of 17.3 months, 80% (15/25) of patients achieved excellent elbow flexion (AMS 6 or 7); 9 of these 15 had full active range of motion. Two patients achieved good elbow flexion (AMS 5) with antigravity movement to less than 50% of the passive range of motion. No cases of superficial or deep infection were reported, and all patients maintained identical motor function, relative to preoperative status, of the muscles innervated by the donor nerves. CONCLUSIONS: Nerve transfer surgery has shown promising short- to midterm results for recovery of nerve and muscle function, particularly for the restoration of elbow flexion. We recommend this treatment option for patients not demonstrating clinical improvement after 6 to 9 months of incomplete recovery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Failed Triangular Fibrocartilage Complex Repair and Reconstruction.

Unsuccessful triangular fibrocartilage complex (TFCC) repair or reconstruction is poorly defined, often stemming from multiple causes, both patient and surgeon-related. Complete evaluation of the patient's psychosocial status and involvement in any litigation claims is essential, as is a thorough history, physical examination, and imaging workup to accurately diagnose TFCC injury, along with any concomitant wrist pathology. Awareness of common complications and technical errors is critical, and preventive treatment strategies should be implemented to minimize these events.

Thumb Carpometacarpal Instability.

The basal joint complex of the thumb provides the framework necessary for function of the human hand. Although its unique saddle articulation allows for a wide range of motion necessary for routine function of the hand, it is rendered inherently unstable because of poor bony congruency and reliance on its capsuloligamentous support. Painful instability of this joint can stem from several causes including traumatic dislocation, various hypermobility conditions, and chronic overuse and microtrauma. A thorough history and examination as well adequate imaging is necessary for proper evaluation of instability. Treatment options range from nonoperative modalities to surgery, which entails closed, percutaneous, or open reduction with numerous ligament repair and reconstruction techniques. Arthroscopy can also serve to be a useful adjunct for assessment of the joint and stabilization of the critical capsuloligamentous structures. This review outlines the critical osseous and soft-tissue anatomy surrounding the thumb carpometacarpal joint, the key points in evaluating patients presenting with acute traumatic and chronic thumb carpometacarpal instability without fracture or arthritis, and reviews both nonoperative and operative treatments of this injury.

Acute Septic Carpal Tunnel Syndrome in a Rock Climber.

INTRODUCTION: Rock climbing is an increasingly popular sport in the United States. Acute and chronic upper extremity injuries related to rock climbing are frequently reported and include flexor pulley ruptures and hamate stress fractures. Deep space hand infections after indoor rock climbing are a sport-related pathology that has yet to be reported. Our purpose is to describe an acute septic carpal tunnel syndrome following rock climbing at an indoor climbing gym in a patient who required urgent irrigation and debridement. CASE REPORT: A 33-year-old Caucasian male presented with an acute septic carpal tunnel syndrome 4 days after rock climbing at an indoor gym. On physical examination, he exhibited numbness over the fingers, significant tenderness to palpation, and pain with passive range of motion. His inflammatory markers were markedly elevated and deep space hand infection was confirmed with computed tomography scans. The patient was taken for urgent exploration, irrigation and debridement, and carpal tunnel release. CONCLUSION: We theorize that the patient had an abrasion on the finger or palm that created an entryway for a pathogen. We are unaware of another report of a deep space hand infection associated with rock climbing activities. This case report will hopefully spread awareness of this clinical entity to improve evaluation and prevention of hand infections in rock climbers, as well as providing guidelines for appropriate and timely treatment of the condition.

Proximal Row Carpectomy Using Decellularized Dermal Allograft: Preliminary Results.

Objective The purpose of this study was to evaluate the short-term outcomes of patients undergoing proximal row carpectomy (PRC) with interposition arthroplasty using a decellularized dermal allograft. Methods Patients with a minimum of 1-year follow-up after undergoing a PRC using decellularized dermal allograft were contacted for clinical evaluation, radiographs, and postoperative outcome questionnaires, including the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire as well as the modified Likert scale for patient satisfaction. Nine of ten (90%) consecutive patients who were treated using this surgical technique were available for follow-up. Results At a mean follow-up of 18 months, a total of nine patients achieved a mean flexion-extension arc of 113 degrees, pronosupination of 170.5 degrees, grip strength of 68 Ibs and pinch strength of 17 Ibs. Relative to the contralateral side, these values were 95, 100, 84 and 82%, respectively. There was significant improvement in the mean DASH score from 63.5 preoperatively to 23.8 postoperatively. Patient satisfaction postoperatively achieved a mean modified Likert score of 1.5. There was no evidence of radiocarpal joint space degeneration or dislocation in any of the patients. No patient suffered wound-related issues, foreign-body reaction to the graft, or other complications. Conclusion PRC with interposition arthroplasty using a decellularized dermal allograft in patients with degenerative changes at the lunate fossa or capitate demonstrates short-term outcomes comparable to what has been reported for routine PRC in patients without degenerative changes affecting the radiocapitate joint. This method of interposition arthroplasty expands the indications for PRC and may help avoid salvage, motion-sacrificing procedures in select patients with late-stage wrist arthritis. Level of Evidence This is a level IV, therapeutic study.

The Effect of Casting Simulation on Maintenance of Fracture Alignment Following Closed Reduction of Pediatric Distal Radius Fractures: Does More Simulation Matter?

BACKGROUND: The purpose of this study was to evaluate the effectiveness of a simulation curriculum on performance of closed reduction (CR) and casting of distal radius and distal both-bone forearm fractures by orthopaedic surgery residents. The secondary aim was to identify if repeated simulation training during the clinical rotation provided additional benefit. METHODS: Orthopaedic surgery residents performed simulated distal radius fracture (DRF) reduction and cast application near the beginning and end of their 6-month pediatric orthopaedic clinical rotation at a tertiary care children's hospital. A subgroup of trainees were randomly assigned additional simulation training halfway through their rotation. Clinically, 28 residents treated 159 distal radius and/or distal both-bone forearm fractures with CR and casting during the study period. Radiographic evaluations were performed comparing postreduction fracture angulation, displacement, cast index, and loss of reduction (LOR) rates at the beginning of a resident's rotation (presimulation cases) and at the end of the resident's rotation (postsimulation cases). Comparisons were also made between residents who had and did not have additional simulation training exposure during their rotation. RESULTS: Overall, postreduction radius angulation, maximal angulation, and cast index were lower in the postsimulation group than in the presimulation group with means 1.8°, 2.6°, and 0.75 vs 4.0°, 4.4° and 0.77, respectively. LOR rate was also lower (14% vs 30%). No significant differences were demonstrated for postreduction ulna angulation as well as for radius, ulna, or maximal displacement between these 2 groups. No significant differences were observed in radiographic parameters, cast indices, or LOR rates between residents who underwent additional mid-rotation training vs those who did not. CONCLUSIONS: The incorporation of a simulation training curriculum for CR and casting of pediatric distal forearm fractures resulted in statistically significant, however, marginally improved postreduction radiographic parameters and LOR rates among orthopaedic residents. The utility of repeated additional simulation training during the course of a clinical rotation remains unclear in the short term.

Scleroderma of the Hand: Evaluation and Treatment.

Scleroderma is derived from Latin meaning hard skin. It is an uncommon, noninflammatory connective tissue disorder characterized by increased fibrosis of the skin and in certain variants, multiple other organ systems. Scleroderma involves a spectrum of pathologic changes and anatomic involvement. It can be divided into localized and systemic scleroderma. Hand involvement is common and can include calcium deposits within the soft tissues, digital ischemia, and joint contracture. Nonsurgical management consists of lifestyle modifications, biofeedback, therapy for digital stiffness/contracture, and various pharmacologic medications. When nonsurgical measures are unsuccessful, certain surgical options may be indicated, each with their inherent advantages and pitfalls. Patients with scleroderma who are undergoing surgical intervention pose unique difficulties because of their poorly vascularized tissue and deficient soft-tissue envelopes, thus increasing their susceptibility to wound healing complications and infection. Some subgroups of patients are frequently systemically ill, and specific perioperative measures should be considered to reduce their surgical risk. The spectrum of hand manifestations seen in patients with scleroderma will be reviewed with the focus on evaluation and management.

Thumb Ulnar Collateral Ligament Repair with Suture Tape Augmentation.

Background: The purpose of this study is to describe our technique of thumb ulnar collateral ligament (UCL) repair with suture tape augmentation and to evaluate the short-term outcomes in our initial series of patients treated with this method of repair. Methods: Patients with minimum one-year follow up after isolated UCL repair with suture tape augmentation were contacted for clinical evaluation, radiographs, and postoperative outcome questionnaires, including the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire and study-specific questions. Thirteen of 15 (87%) consecutive patients who were treated using this method of repair were available for follow-up, 9 with acute tears and 4 with chronic tears. Results: Average post-operative thumb metacarpophalangeal (MCP) and interphalangeal (IP) joint range-of-motion (ROM) was 0-57.5° and 0-71°, respectively, for chronic tears and 2.2-53.9° and 0-71°, respectively, for acute tears. Average grip and pinch strength relative to the unaffected hand was 102% and 84%, respectively, among patients with chronic tears and 103.3% and 88.7%, respectively, among those with acute tears. All patients demonstrated stability with a firm endpoint, relative to the unaffected thumb. The average QuickDASH score among all patients was 11.9 for the disability/symptom module, 0 for the sport module and 16.5 for the work module. Stiffness was reported among 4 patients and no patient suffered wound-related issues or other complications. Conclusions: Thumb UCL repair with suture tape augmentation demonstrates short-term outcomes comparable to what has been reported for other methods of repair. It may potentially allow for an expedited recovery and rehabilitation process.

Intraoperative Tilted Posteroanterior View for the Measurement of Distal Radius Articular Step-Off.

The purpose of this study is to more accurately determine distal radius articular step-off in the posteroanterior (PA) view. A cadaveric forearm was osteotomized with varying amounts of articular displacement. A second osteotomy was made through the distal radius metaphysis to create four positions of tilt in the lateral plane (5° and 15° dorsal tilt; 5° and 15° volar tilt). Using fluoroscopy, the beam was positioned in the lateral plane from 25° volar to 20° dorsal, separated by 5° increments, obtaining modified PA images of the distal radius in its various configurations. The images were randomly evaluated for step-off by three hand surgeons in a blinded fashion. Statistical analysis was performed to determine the accuracy between estimated and actual step-off and was demonstrated to be greater when the PA view was parallel to the distal radius tilt in the lateral plane, for all four configurations of distal radius tilt. Data pertaining to the distal radius with 0 mm of step-off did not demonstrate the PA view, parallel to the distal radius tilt, to be superior than the PA views not parallel to the tilt; reaffirming that with anatomic reduction, any fluoroscopic image exhibits good alignment. This study confirms that the most accurate method of accessing PA step-off is to first determine the tilt of the radius on a lateral film and then align the beam in the PA plane to match this tilt.

Ulnar nerve transposition in the hand: a cadaveric study.

Primary repair of a nerve is preferable over nerve grafting when a tension-free environment can be achieved. The purpose of this cadaveric study was to evaluate the facility of nerve-gap closure gained by removing the hamate hook, eliminating the circuitous path of the motor branch of the ulnar nerve in the hand. Six cadaveric specimens were dissected and the length of the motor branch coursing through Guyon's canal before and after hamate hook excision and nerve transposition was recorded. Average length was significantly shorter in specimens after transposition, with a mean 21% reduction relative to the nerve's original course. This knowledge may help guide surgeons on whether excision of the hamate hook will allow for primary repair of the nerve when a segmental defect or retraction and scarring of the nerve stumps is encountered.

The Anterior Approach for Transfer of Radial Nerve Triceps Fascicles to the Axillary Nerve.

Nerve transfers are an increasingly popular method for surgical treatment of nerve injuries. One of the most popular of these is the transfer of radial nerve triceps fascicles to the axillary nerve. The most common approach for this transfer is the posterior approach, which gives excellent access to both nerves but is not easy to combine with other nerve transfers. We describe here an alternative, the anterior approach, that offers safe access to both radial and axillary nerves and has the added advantage of compatibility with approaches for other common nerve transfers.

Proximal Row Carpectomy Using Decellularized Dermal Allograft.

Wrist arthritis is a common problem. When managed early, motion-sparing procedures can be performed with successful outcomes. Proximal row carpectomy (PRC) has demonstrated good functional results and high patient satisfaction with up to 20-year follow-up. The majority of patients with longer follow-up have, however, exhibited radiographic signs of progressive degeneration of the radiocapitate space. Although radiographic changes have not been shown to correlate with wrist pain and function, it remains a concern and questions the durability of the radiocapitate articulation with continued patient follow-up, especially those who underwent the original procedure at a younger age. Several modifications have been proposed and used to address this concern, including radiocapitate arthroplasty, with either distal radius hemiarthroplasty or tissue interposition grafts. Theoretical benefits to these adjuncts include minimizing wear and preserving the radiocapitate articulation as well as expanding the utility of a PRC even in the setting of a wrist with arthritis of the capitate head. We describe our surgical technique for managing radiocarpal arthritis with PRC and decellularized dermal allograft. Dermal matrix allografts have proved to be a safe adjunct in various orthopedic procedures, including those in the wrist and hand. This technique adds another surgical option for the treatment of radiocarpal arthritis and expands the indications for PRC to include select patients with degeneration of the capitate head.

The Double Thenar Flap: A Technique to Reconstruct 2 Fingertip Amputations Simultaneously.

Fingertip injuries are a common problem. There may be pulp loss and exposed bone. Various techniques have been described to reconstruct function as well as aesthetics; yet it is still unclear which treatment options should be chosen for each specific injury. Evidence-based treatment strategies are limited because there are no prospective randomized clinical trials evaluating one method with another. Fingertip injuries are usually variable in their presentation, and therefore treatment decisions are often dictated by the knowledge and expertise of the treating physician combined with the patient's unique injury. With exposed bone and major distal soft tissue loss, many reconstructive techniques have been well-described including local advancement flaps, thenar flaps, and cross-finger flaps. There is scarce literature discussing surgical options when multiple fingers are involved. This report details a novel technique used to reconstruct 2 simultaneously injured fingers using the double thenar flap.

The Relationship between the School Function Assessment (SFA) and the Gross Motor Function Classification System (GMFCS) in Ambulatory Patients with Cerebral Palsy.

PURPOSE: Determine the relationship between the SFA and GMFCS in children with cerebral palsy (CP). METHODS: Through correlation, regression, and ANOVA analysis, data from 103 children were examined. A regression model was used to compare SFA-predicted versus actual GMFCS levels. One-way ANOVA was utilized to determine differences between SFA subscale scores in the context of GMFCS. RESULTS: A significant correlation between composite SFA scores and GMFCS levels (r = -0.847, p < 0.020) was observed. Subscale-SFA and GMFCS correlations included Regular Class (r = -0.338, p < 0.001), Physical Tasks Adaptation (Phys1; r = -0.340, p < 0.001) and Assistance (Phys2; r = -0.340, p < 0.001), Position (r = -0.338, p<0.001), Recreational Movement (RecMvmt; r = -0.387, p <0.0001), Manipulation Movement (ManMvmt; r = -0.494, p < 0.0001), and Up/Down Stairs (UDStairs; r = -0.453, p< 0.0001). Between predicated and actual GMFCS levels, no statistical difference was observed. One-way ANOVA demonstrated SFA differences at GMFCS levels: Phys1 (F= 5.32, p < 0.002), Phys2 (F = 4.54, p < 0.005), Position (F = 4.63, p < 0.004), RecMvmt (F = 7.92, p < 0.0001), ManMvmt (F = 13.50, p < 0.0001), and UDStairs (F = 6.18, p < 0.001). CONCLUSION: Utilizing both SFA-predicted and actual GMFCS levels may help determine if a child is performing at an expected level of daily function.

Complex ankle arthrodesis: Review of the literature.

Complex ankle arthrodesis is defined as an ankle fusion that is at high risk of delayed and nonunion secondary to patient comorbidities and/or local ankle/hindfoot factors. Risk factors that contribute to defining this group of patients can be divided into systemic factors and local factors pertaining to co-existing ankle or hindfoot pathology. Orthopaedic surgeons should be aware of these risk factors and their association with patients' outcomes after complex ankle fusions. Both external and internal fixations have demonstrated positive outcomes with regards to achieving stable fixation and minimizing infection. Recent innovations in the application of biophysical agents and devices have shown promising results as adjuncts for healing. Both osteoconductive and osteoinductive agents have been effectively utilized as biological adjuncts for bone healing with low complication rates. Devices such as pulsed electromagnetic field bone stimulators, internal direct current stimulators and low-intensity pulsed ultrasound bone stimulators have been associated with faster bone healing and improved outcomes scores when compared with controls. The aim of this review article is to present a comprehensive approach to the management of complex ankle fusions, including the use of biophysical adjuncts for healing and a proposed algorithm for their treatment.