Modified Extensor Indicis Proprius Opponensplasty.

Extensor indicis proprius (EIP) opponensplasty is one of the commonly used techniques to restore thumb abduction and opposition in patients with thenar muscle dysfunction from various causes of median nerve palsy. However, its subcutaneous route around the distal ulna may not represent a straight line of pull, and part of the extensor hood sometimes has to be harvested along with the EIP tendon to gain adequate length to reach the insertion. The purpose of the study is to present the alternative method of EIP opponensplasty and report the clinical outcomes. The modified EIP opponensplasty was performed on 16 patients with severe carpal tunnel syndrome. At the final follow-up examination, all patients were able to regain their desired level of activities. The Kapandji score, abduction angle, and the disabilities of the arm, shoulder, and hand score improved in all patients. There were no complications related to harvesting the EIP tendon. Two patients developed finger stiffness, which improved after rehabilitation. This technique is safe and effective for restoring thumb function and can solve the insufficient tendon length problem of the original EIP opponensplasty.

Posterior Deltoid Function After Transfer of Branch to the Long Head Triceps Brachii of the Radial Nerve to the Anterior Branch of the Axillary Nerve.

PURPOSE: The aim of this study was to evaluate the function of the posterior part of the deltoid after nerve transfer of the long head triceps branch of the radial nerve to the anterior branch of the axillary nerve in patients with an upper brachial plexus injury or isolated axillary nerve injury. METHODS: We retrospectively reviewed 26 patients diagnosed with an upper brachial plexus injury or isolated axillary nerve injury who underwent nerve transfer of the long head triceps muscle branch of the radial nerve to the anterior branch of the axillary nerve in our institute between 2012 and 2017. Data on age, sex, the mechanism of injury, the pattern of injury, and operative treatment were collected from medical records. Preoperative and postoperative clinical examinations, including motor powers of shoulder abduction and extension according to Medical Research Council grading, were evaluated. At a minimum of 2 years after the operation, we evaluated the recovery of the posterior deltoid function using the swallow-tail test. RESULTS: Twenty-two patients (84.6%) had recovery of posterior deltoid function confirmed by the swallow-tail test. There were 23 patients (88.5%) who achieved at least Medical Research Council grade 4 of shoulder abduction. CONCLUSIONS: Nerve transfer from the branch to the long head triceps to the anterior branch of the axillary nerve is an effective technique for restoring deltoid function in an upper brachial plexus injury or isolated axillary nerve injury. This technique can provide shoulder abduction and shoulder extension, which are the functions of the posterior deltoid muscle. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Gunshot Injuries of the Hand: Incidence, Treatment Characteristics, and Factors Associated With Healthcare Utilization.

BACKGROUND: The objectives of this study are to: (1) describe the demographics, injury patterns, and treatment characteristics of patients who sustained a gunshot injury (GSI) of the hand; and (2) examine the utilization of healthcare resources in patients with a GSI of the hand. METHODS: We retrospectively identified 148 adult patients who were treated for a GSI of the hand between January 2000 to December 2017 using multiple International Classification of Diseases Ninth and Tenth Edition (ICD-9 and ICD-10) codes. We used bivariate and multivariable analysis to identify which factors are associated with unplanned reoperation, length of hospitalization, and number of operations. RESULTS: Multivariable logistic regression showed that fracture severity was associated with unplanned reoperation. Multivariable linear regression showed that fracture severity is associated with a higher number of hand operations after a GSI of the hand, and that a retained bullet (fragment) and patients having gunshot injuries in other regions than the hand had a longer length of hospitalization. Seventy (47%) patients had sensory or motor symptoms in the hand after their GSI, of which 22 (15%) patients had a transection of the nerve. CONCLUSIONS: Sensory and motor nerve deficits are common after a GSI of the hand. However, only 31% of patients with symptoms had a transection of the nerve. A retained bullet (fragment), having more severe hand fractures, and GSI in other regions than the hand are associated with a higher number of operation and a longer period of hospitalization.

The Intercostal Nerves Transfer to the Radial Nerve Branch to the Long Head Triceps Muscle: Influencing Factor and Outcome of 55 Cases.

PURPOSE: The objective of this study was to report the functional outcomes and factors affecting the result of intercostal nerves transfer to the radial nerve branch to the long head triceps muscle for restoration of elbow extension in patients with total brachial plexus palsy or C5 to C7 palsy with the loss of triceps muscle function. METHODS: Fifty-five patients with total brachial plexus palsy or C5 to C7 palsy with no triceps muscle function had a reconstruction of elbow extension by transferring the third to fifth intercostal nerves to the radial nerve branch to the long head triceps muscle. The functional outcomes determined by the Medical Research Council grading were evaluated. Factors influencing the outcomes were determined using logistic regression analysis. RESULTS: At the follow-up of at least 2 years, 36 patients (65%) had antigravity motor function (Medical Research Council grade, ≥3). Multivariable logistic regression analysis showed that the body mass index, time to surgery, and injury of the dominant limb were associated with the outcome. CONCLUSIONS: The third to fifth intercostal nerves transfer to the radial nerve branch to the long head triceps muscle is an effective procedure to restore elbow extension. We would recommend using 3 intercostal nerves without grafts; in cases of nerve root avulsion in which there is no chance of spontaneous recovery, early surgery should be considered. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Dorsoradial Ligament Reconstruction in Trapeziometacarpal Joint Arthritis.

BACKGROUND: The main purpose of the study is to present the alternative novel surgical technique in treating patients with trapeziometacarpal (TMC) joint arthritis using dorsoradial ligament (DRL) reconstruction technique and report the clinical outcomes. METHODS: Patients who were diagnosed with TMC joint arthritis and underwent DRL reconstruction were evaluated. Visual analog pain score; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score; grip, tip pinch, tripod pinch, and key pinch strengths along with range of motion of the thumb; and Kapandji score were recorded in the preoperative period and at follow-up. Stress examination was also performed under a fluoroscope. RESULTS: Eleven patients were included in the study. Median follow-up time was 13 months. At follow-up, postoperative visual analog scale and QuickDASH score improved in all patients. Grip, tip pinch, tripod pinch, and key pinch strengths also improved. The range of motion and Kapandji score were slightly improved compared with the preoperative period except for the thumb metacarpophalangeal flexion. Two patients had numbness at the thumb and spontaneously recovered after 3 months. CONCLUSIONS: According to recent evidence which proposed the importance of DRL in TMC joint stability, our DRL reconstruction technique may be an alternative treatment in treating patients presented with TMC joint arthritis. Further study with a longer follow-up period is needed.

Forearm Plate Fixation: Should Plates Be Removed?

Background: Refracture after both bone forearm fracture fixation may vary with or without plate removal. We tested the null hypothesis that there is no difference in the rate of refracture in patients who have undergone open reduction and internal fixation of a diaphyseal forearm bone who have retained implants versus removed implants. We also studied factors associated with plate removal. Methods: We retrospectively identified 645 adult patients with a total of 925 primary fractures that underwent primary plate fixation of an ulnar or radial shaft fracture between 2002 and 2015 at a single institutional system. Patients with nonunion, pathological fracture or infection were excluded. Independent factors associated with refracture and plate removal were identified using multivariable analysis. Results: Refractures occurred in 6.3% of the fractures that had forearm implant removal, compared to 2.1% of the fractures with retained plates. Refractures were independently associated with plate removal (OR: 3.7, 95% CI: 1.2-11.7, P=0.023) and was more frequent in the radius (OR: 2.4, 95% CI: 1.0-5.8, P=0.06). A refracture after implant removal occurred within 3 months after removal. Ulnar plates were removed more often compared to radial plates (OR: 2.6, 95% CI: 1.4-4.7, P=0.002) as were plates used for type A fractures compared to type C fractures (OR: 3.2, 95% CI: 1.1-9.2, P=0.032). Conclusion: The rate of refracture is higher after plate removal compared to patients who did not have plates removed. Although uncommon, refractures of the radius tend to be more common than a refracture of the ulna. If the implant is symptomatic on the ulnar side, it may be preferable to remove the ulnar implant and retain the radius implant rather than remove both plates when possible. Furthermore, limiting strenuous activity for three months after implant removal is a consideration.

Outcomes of Spinal Accessory Nerve and Intercostal Nerve Transfers for Shoulder Stabilisation and Elbow Extension in Patients with C5,6,7 Root Avulsion Injury.

Background: Upper arm type brachial plexus palsy results in decreased shoulder and elbow function. Reanimation of shoulder and elbow function is beneficial in these patients. The aim of this study is to report the results of restoring the shoulder abduction and elbow extension in patients with C5,6,7 root avulsion injury by simultaneous transfer of the spinal accessory nerve for the supraspinatus muscle combined with the transferring of the sixth and seventh intercostal nerves for the serratus anterior muscle along with the third to fifth intercostal nerves to the triceps muscle. Methods: All patients who underwent the above set of nerve transfers and had at least 2 years of follow-up were included in the study. The outcome measures included the Medical Research Council (MRC) grading of motor strength of shoulder abduction and elbow extension and range of motion of shoulder abduction and shoulder external rotation. Results: The study included 10 patients with an average age of 27. The mean time from injury to surgery was 6 months and the mean follow-up period was 35 months. M4 grade shoulder abduction was restored in five patients, M3 grade in three patients and M2 grade in two. M4 grade elbow extension was achieved in four patients, M3 grade in four patients and M2 grade in two patients. The average arc of shoulder abduction and external rotation was 71° and -21°, respectively. Conclusions: The spinal accessory nerve and the sixth and seventh intercostal nerves transfer to the supraspinatus muscle and serratus anterior muscle with the third to fifth intercostal nerves transfer to the triceps muscle provided satisfactory results for both shoulder abduction and elbow extension in C5,6,7 root avulsion injury. Level of Evidence: Level IV (Therapeutic).

Anatomy of Distal Articular Surface of Hamate Bone, A Cadaveric Study.

Background: Hemi-hamate arthroplasty is one of the treatment options for dorsal proximal interphalangeal joint fracture dislocation. Many studies reported favorable outcomes. However, some long term studies demonstrated the degenerative change of PIP joint. The articular mismatch of the hemi-hamate autograft might play an important role of this complication. Methods: We studied the anatomy of distal articular surface of the hamate bone in embalmed hamate bones. The anatomy of distal articular surface and dimensions of the hamate bone were measured and recorded. Results: Seventy hamate bones were dissected out from embalmed cadavers and included in this study. The mean angle of the 4th metacarpal articulation was 85.54 degrees (SD = 3.53) and mean angle of the 5th metacarpal articulation was 95.51 degrees (SD = 3.57). The inter-articular ridge was approximately 5 degrees radial inclination. Conclusions: The inter-articular ridge of distal articular surface was approximately 5 degrees radial inclination. In order to minimize the graft mismatch, we recommend making the bone cut with the saw blade tilted to radial side 5 degrees to achieve better alignment of inter-articular ridge of the graft.

Surgery for lower extremity symptomatic neuroma: Long-term outcomes.

INTRODUCTION: Traumatic neuroma caused by injuries or surgery can result in neuropathic pain, functional impairment, and psychological distress, which has an impact on quality of life. The aim of this study was to identify the factors related to successful treatment of symptomatic lower extremity symptomatic neuromas using patient-reported outcome measures (PROMs). METHODS: Thirty-two patients with 48 symptomatic neuromas completed the PROMIS mobility, PROMIS pain interference (PI), Numeric Rating Scale (NRS) for pain (0-10) for both pre- and post-operative pain, and the PROMIS depression at a mean of 8.9±4.5 years following neuroma surgery. Neuromas were located around the foot and ankle (n=18, 38%), leg (n=14, 29%), around the knee (n=13, 27%), and in the thigh (n=3, 6.3%). Surgical treatment included neuroma excision and implantation (n=29, 60%) followed by neuroma excision alone or excision with placement in the subcutaneous tissue (n=12, 25%). We performed multivariable analysis to identify the factors influencing the PROMs. RESULTS: Patients reported significant reduction in mean NRS pain after surgery (7.3 vs 4.9, p=0.0013). Higher PROMIS depression scores were independently associated with inferior PROMIS mobility scores (ß=-0.38, p=0.001), higher PROMIS PI scores (ß=0.68, p<0.001), and higher NRS pain scores (ß=0.1, p=0.001). Additionally, smoking was independently associated with higher NRS pain scores (ß=1.59, p=0.049) CONCLUSION: Surgical treatment of symptomatic neuromas of the lower extremity provides a long-term improvement in 59% of patients, but 19% of patients still reported severe persistent pain despite surgical treatment. Smoking and negative mood have negative effects on patient-reported outcomes after neuroma surgery.

Radial Half of the Second Metacarpal Bone and the First Dorsal Interosseous Muscle Composite Flap for Treating the First Metacarpal Bone Defect: A Case Report.

Traumatic bone defect is a challenging problem for both patient and doctor. The goal of treatment is the restoration of hand function with acceptable appearance of an injured hand. Especially in the injury of the thumb, length and stability are very important to achieve good holding and pinching functions. We reported a 23-year-old patient with traumatic first metacarpal bone loss after a motor vehicle accident treated with vascularized radial half of the second metacarpal bone and the first dorsal interosseous muscle composite flap.

Simultaneous Phrenic and Intercostal Nerves Transfer for Elbow Flexion and Extension in Total Brachial Plexus Root Avulsion Injury.

BACKGROUND: To report the results of restoring the elbow flexion and extension in patients with total brachial root avulsion injuries by simultaneous transfer of the phrenic nerve to the nerve to the biceps and three intercostal nerves to the nerve of the long head of the triceps. METHODS: Ten patients with total brachial root avulsion injuries underwent the spinal accessory nerve transfer to the suprascapular nerve for shoulder reconstruction. Simultaneous transfer of the phrenic nerve to the nerve to the biceps via the sural nerve graft and three intercostal nerves to the nerve of the long head of the triceps was done for restoration of the elbow flexion and extension. Trunk flexion exercise program was used for all patients postoperatively. The mean follow up period was 36 months. RESULTS: For elbow flexion, there were two M4, seven M3, and one M1. For elbow extension, there were three M4, four M3, two M2, and one M1. No patient demonstrated a respiratory problem clinically postoperatively. The average FVC% decreased to 61% of the predicted value at 24 months after surgery. CONCLUSIONS: The simultaneous nerve transfer using the phrenic nerve to the nerve to the biceps and 3 intercostal nerves to the nerve of the long head of the triceps with postoperative trunk flexion exercise provide a comparable result for restoration of elbow function in total brachial plexus root avulsion injury. The patients who appear to have a respiratory problem and are unable to comply with the post-operative respiratory muscles training should be contraindicated for this simultaneous transfer.

Painful Snapping of Thumb Caused by Osteochondroma of Trapezium.

Osteochondroma is the most common benign bone tumor. Lesions occurring at the carpal bones are extremely rare. There are very few cases of osteochondroma at the trapezium had been reported in the English literature. We reported a 47-year-old patient with an osteochondroma of the left trapezium presented with painful snapping of abductor pollicis longus tendon.