A Review on Volar Fracture-Dislocations of the Proximal Interphalangeal Joint.

Volar fracture-dislocations of the proximal interphalangeal joint are rare injuries caused by an axial force on a flexed digit resulting in an avulsion fracture of the dorsal lip of the middle phalanx with volar dislocation of the joint. This volar subtype is analogous to the more common dorsal subtype with a mirror image fracture on the dorsal lip of the middle phalanx. The main significance in this type of injury lies in the disruption of the extensor mechanism at the central slip. The goals of treatment, apart from restoring a congruent and stable joint, is to restore the extensor mechanism to prevent a boutonnière deformity. In this article, we summarise the current literature and discuss the principles for treatment of this uncommon injury. Level of Evidence: Level V (Therapeutic).

The role of reconstructive microsurgeons in liver transplantation-a narrative review.

Background and Objective: Liver transplantation is a life-saving procedure, but also associated with complications. Hepatic artery thrombosis is one of the most devastating complications, especially for living donor liver transplantation. The application of microsurgical techniques for hepatic artery reconstruction has greatly reduced the risk of hepatic artery thrombosis. In this narrative review, we discuss the technical considerations and challenges faced in microsurgical reconstruction of hepatic artery in liver transplantation. Methods: PubMed, Web of Science, and Google Scholar were searched for keywords relating to "liver transplantation", "microsurgery", "living donor liver transplantation", "deceased donor liver transplantation", "hepatic artery", "hepatic artery thrombosis", "hepatic artery reconstruction" and "microsurgical anastomosis". Relevant articles pertaining to the technical considerations and challenges of microsurgery in liver transplantation were included. Key Content and Findings: The conditions of liver transplantation pose unique challenges to the microsurgeon. Nonetheless, there are described strategies that can overcome these conditions, as well as technical details that may improve the outcomes of hepatic artery reconstruction. These strategies start from proper positioning of the patient, conscientious selection of donor and recipient hepatic vessels, and minimizing movements during critical microsurgical anastomosis. Technical details include techniques to overcome vessel delamination, size mismatch, poor quality vessels, and short vessel stump. This review also explores the outcomes of microsurgical hepatic arterial reconstruction. Conclusions: There are various strategies to mitigate the challenges of microsurgery in liver transplant. Microsurgery improves the outcome of liver transplantation. Microsurgeons will continue to be a priceless resource that all liver transplant teams should have.

Middle-phalanx-base radiographic morphology and its clinical implications.

The aim of this study was to establish normative values for the teardrop angle at the base of the middle phalanx. Our results showed a consistent mean teardrop angle in the range of 50°-51°, with no statistically significant difference observed between digits.Level of evidence: III.

Forecasting the rate of hand injuries in Singapore.

PURPOSE: This study aims to analyse the correlation between the incidence rate of hand injuries and various major economic indicators in Singapore. We hypothesise that the number of hand injuries is correlated to activity in the construction and manufacturing industries in Singapore. METHODS: Twenty thousand seven hundred sixty-four patients who underwent hand surgeries in a tertiary institution between 2012 to 2018 were reviewed. Two independent, blinded observers extracted the frequency of hand surgeries performed from Electronic Medical Records. Economic indicators pertinent to Singapore's economic activity were collected and smoothed by simple moving average of the prior 3 months. Results were analysed using IBM SPSS v25.0. RESULTS: Significant independent univariate variables were Purchasing-Manager-Index and Industrial-Production-Index. Multiple linear regression of quarterly reported figures showed that Total-Livestock-Slaughtered, Total-Seafood-Handled, Purchasing-Manger-Index, Industrial-Production-Index, Gas-Tariffs, Construction-Index, Consumer-Price-Index, Total-Air-Cargo-Handled, Total-Container-Throughput, Total-Road-Traffic-Accident-Casualties, Food-&-Beverage-Services-Index were significantly correlated (p < 0.05) with hand injuries, with R2 = 62.3%. CONCLUSION: Quarterly economic indicators from major economic industries can be used to predict the incidence of hand injuries with a 62.3% correlation. These findings may be useful for anticipating healthcare resource allocation to treat hand injuries. TYPE OF STUDY AND LEVEL OF EVIDENCE: Economic and decision, Level II.

Radioscaphoid Impingement after Volar Plate Fixation and Bone Grafting of a Non-United Scaphoid Fracture.

Volar plate fixation (VPF) of scaphoid fractures has received increased attention over the past decade. The purported benefits over headless screw fixation are increased rigidity, better purchase of small fragments, the ability to prevent extrusion of bone graft, and to act as a buttress against excessive scaphoid flexion. We report a case of symptomatic radioscaphoid impingement presenting two years after successful VPF for a non-united scaphoid fracture. We performed an arthoscopic evaluation, synovectomy and chondroplasty, followed by open radial styloidectomy and implant removal. This article highlights the pertinent clinical features, relevant imaging, and key intra-operative findings. We have analyzed the factors that led to this complication and have highlighted several technical tips to minimize radiocarpal impingement and ongoing chondral damage.

Emergency Hand and Reconstructive Microsurgery in the COVID-19-Positive Patient.

The case spectrum in hand surgery is one of extremes-purely elective day surgery cases under local anesthesia to mangling limb injuries that require immediate, and frequently, lengthy, surgery. Despite the cancellation of most elective orthopedic and plastic surgical procedures, hand surgeons around the world continue to see a steady stream of limb-threatening cases such as severe trauma and infections that require emergent surgical care. With the increase in community-spread, an increasing number of COVID-19-infected patients may be asymptomatic or have mild, nonspecific or atypical symptoms. Some of them may already have an ongoing, severe infection. The time-sensitive nature of some of these cases means that hand surgeons may need to operate urgently on patients who may be suspected of COVID-19 infections, often before confirmatory test results are available. General guidelines for perioperative care of the COVID-19-positive patient have been published. However, our practices differ from those of general orthopedic and plastic surgery, primarily because of the focus on trauma. This article discusses the perioperative and technical considerations that are essential to manage the COVID-19 patient requiring emergency care, without compromising clinical outcomes and while ensuring the safety of the attending staff.

The Importance of Restoring Anatomy of the Proximal Interphalangeal Joint in Dorsal Fracture Dislocations.

The proximal interphalangeal joint (PIPJ) is a complex anatomical structure. In managing fracture dislocations about the PIPJ, the aim is to restore a congruent joint that allows for smooth gliding motion. Detailed knowledge of the anatomy and biomechanics of the PIPJ is necessary in managing these injuries with predictable success. The breadth of techniques previously described in the treatment of such injuries is testament to the difficulties faced in achieving optimal clinical and radiological outcomes. In this article we detail the anatomy and biomechanics of the PIPJ and summarize current literature and principles for the treatment of dorsal fracture dislocations.

Injuries Around the Proximal Interphalangeal Joint.

Proximal interphalangeal joint (PIPJ) injuries are common and challenging to treat, involving a spectrum of conditions ranging from isolated ligamentous injuries to severe fracture dislocations. The main goal of treatment is to achieve a congruent, stable joint, which is key to achieving early range of motion and a favorable outcome. Injuries that do not compromise the stability of the joint may be treated nonsurgically, whereas those that render the joint unstable may be managed with one of many surgical strategies available. This article focuses on the current practices of treatment of injuries around the PIPJ.

Ex-vivo Tendon Repair Augmented with Bone Marrow Derived Mesenchymal Stem Cells Stimulated with Myostatin for Tenogenesis.

BACKGROUND: To investigate the effect of myostatin (GDF-8) stimulation of bone marrow derived mesenchymal stem cells (BMSCs) on tenogenesis in the setting of tendon repair. GDF-8 has demonstrated the ability to augment tenogenesis and we sought to identify if this effect could lead to the focused differentiation of pluripotential stem cells down a tenocyte lineage ex vivo. METHODS: Cadaveric upper limb flexor tendons were harvested, decellularized and divided into 1 cm segments. Sutures seeded with stem cells were passed through tendon segments to simulate repair. The repaired tendons were then cultured either with or without myostatin for 3, 5, and 7 days. The experiment was also repeated with non-decellularized tendons for a total of 4 groups. The tendons were then evaluated for the expression of scleraxis and tenomodulin, two biomarkers for tendon. RESULTS: Myostatin stimulation led to an increase in expression of tenomodulin and scleraxis at 5 and 7 days in both the decellularized and non-decellularized tendons. Myostatin increased the differentiation of BMSCs into tenocytes and/or led to the upregulation of tenomodulin and scleraxis production by the native tenocytes present within the non-decellularized tendons. CONCLUSIONS: The addition of myostatin to BMSCs leads to tenocyte differentiation as evidenced by the expression of tenocyte biomarkers, scleraxis and tenomodulin. This effect is maintained in an ex vivo tendon repair model suggestive that these cells survive the passage through tendon tissue and remain metabolically active.

Mean 5-Year Follow-up for Suture Button Suspensionplasty in the Treatment of Thumb Carpometacarpal Joint Osteoarthritis.

PURPOSE: Suture button suspensionplasty (SBS) has been used to treat thumb carpometacarpal joint osteoarthritis (CMC joint OA). Although promising short-term outcomes have been reported, no outcomes beyond 4 years have been published. The aim of this article is to report intermediate outcomes of SBS. METHODS: We reviewed the charts of 14 patients who underwent 16 SBS procedures for symptomatic thumb CMC joint OA. We recorded demographic data, preoperative Eaton stage, length of follow-up, Quick-Disabilities of the Arm, Shoulder, and Hand questionnaire scores, as well as pinch strength, grip strength, range of motion, and metacarpal subsidence. Operative time and postoperative complications were documented. RESULTS: Average age was 64 years. There were 12 women and 2 men. Preoperative Eaton stages were III and IV in 8 thumbs each. Mean operative time was 93 minutes. Mean follow-up was 64 months with mean Quick-Disabilities of the Arm, Shoulder, and Hand score improvement of 58.2. Mean palmar and radial abduction were 105% and 97%, respectively, of the nonsurgical thumb. Kapandji scores for all operated thumbs were either 9 or 10. Pinch and grip strength were 107% and 102%, respectively, of the nonsurgical side. Mean trapezial space height was 71%. One patient underwent removal of a symptomatic implant and 2 patients had transient neuropraxia of the dorsal radial sensory nerve. CONCLUSIONS: Favorable outcomes (improvement in range of motion and pain relief) of SBS remain durable over time. Our results show that improvement in strength may also be expected over time when using SBS after trapeziectomy for the treatment of thumb CMC joint OA. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Incidence of Posterior Interosseous Nerve Trauma During Creation of the 3-4 Wrist Arthroscopy Portal in Cadavers.

PURPOSE: To describe histologic evidence of nerve trauma during the creation and use of the 3-4 portal. METHODS: Fourteen fresh-frozen cadaveric wrists were mounted on a custom-built frame that simulated a wrist arthroscopy traction tower. After the 3-4 portal was created in the usual manner, the skin was dissected off to identify possible trauma to the posterior interosseous nerve (PIN). Specimens were categorized into those where there was clearly no trauma to the PIN and those where trauma was possible. In the cases where trauma was possible, we harvested the PIN with a cuff of the proximal edge of the portal and examined the cross-sectional histology of the most distal sections for the presence of neural tissue. RESULTS: There was clearly no trauma to the PIN in 3 of the wrists during the creation of the 3-4 portal. In the remaining 11 wrists with possible trauma to the PIN, we identified axonal tissue on histologic examination at the proximal edge of the 3-4 portal in 7 of these specimens. In summary, 50% (7 of 14) of our specimens had visual and histologic evidence of trauma to the PIN. CONCLUSIONS: Based on the findings of this study, there may be more instances of trauma to the PIN during routine wrist arthroscopy than have been previously reported. CLINICAL RELEVANCE: Findings suggest that transection or injury to this nerve may not lead to any clinical sequelae. However, if there is an instance where a patient has persistent, otherwise unexplained, dorsal wrist pain after a wrist arthroscopy procedure, iatrogenic neuroma of the PIN may be responsible and should be considered.

Post-Reduction Stability of the Proximal Interphalangeal Joint after Dorsal Fracture Dislocation-A Cadaveric Study.

BACKGROUND: Proximal interphalangeal joint (PIPJ) dorsal fracture dislocations (DFD) are challenging injuries. Treatment aims to achieve stability of the PIPJ after reduction so that early motion can be initiated. We studied how increasing articular destruction would affect post reduction stability and investigate the amount of traction and PIPJ flexion needed to maintain the reduction. METHODS: Increasing amounts (20%, 40% and 60%) of damage to the volar lip of the middle phalanx in cadaveric specimens were created to represent PIPJ DFD that were stable, of tenuous stability and frankly unstable. Traction forces and PIPJ flexion needed to maintain the reduction were then measured. RESULTS: The PIPJ DFD with 20% damage were stable and did not subluxe while the one with 40% articular involvement was stable after reduction. For unstable the PIPJ with 60% involvement, the more the PIPJ was flexed, the less traction force was needed to hold the joint in reduction. For PIPJ flexion of 20 degrees, a minimum 4.4N of force is needed to maintain reduction while PIPJ flexion of 10 degrees required a minimum 5.0N of force. No amount of force could maintain PIPJ reduction if traction was performed in full extension. CONCLUSIONS: In our model, PIPJ DFD with less than 30% articular damage are stable while those with 30% to 50% of involvement have tenuous stability. For the unstable PIPJ DFD, traction obviates the need for excessive flexion of the PIPJ to maintain joint reduction. This information should be considered in treatment modalities for PIPJ DFD, as well in the design of external traction devices for the treatment of PIPJ DFD.

Radial Nerve Tendon Transfers.

Radial nerve palsy typically occurs as a result of trauma or iatrogenic injury and leads to the loss of wrist extension, finger extension, thumb extension, and a reduction in grip strength. In the absence of nerve recovery, reconstruction of motor function involves tendon transfer surgery. The most common donor tendons include the pronator teres, wrist flexors, and finger flexors. The type of tendon transfer is classified based on the donor for the extensor digitorum communis. Good outcomes have been reported for most methods of radial nerve tendon transfers as is typical for positional tendon transfers not requiring significant power.

Hand Fractures: Indications, the Tried and True and New Innovations.

Hand fractures are the second most common fracture of the upper extremity, and management of patients with these injuries is common for most hand surgery practices. In this article, we outline the principles of management of these injuries with a special focus on those that are common or complex. We also highlight recent innovations in the context of these injuries. From this cross-section of contemporary evidence on phalangeal and metacarpal fracture treatment, we have noted a trend toward minimally invasive surgery with immediate postoperative mobilization, the use of wide-awake anesthesia, as well as sustained investigation and innovation in the biomechanics and treatment of proximal interphalangeal joint fracture dislocations.

Surgical Approaches to the Proximal Interphalangeal Joint.

The proximal interphalangeal (PIP) joint may be affected by many conditions such as arthropathy, fractures, dislocations, and malunions. Whereas some of these conditions may be treated nonsurgically, many require open surgical intervention. Open interventions include implant arthroplasty or arthrodesis for arthropathy, open reduction internal fixation, or hemi-hamate arthroplasty for dorsal fracture-dislocations. Volar plate arthroplasty and corrective osteotomy for malunion about the PIP joint are also surgeries that may be required. The traditional approach to the PIP joint has been dorsal, which damages the delicate extensor apparatus with subsequent development of an extensor lag. This has led surgeons to explore volar and lateral approaches to the PIP joint. In this article, we describe each of these surgical approaches, discuss their advantages and disadvantages, and provide some guidance on which approach to choose based on the surgery that is to be performed.