Comparison of Intramedullary Screw Fixation, Plating, and K-Wires for Metacarpal Fracture Fixation: A Meta-Analysis.

BACKGROUND: Metacarpal fractures are common injuries with multiple options for fixation. Our purpose was to compare outcomes in metacarpal fractures treated with intramedullary screw fixation (IMF), Kirschner wires (K-wires), or plating. METHODS: A systematic literature review using the MEDLINE database was performed for studies investigating metacarpal fractures treated with IMF, plating, or K-wires. We identified 34 studies (9 IMF, 8 plating, 17 K-wires). A meta-analysis using both mixed and fixed effects models was performed. Outcome measures included mean Disabilities of the Arm, Shoulder, and Hand (DASH) scores, total active motion (TAM), grip strength, time to radiographic healing, and rates of infection and reoperation. RESULTS: Patients with IMF had significantly lower DASH scores (0.6 [95% confidence interval [CI], 0.2-1.0]) compared with K-wires (7.4 [4.8-9.9]) and plating (9.8 [5.3-14.3]). Intramedullary screw fixation also had significantly lower rates of reoperation (4%, [2%-7%]), compared with K-wires (11% [7%-16%]) and plating (11% [0.07-0.17]). Grip strength was significantly higher in IMF (104.4% [97.0-111.8]) compared with K-wires (88.5%, [88.3-88.7]) and plating (90.3%, [85.4-95.2]). Mean odds ratio time was similar between IMF (21.0 minutes [10.4-31.6]) and K-wires (20.8 minutes [14.0-27.6]), but both were shorter compared with plating (52.6 minutes [33.1-72.1]). There were no statistically significant differences in time to radiographic healing, TAM, or rates of reoperation or infection. CONCLUSIONS: This meta-analysis compared the outcomes of metacarpal fixation with IMF, K-wires, or plating. Intramedullary screw fixation provided statistically significant lower DASH scores, higher grip strength, and lower rates of reoperation, suggesting that it is a comparable method of fixation to K-wires and plating for metacarpal fractures.

Building a Multidisciplinary Clinic Dedicated to Upper-Extremity Limb Loss.

Complete care of the patient with upper limb loss mandates a long-term, multifaceted approach. Increased functionality and quality of life require collaborative efforts between the patient's surgeon, prosthetist, hand therapists, mental health professionals, and peers. An individual surgeon may find that initiating and maintaining a practice offering total integrated treatment for upper-extremity amputees is a formidable task, but with specific, actionable recommendations, the process can be demystified. The upper-extremity surgeon must be facile with operative techniques such as targeted muscle reinnervation (TMR), regenerative peripheral nerve interface (RPNI), and soft tissue reconstruction and focus on team recruitment strategy and promotion of the clinic within the community. Consistent communication and team decision-making shape each patient's preoperative and postoperative course. We aim to relay effective interventions at each step of recovery from each clinic member and describe clinic workflow designed to reinforce holistic care. We present a blueprint for creating a functional and comprehensive multidisciplinary center for patients with upper-extremity limb loss for those providers interested in providing care, but who are missing the logistical roadmap for how to do so.

Vascularized Bone Grafting Versus the 2-Stage Masquelet Technique for Upper-Extremity Bone Reconstruction: A Meta-Analysis.

PURPOSE: Vascularized bone grafting (VBG) has been described as the technique of choice for larger bone defects in bone reconstruction, yielding excellent results at the traditional threshold of 6 cm as described in the literature. However, we hypothesize that the 2-stage Masquelet technique provides equivalent union rates for upper-extremity bone defects regardless of size, while having no increase in the rate of patient complications. METHODS: A systematic literature review was conducted using PubMed and Scopus for outcomes after VBG and the Masquelet technique for upper-extremity bone defects of the humerus, radius, ulna, metacarpal, or phalanx (carpal defects were excluded). A meta-analysis was performed to compare outcomes following VBG and the Masquelet technique at varying defect sizes. RESULTS: There were 77 VBG (295 patients) and 25 Masquelet (119 patients) studies that met inclusion criteria. Patients undergoing the Masquelet technique had defect sizes ranging from 0-15 cm (average 4.5 cm), while patients undergoing VBG had defect sizes ranging from 0-24 cm (average 5.9 cm). The union rate for Masquelet patients was 94.1% with an average time to union of 5.8 months, compared to 94.9% and 4.4 months, respectively, for VBG patients. We did not identify a defect size threshold at which VBG demonstrated a significantly higher union rate. No statistically significant difference was found in union rates between techniques when using multivariable logistic regression analysis. CONCLUSION: There was no statistically significant difference in union rates between VBG and the Masquelet technique in upper-extremity bone defects regardless of defect size. Surgeons may consider the Masquelet technique as an alternative to VBG in large bone defects of the upper extremity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The Combination of Fractional Tendon Lengthening and the Wide Awake, Local Anesthesia, No Tourniquet Technique for Secondary Tendon Reconstruction.

Rupture is a major concern after primary flexor tendon repair. The predominant treatment for rupture of the primary repair is immediate surgical exploration and repeat repair. However, repeat repair is challenging, including achieving ideal tension in the flexor mechanism. Further, immediate repeat repair is associated with poor outcomes, particularly in the small finger. As such, there is a need to improve both the technique and outcomes of repeat repair of primary flexor tendon rupture. We present a case of primary flexor tendon repair rupture treated with a novel combination of fractional tendon lengthening and the wide awake, local anesthesia, no tourniquet technique. A combination of these techniques has multiple benefits. An intraoperative, dynamic assessment of the digits enables immediate optimization of the repair. Further, these techniques allow for better intraoperative patient education and communication, increasing the likelihood of adherence to postoperative therapy and better overall outcomes.

The Treatment of Complex Extremity Wounds Using External Tissue Expansion: A Case Series.

SUMMARY: The goal of wound reconstruction is the approximation of soft tissue and re-establishment of an acceptable appearance with minimal risk of complications. For large wound closure in the extremities, skin graft and flap reconstruction are common treatments but are associated with a variety of complications. Comparatively, tissue expansion can provide the opportunity to reconstruct large wounds with native, durable, and sensate tissue without significant donor site morbidity. External tissue expansion is less invasive and avoids complications associated with internal expansion. The authors treated 11 patients with varying extremity wound types and sizes with an external tissue expansion device. Patient age ranged from 18 to 68 years with an average age of 43.7 years (SD, ± 13.1 years). Average wound surface area was approximately 235 cm 2 (SD, ± 135.3 cm 2 ). Devices were affixed and left for 7 to 11 days before closure of the wounds. Outcomes were assessed at 2 to 36 weeks postoperative follow-up. All wounds were fully closed after treatment without need for secondary reconstructive procedures. No patient experienced major complications. All patients demonstrated intact sensation within the area of reconstruction equivalent to surrounding tissues. External tissue expansion, an excellent treatment option in extremity reconstruction, is efficacious and associated with lower complication rates compared with internal tissue expansion, skin grafts, and flap reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Tendon Transfer to Treat Radial Nerve Palsy Following COVID-19 Infection.

Multiple manifestations have been associated with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. Among them are mononeuritis multiplex (MNM) and other neurological complications, whose connection to coronavirus disease 2019 (COVID-19) is still unclear. One of the most common sites of nerve injury is the radial nerve, which can be treated with both nerve or tendon transfer. In this case report, a patient who was afflicted with severe COVID-19 infection and developed mono neuritis multiplex after prolonged mechanical ventilation with radial nerve palsy was treated with multiple tendon transfers. This is a way to use an established mechanism of resolving the manifestations of radial nerve palsy to aid in the recovery of COVID-19-related mononeuritis multiplex.

External tissue expansion to salvage failed scalp and forehead reconstruction: a case report.

The reconstruction of forehead and scalp defects is a difficult task. Common reconstructive methods are associated with multiple complications and may fail, requiring a difficult second surgery. We present the use of external tissue expansion as a method to achieve effective closure of a failed scalp and forehead reconstruction.

Contralateral diaphragmatic injury sustained from transhumeral amputation: an unusual case and brief literature review.

Right-sided diaphragmatic injury is an uncommon sequelae from blunt trauma and may be associated with other severe thoracoabdominal injuries. This injury can be easily missed on initial assessment and a high index of suspicion and clinical judgment is required. Recently, we treated a 25-year-old male inflicted with a right-sided diaphragmatic injury after a left-sided transhumeral amputation sustained from an overturned motor vehicle collision with thoracoscopic exploration and reapproximation.

Single-stage extremity reconstruction through the use of dermal matrices: the power of Integra® bilayer wound matrix in the face of medical comorbidities, patient preference and non-compliance.

We report 4 cases of extremity reconstruction using Bilayer Wound Matrix with plan to perform two-stage procedures. Patient preference or non-compliance led to single-stage reconstruction with wound re-epithelialization. In this setting, dermal matrices may be used as single-stage stand alone wound reconstruction procedures, even in patients with comorbid conditions. Ajul Shah is a consultant of Integra LifeSciences Corporation Philippe Taupin is an employee of Integra LifeSciences Corporation.

Strategies for extremity reconstruction with exposed bones and tendons using acellular dermal matrices: concept of sequential vascularization.

We report 3 cases of patients treated with Bilayer Wound Matrix over exposed structures. In all patients, dermal matrices revascularization occurred sequentially over the course of 6-12 weeks, leading to successful wound closure. Acellular dermal matrices allow more difficult areas with poor vascularity to be covered from the 'inside-out'.

First Carpometacarpal Joint Denervation: A Systematic Review.

PURPOSE: The first carpometacarpal (CMC) joint is a frequent location of osteoarthritis in the hand. The denervation of the first CMC joint has gained traction as a viable treatment for CMC arthritis. This study reviewed literature on CMC denervation for first CMC arthritis. METHODS: A systematic review of papers and abstracts was conducted. The preferred reporting items for systematic reviews and meta-analyses guidelines were followed. Articles including the results of CMC denervation were included. We compiled data on patient demographics, preoperative testing, intraoperative technique, and postoperative outcomes. Anatomic literature was also reviewed to assess agreement on the innervation of the first CMC joint. RESULTS: Six anatomic studies and 9 clinical studies were included in this systematic review. Pinch strength, grip strength, and Kapandji scores increased on average in patients. Pain relief was noted on average in patients in 5 studies that reported pain outcomes. In studies that reported postoperative complications, the most frequent complications were radial paresthesias, hypoesthesia dorsal and/or distal to the surgical site, and wound infection. CONCLUSIONS: The innervation of the CMC joint is controversial. This is reflected in clinical practice, wherein varied surgical approaches are used. Carpometacarpal denervation shows promise as an option to treat patients with CMC arthritis without joint instability, but its results vary. Additional clinical studies with longer-term follow-up and control groups are necessary to better determine its longevity and efficacy. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Intramedullary Screw Fixation Comprehensive Technique Guide for Metacarpal and Phalanx Fractures: Pearls and Pitfalls.

BACKGROUND: Phalangeal and metacarpal fractures are the second and third most common upper extremity fractures after distal radius fractures with varying methods of fixation techniques. Intramedullary screw fixation is an increasingly preferred method of fixation. Benefits include early range of motion, faster recovery, limited dissection, and reduced complications. Improper technique, which is readily avoidable, can lead to suboptimal results. METHODS: A review of recent literature on current techniques aims to summarize the biomechanics of intramedullary screw fixation and outline appropriate technique of placing headless compression screws for metacarpal and phalangeal fractures. RESULTS: We discuss through images and videos the indications, preoperative workup, and technical pearls and pitfalls to encourage surgeons to add this technique to their armamentarium and improve outcomes. CONCLUSIONS: intrameduallry screw fixation is a powerful option for metacarpal and phalanx fixation that allows rigid stability, enabling early return of function with excellent rates of union and total active motion. With knowledge of technical pearls presented in this article, common mistakes can be avoided to improve efficiency of screw placement and optimize patient outcomes.

External Tissue Expansion in Complex Extremity Reconstruction.

Skin grafting and flap-based reconstruction have been the conventional treatments for complex extremity wounds. However, these methods can be associated with relatively high complication rates and involve increasing levels of complexity. External tissue expansion has recently emerged as an attractive alternative to its conventional counterparts. It is a technically simple and low-morbidity technique for complex wound reconstruction. This article provides a review of internal and external tissue expansion with a focus on the evolution, indications, and recent successes of external expansion for soft tissue coverage.

Techniques for Injection of the Scaphotrapezium-Trapezoid Joint Without Image Guidance.

Purpose: Scaphotrapezium-trapezoid (STT) joint arthritis is one of the most common forms of wrist arthritis. Conservative management often involves corticosteroid injection. Despite this, there is a scarcity of literature on palpation-guided injection techniques for the STT joint. We aimed to determine a standardized palpation-guided injection method that is easily reproducible and poses minimal risk to local anatomic structures. Methods: Six fresh-frozen cadaveric upper extremity specimens were tested. Access to the STT joint was attempted with dorsal, volar, and radial approaches. Fluoroscopy was used to confirm accurate placement within the joint. Needle placement was documented in relation to the surrounding soft tissue and bony landmarks were measured with a ruler, and the angle of the needle entry was recorded using a goniometer. The cadavers were carefully dissected to identify the surrounding neurovascular structures at risk of injury. Results: To access the STT joint with the dorsal approach, the needle was angled at 90º and inserted one-third of the distance from the prominence of the base of the second metacarpal to Lister tubercle. No neurovascular structures were found in the immediate vicinity of the needle. For the volar approach, the needle was angled at 65º and inserted at the distal wrist crease, 1 cm ulnar to the radial border of the wrist, in line with the second metacarpal. The volar branch of the radial artery was at risk with this approach. For the radial approach, the needle was angled at 60º and inserted immediately dorsal to the extensor pollicis brevis tendon, midway between the radial styloid and the prominence of the thumb metacarpal base. The dorsal branch of the radial artery was at risk with this approach. Conclusions: In a clinical setting where fluoroscopy or ultrasound is not readily available, the dorsal approach may allow for safe and accurate placement of the injectate into the STT joint. Type of study/level of evidence: Therapeutic IV.

Immediate plastic surgery closure at index spinal surgery minimizes complications compared to delayed reconstruction: A retrospective cohort review.

BACKGROUND: Complex spine surgery in patients with major comorbidities leads to increased need for midline back wound reconstruction by plastic surgeons. Literature suggests that back wound reconstruction concurrent with high-risk immediate/index spine surgery may lead to fewer complication. This study aimed to validate this claim in a large cohort treated at a tertiary center. We hypothesize that immediate reconstruction may lead to fewer adverse events in comparison to delayed reconstruction. METHODS: This was a retrospective single-center review of 659 patients who underwent spinal surgery with/without reconstruction by plastic surgeons between November 2011 and December 2015. Three main cohorts were evaluated: patients who underwent spinal surgery with no reconstruction, patients with delayed reconstruction after spine surgery, and patients with immediate back wound reconstruction with index spine surgery. Demographic, clinical, and outcomes data were collected from electronic medical records. Primary endpoints were the incidence of any complications such as dehiscence, infection, seroma/hematoma, and exposed hardware. The secondary endpoint was return to the operating room and most recent follow-up. RESULTS: Forty-three patients underwent index reconstruction (follow-up 25.3 ± 12.7 months), 33 were delayed (follow-up 23.7 ± 12.5 months), and 583 had no reconstruction (follow-up 22.1 ± 15.2 months). Patients who underwent index reconstruction had more spinal levels involved than delayed reconstruction (7.8 ± 0.75 vs 5.6 ± 0.68; p = 0.03). The overall complications rate was 7.7%, most commonly wound dehiscence (2.7%), infections (0.9%), exposed hardware (2.0%), cerebrospinal fluid leaks (0.6%), and return to OR (3.8%). Patients who underwent index spinal wound reconstruction had a significantly lower complication rate (4.65%) than secondary spinal surgery patients (27.3%; p = 0.048). CONCLUSIONS: The data confirmed significantly decreased complication rates for index back wound reconstructions for high-risk patients compared to delayed spine wound reconstruction. Increased rates of wound dehiscence, exposed hardware, and revisions occurred with delayed reconstruction. Early employment of tension free, robust vascular flap closure may attribute to a decreased complication profile.

The extent of brachial plexus injury: an important factor in spinal accessory nerve to suprascapular nerve transfer outcomes.

Objective: The purpose of this study was to assess the association between extent of brachial plexus injury and shoulder abduction/external rotation outcomes after spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer.Methods: A systematic review of the literature was conducted according to PRISMA guidelines. Inclusion criteria were studies reporting outcomes on patients undergoing SAN to SSN nerve transfer. Patients were excluded for the following reasons: age under 18, nerve transfer for reanimation of the shoulder other than SAN to SSN, and less than 12 months of follow-up postoperatively. Pooled analysis was performed, and primary outcomes were Medical Research Council (MRC) score and range of motion (ROM) for shoulder abduction and external rotation. Univariate logistic regression analysis was used to assess the association between extent of brachial plexus injury and shoulder abduction/external rotation outcomes after SAN to SSN transfer. A multivariate logistic regression analysis model including age, injury to surgery interval, and extent of injury as factors was also created.Results: Univariate logistic regression analysis showed greater extent of injury to be a predictor of poorer shoulder abduction outcomes (OR: 0.502; 95% CI: 0.260-0.971, p = 0.040). Multivariate logistic regression analysis confirmed this association (OR: 0.55; 95% CI: 0.236-0.877, p = 0.019). Extent of injury was not significantly associated with external rotation outcomes on univariate analysis (OR: 0.435; 95% CI: 0.095-1.995, p = 0.284) or multivariate analysis (OR: 0.445; 95% CI: 0.097-2.046, p = 0.298). Age and injury to surgery interval were not significantly associated with postoperative outcomes.Conclusions: More extensive brachial plexus injuries are associated with inferior outcomes after SAN to SSN transfer. A potential explanation for this finding includes lost contribution of muscles from the shoulder girdle that receive innervation from outside of the upper brachial plexus. The relationship between extent of injury and postoperative outcomes is important to recognize when determining and discussing operative intervention with patients.

Proximal Row Carpectomy versus Four-Corner Arthrodesis for the Treatment of Scapholunate Advanced Collapse/Scaphoid Nonunion Advanced Collapse Wrist: A Cost-Utility Analysis.

BACKGROUND: Two mainstay surgical options for salvage in scapholunate advanced collapse and scaphoid nonunion advanced collapse are proximal row carpectomy and four-corner arthrodesis. This study evaluates the cost-utility of proximal row carpectomy versus three methods of four-corner arthrodesis for the treatment of scapholunate advanced collapse/scaphoid nonunion advanced collapse wrist. METHODS: A cost-utility analysis was performed in accordance with the Second Panel on Cost-Effectiveness in Health and Medicine. A comprehensive literature review was performed to obtain the probability of potential complications. Costs were derived using both societal and health care sector perspectives. A visual analogue scale survey of expert hand surgeons estimated utilities. Overall cost, probabilities, and quality-adjusted life-years were used to complete a decision tree analysis. Both deterministic and probabilistic sensitivity analyses were performed. RESULTS: Forty studies yielding 1730 scapholunate advanced collapse/scaphoid nonunion advanced collapse wrists were identified. Decision tree analysis determined that both four-corner arthrodesis with screw fixation and proximal row carpectomy were cost-effective options, but four-corner arthrodesis with screw was the optimal treatment strategy. Four-corner arthrodesis with Kirschner-wire fixation and four-corner arthrodesis with plate fixation were dominated (inferior) strategies and therefore not cost-effective. One-way sensitivity analysis demonstrated that when the quality-adjusted life-years for a successful four-corner arthrodesis with screw fixation are lower than 26.36, proximal row carpectomy becomes the optimal strategy. However, multivariate probabilistic sensitivity analysis confirmed the results of our model. CONCLUSIONS: Four-corner arthrodesis with screw fixation and proximal row carpectomy are both cost-effective treatment options for scapholunate advanced collapse/scaphoid nonunion advanced collapse wrist because of their lower complication profile and high efficacy, with four-corner arthrodesis with screw as the most cost-effective treatment. Four-corner arthrodesis with plate and Kirschner-wire fixation should be avoided from a cost-effectiveness standpoint.

Incisional Negative Pressure Wound Therapy Augments Perfusion and Improves Wound Healing in a Swine Model Pilot Study.

BACKGROUND: A commonly used treatment for open wounds, negative pressure wound therapy (NPWT) has recently been used to optimize wound healing in the setting of surgically closed wounds; however, the specific mechanisms of action by which NPWT may benefit patients after surgery remain unknown. Using a swine wound healing model, the current study investigates angiogenesis as a candidate mechanism. METHODS: Multiple excisional wounds were created on the dorsa of 10 male Yorkshire pigs and closed by primary suture. The closed wounds underwent treatment with either NPWT dressing or control dressings in the absence of negative pressure. Dressings were maintained for 8 days followed by euthanasia of the animal. Scar evaluation of the wounds by photographic analysis was performed, and wounds were analyzed for angiogenesis markers by enzyme-linked immunosorbent assay and immunohistochemistry. RESULTS: Scar evaluation scores were observed to be significantly higher for the NPWT-treated sites compared with the control sites (P < 0.05). The enzyme-linked immunosorbent assay results demonstrated increases for vascular endothelial growth factor (VEGF) staining at the incision site treated with NPWT compared with other treatment groups (P < 0.05). In addition, an approximately 3-fold elevation in VEGF expression was observed at the NPWT-treated sites (2.8% vs. 1%, respectively; P < 0.0001).). However, there was no significant difference in immunohistochemistry staining. CONCLUSIONS: The use of NPWT improves the appearance of wounds and appears to increase VEGF expression after 8 days in the setting of a closed excisional wound model, suggesting that improved angiogenesis is one mechanism by which NPWT optimizes wound healing when applied to closed surgical wound sites.

Axillary artery pseudoaneurysm and distal ulnar embolization in collegiate pitcher: a case report and review.

Twenty five-year-old pitcher presented with acute right middle and index finger numbness and coolness. Angiogram showed a 5mm axillary pseudoaneurysm and near complete occlusion of ulnar and common interosseous artery, ulnar side of the palmar arch, and ulnar digital artery. Patient deferred surgery, treatment with tPA and heparin succeeded in reperfusion.

A 3D Mammometric Comparison of Implant-Based Breast Reconstruction With and Without Acellular Dermal Matrix (ADM).

This retrospective study utilizes 3D imaging and mammometrics to compare implant-based breast reconstruction with and without the use of ADM. Previous studies have suggested improved aesthetic outcomes with the use of ADM, but none have been able to quantify this difference. Images were obtained at early and late time points following the expander-implant exchange procedure. Measurements included the point of maximum projection, the superior, inferior, medial and lateral volumetric distribution, and the distance from the point of maximum projection to the inframammary fold along the breast meridian. The patients' demographic information, implant size, and complication rate between the two cohorts were similar. In the early post-operative period, the patients with ADM demonstrated higher medial pole volume; however, this difference did not persist in the late post-operative period. Patients with ADM demonstrated a small but statistically significant greater point of maximum projection and length of lower pole curvature in comparison with the non-ADM cohort. In summary, the results of this study demonstrate improved mammometric measurements when ADM is used in implant-based breast reconstruction, supporting superior aesthetic outcomes in early and late post-operative time points. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .