Dual Antegrade Intramedullary Headless Screw Fixation for Treatment of Unstable Proximal Phalanx Fractures.

Background: Although intramedullary headless screw (IMHS) fixation is a promising minimally invasive surgical treatment option for unstable proximal phalanx fractures, a single IMHS may provide inadequate fixation for certain fracture patterns. The purpose of this study was to evaluate the short-term clinical outcomes in a pilot series of patients with proximal phalanx fractures treated with dual antegrade IMHS fixation. Methods: We performed a retrospective chart review of proximal phalanx fractures treated with dual antegrade IMHS fixation with a minimum 1 year of follow-up. Demographic information including patient age, sex, occupation, workers' compensation status, mechanism of injury, hand dominance, and injured digit were obtained. Postoperative outcomes measured included range of motion, grip strength, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) outcome scores, return to full-duty work interval, and complications. Results: Ten fractures in 10 patients (4 male, 6 female) satisfied study inclusion. The mean age of patients was 39 years (range, 20-62), and average follow-up duration was 84 weeks (range, 61-106). Final postoperative total active motion was 258° (range, 245°-270°), mean grip strength was 97% (range, 84%-104%) of the uninjured side, and QuickDASH score was 3.9 (range, 0-13.6). No complications occurred, and no patients required additional intervention. Conclusions: Dual antegrade IMHS fixation of proximal phalanx fractures resulted in excellent postoperative motion, near-normal grip strength, positive self-reported patient outcomes, and no complications with follow-up of at least 1 year. Further study in a larger number of patients is warranted to determine if this promising technique is superior to other modes of fixation.

Late Reconstruction of the Interosseous Membrane with Bone-Patellar Tendon-Bone Graft for Chronic Essex-Lopresti Injuries: Outcomes with a Mean Follow-up of Over 10 Years.

BACKGROUND: The purpose of this study was to report our long-term outcomes following reconstruction of the forearm interosseous membrane (IOM) with bone-patellar tendon-bone (BPTB) graft for treatment of chronic Essex-Lopresti injuries. METHODS: We identified 33 patients who underwent IOM reconstruction with BPTB graft for chronic Essex-Lopresti injuries over a 20-year treatment interval. Twenty male and 13 female patients, with a mean age of 42.1 years (range, 19 to 73 years) and a minimum follow-up interval of 5 years, were included. Preinjury clinical examination and radiographic measurements were obtained from records for comparison with prospectively collected data. Additional functional outcome data collected postoperatively included QuickDASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH]), modified Mayo wrist (MMW), and Broberg-Morrey elbow function scores. RESULTS: IOM reconstruction was performed at a mean interval (and standard deviation) of 44.9 ± 60.0 months (range, 6.4 to 208 months) from the time of the initial injury. At a mean follow-up of 10.9 ± 4.4 years (range, 5.5 to 24.2 years), significant improvements were observed in mean elbow flexion-extension arc (+13° [95% confidence interval (CI), 4° to 22°]; p = 0.005), wrist flexion-extension arc (+19° [95% CI, 4° to 34°]; p = 0.016), forearm pronation-supination (+23° [95% CI, 8° to 39°]; p = 0.004), and grip strength (+25% of that of the contralateral side [95% CI, 18% to 32% of contralateral side]; p < 0.001). Improvements in ulnar variance were sustained over the long term from +3.9 mm (95% CI, 3.2 to 4.6 mm) preoperatively to -1.6 mm (95% CI, -2.3 to -0.9 mm) immediately postoperatively and -1.1 mm (95% CI, -1.8 to -0.4 mm) at the time of the final follow-up (p < 0.001). The mean QuickDASH, MMW, and Broberg-Morrey scores were 29.8 (range, 5 to 61), 82.7 (range, 60 to 100), and 91.6 (range, 64 to 100), respectively. CONCLUSIONS: IOM reconstruction with a BPTB graft is an effective treatment option for chronic Essex-Lopresti injuries, with satisfactory clinical and functional outcomes over the long term. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Single- versus double-bundle suture button reconstruction of the forearm interosseous membrane for the chronic Essex-Lopresti lesion.

PURPOSE: Reconstruction of the ruptured interosseous membrane (IOM) is critical to restore forearm stability for the chronic Essex-Lopresti injury. Positive outcomes have been reported following IOM reconstruction with a single-bundle suture button (Mini-Tightrope) construct, although recent work suggests that double-bundle Mini-TightRope® IOM reconstruction is biomechanically superior. The purpose of this study was to determine whether double-bundle Mini-TightRope® reconstruction of the forearm IOM results in superior clinical outcomes to the single-bundle technique. METHODS: Five patients with chronic Essex-Lopresti injuries treated with double-bundle Mini-TightRope® IOM reconstruction were matched to five patients treated with single-bundle Mini-TightRope® reconstruction. Improvement in clinical examination measures and patient-reported outcomes was compared between the groups. RESULTS: Results were good to excellent in all 10 patients. At final follow-up, forearm rotation was significantly better in the single-bundle group, while maintenance of ulnar variance was better in the double-bundle group. No significant differences were noted between the two groups for any other numerical outcomes, and no complications occurred. CONCLUSION: These findings suggest that while IOM reconstruction with a double-bundle Mini-TightRope® construct results in greater resistance to proximal migration of the radius in the intermediate term, there is a modest concomitant loss of forearm rotation when compared to single-bundle reconstruction. LEVEL OF EVIDENCE: Therapeutic Level IV.

Platelet-Rich Plasma Injection With Percutaneous Needling for Recalcitrant Lateral Epicondylitis: Comparison of Tenotomy and Fenestration Techniques.

BACKGROUND: Recalcitrant lateral epicondylitis (LE) is a common debilitating condition, with numerous treatment options of varying success. An injection of platelet-rich plasma (PRP) has been shown to improve LE, although it is unclear whether the method of needling used in conjunction with a PRP injection is of clinical importance. PURPOSE: To determine whether percutaneous needle tenotomy is superior to percutaneous needle fenestration when each is combined with a PRP injection for the treatment of recalcitrant LE. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 93 patients with recalcitrant LE were treated with a PRP injection and percutaneous needle fenestration (n = 45) or percutaneous needle tenotomy (n = 48) over a 5-year study interval. Preoperative patient data, including visual analog scale for pain (VAS-P), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Patient-Rated Tennis Elbow Evaluation (PRTEE) scores and grip strength, were obtained from a chart review and compared with postoperative values obtained prospectively. Secondary outcomes included the incidence of complications, need for additional interventions, return to work, and patient satisfaction. RESULTS: At a mean follow-up of 40 months, significant improvements in VAS-P (mean, -6.1; 95% CI, -6.8 to -5.5; P < .0001), QuickDASH (mean, -46; 95% CI, -52 to -40; P < .0001), and PRTEE (mean, -57; 95% CI, -64 to -50; P < .0001) scores and grip strength (mean, +6.1 kg; 95% CI, 4.9 to 7.3; P < .0001) were observed across the entire study cohort, with no significant differences noted between the fenestration and tenotomy groups. Nine of 45 patients (22%) underwent additional procedures to treat recurrent symptoms in the fenestration group compared with 5 of 48 patients (10%) in the tenotomy group (P = .05). No complications occurred in any patients, and no patients expressed dissatisfaction with their treatment course. CONCLUSION: A PRP injection with concomitant percutaneous needling is an effective treatment for recalcitrant LE, with sustained improvements in pain, strength, and function demonstrated at a mean follow-up of longer than 3 years. Although the method of concomitant needling does not appear to have a significant effect on treatment outcomes, more aggressive needle tenotomy is less likely to require conversion to open tenotomy than needle fenestration in the short term to midterm.

Osteochondral Autograft Transplantation for Proximal Lunate Articular Defects.

BACKGROUND: No consensus treatment option for focal osteochondral defects of the proximal lunate exist in the literature. Surgical management has thus far been limited to salvage procedures such as proximal row carpectomy and partial arthrodesis. CASE DESCRIPTION: We report our experience using the osteochondral autograft transplantation surgery (OATS) procedure in two young, active patients with focal osteochondral defects of the proximal lunate. At mean follow-up of 6 years, sustained improvements in pain, motion, and function were observed. Both patients reported high levels of satisfaction and neither experienced any complications. LITERATURE REVIEW: To our knowledge, this is the first report describing the use of OATS to treat proximal lunate defects. CLINICAL RELEVANCE: OATS is a valuable surgical option for treating focal chondral defects of the proximal lunate, with positive outcomes at greater than 5 years postoperatively. This may be an especially useful technique for younger, active patients, and those wishing to maintain maximum functionality.

Arthroscopic Management of Bennett Fracture.

Bennett fracture is the most common fracture of the thumb. Choosing the appropriate approach to fracture fixation requires a thorough knowledge of the anatomy surrounding the first carpometacarpal joint, which is necessary to prevent injury to local sensory nerves and tendons. Although no study has shown superior outcomes compared with open reduction internal fixation and fluoroscopically guided closed reduction and percutaneous pinning, arthroscopic-assisted fixation allows for debridement of the carpometacarpal joint, direct visualization of the articular surface during reduction, and has minimal morbidity and associated complications.

Modified Long Toe Extensor Tendon Harvest for Use as Intercalary Graft in Upper Extremity Reconstruction.

Autograft tendon harvested from the long toe extensors are of great utility as intercalary grafts in upper extremity reconstruction. However, standard full-length harvest is complicated by the presence of extensor retinacula and multiple juncturae between adjacent extensors, which often necessitate extensive dissection, increasing the potential for morbidity. We describe a modified technique for partial harvest of the long toe extensors, which is performed entirely proximal to the superior extensor retinaculum. This technique requires a single incision and provides adequate length of graft for the majority of forearm to fingertip reconstructions. The technique is described in the context of our preliminary cadaver findings, with a case example provided to further illustrate the utility of this technique.

Orthogonal Plate Fixation With Corrective Osteotomy for Treatment of Distal Radius Fracture Malunion.

PURPOSE: To report outcomes of patients with distal radius fracture malunions treated with corrective osteotomy and orthogonal volar and radial "90-90" plate fixation. METHODS: We performed a retrospective review of all patients who underwent distal radius corrective osteotomy and 90-90 fixation from January 2008 through December 2014. Demographic data, injury history, prior treatments, and clinical examination values were recorded. Preoperative radiographic measurements were used to classify the type and severity of deformity. The outcomes were patient-reported pain levels, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) functional scores, and radiographic outcomes. Secondary outcomes, including complications and the need for additional surgeries, were also noted. RESULTS: Thirty-nine cases (31 extra-articular, 8 combined intra- and extra-articular) were included. At mean postoperative follow-up interval of 4 years, significant improvements were observed clinically in wrist flexion-extension arc, grip strength, pain, and Quick Disabilities of the Arm, Shoulder, and Hand scores. Radiographically, significant postoperative improvements were noted in ulnar variance, radial inclination, intra-articular stepoff, and radial tilt, with volarly and dorsally angulated malunions corrected to 9° and 7° of volar tilt, respectively. Twelve patients (31%) underwent additional surgery, the most common being plate removal in 7 patients, 3 of which involved removal of the radial plate. CONCLUSIONS: For patients with symptomatic malunion of the distal radius, corrective osteotomy with 90-90 plate fixation is an effective treatment option for improving pain and restoring function for both volarly and dorsally angulated malunions, including malunions with an intra-articular component. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Pleomorphic Hyalinizing Angiectatic Tumor Arising in the Hand: A Case Report.

Background: Background: Pleomorphic hyalinizing angiectatic tumors (PHATs) are extremely rare, non-metastasizing tumors of uncertain origin that are typically seen in the lower extremities. To date, it is estimated that less than 100 cases have been reported worldwide since first described in 1996. Methods: The case of a 35-year-old male with a several-year history of a dorsal hand mass is presented. Although the patient was initially asymptomatic, in the months prior to presentation, the patient complained of pain with power grasp and direct pressure over the mass. The patient underwent uncomplicated surgical excision, during which the mass was noted to be adherent to the underlying extensor tendons. Results: Immunopathology confirmed the mass to be PHAT. We believe this is the first documented case of this rare tumor occurring in the hand. Conclusions: History and epidemiology of PHAT are reviewed. Then, in the context of the presented case, pre-operative evaluation, surgical management, pathologic findings and post-operative follow-up are all discussed.

Novel Treatment of a Scapholunate Ligament Injury with Proximal Pole Scaphoid Nonunion.

BACKGROUND: Nonunion of scaphoid proximal pole fractures presents a challenging management dilemma to hand surgeons. This problem is further complicated in the uncommon concurrence of scapholunate (SL) ligament disruption. CASE DESCRIPTION: A 39-year-old male patient presented with new-onset wrist pain following a remote history of a proximal pole scaphoid fracture sustained as a teenager, which was treated nonoperatively. Six months before presentation, the patient sustained a fall while snowboarding. The patient was found to have a chronic nonunion of his scaphoid proximal pole with an associated SL ligament disruption. As the proximal fragment was too small to be amenable to fixation, the patient was treated with an arthroscopic partial scaphoid excision and SL ligament reconstruction using a scapholunateintercarpal screw placed percutaneously. At 26 months, the patient exhibited no pain, near-normal strength, and wrist motion, and expressed a high-level of satisfaction from his surgery. LITERATURE REVIEW: Although cases of SL ligament disruption with concomitant proximal scaphoid fractures have been reported, to our knowledge, this is the first report of SL ligament rupture occurring in the setting of a preexisting proximal pole scaphoid nonunion. CLINICAL RELEVANCE: We report the use of SL ligament reconstruction augmented with intercarpal screw fixation, and excision of the proximal pole scaphoid nonunion. This minimallyinvasive approach may be a particularly useful option in young, active patients such as our own, where a motion-sacrificing salvage procedure would be less than ideal.

Interosseous membrane reconstruction with a suture-button construct for treatment of chronic forearm instability.

BACKGROUND: The purpose of this study was to report outcomes of interosseous membrane (IOM) reconstruction with a suture-button construct for treatment of chronic longitudinal forearm instability. METHODS: We performed a retrospective review with prospective follow-up of patients who underwent ulnar shortening osteotomy and IOM reconstruction with the Mini TightRope device from 2011 through 2014. Bivariate statistical analysis was used for comparison of preoperative and postoperative Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, range of motion, grip strength, and ulnar variance. Complications and patient satisfaction were also recorded. RESULTS: Ten patients (mean age, 45.3 years) satisfied inclusion criteria: 8 treated for post-traumatic sequelae of Essex-Lopresti-type injuries, 1 for forearm instability secondary to previous elbow surgery, and 1 for instability secondary to trauma and multiple elbow surgeries. Surgeries were performed an average of 28.6 months from initial injury. At mean follow-up of 34.6 months after surgery, significant improvement was observed in elbow flexion-extension arc (+23° vs. preoperatively; P = .007), wrist flexion-extension arc (+22°; P = .016), QuickDASH score (-48; P = .000), and ulnar variance (-3.3 mm; P = .006). Three patients required additional surgery: 1 revision ulnar shortening osteotomy for persistent impingement, 1 revision ulnar osteotomy and Mini TightRope removal for lost forearm supination, and 1 fixation of a radial shaft fracture after a fall. CONCLUSION: IOM reconstruction using a suture-button construct is an effective treatment option for chronic forearm instability.

Arthroscopic Trapeziectomy With Suture Button Suspensionplasty: A Retrospective Review of 153 Cases.

BACKGROUND: Arthroscopic trapeziectomy with suture button suspensionplasty (ATBS) is a relatively new surgical option for the treatment of thumb carpometacarpal (CMC) osteoarthritis. Although ATBS has many potential benefits over alternative surgical treatments for CMC arthritis, little data exist regarding its safety and complication rates. The purpose of this study was to demonstrate that ATBS is associated with a low risk of complications within 1 year of surgery. METHODS: A retrospective review of patients treated with ATBS by one senior hand surgeon over a span of 3 years was performed. RESULTS: A total of 153 cases of ATBS were performed in 136 patients. Ninety-seven cases involved arthroscopic hemitrapeziectomies, and 56 involved arthroscopic complete trapeziectomies. There were 44 males and 92 females with a mean age of 62. Thirty-eight percent of the cases were graded as Eaton stage IV, 46% stage III, and 14% stage II CMC arthritis, while 3 cases (2%) were performed as revisions. Mean follow-up duration was 58 weeks. Mean preoperative key pinch strength of the affected versus the unaffected side was 92% compared with 95% postoperatively. Revision surgery was performed in 9 out of 153 cases (<6%). Of those 9 cases, 5 had additional minor bony debridement with subsequent improvement in pain, 3 had the implant repositioned due to button prominence, and 1 patient presented with osteomyelitis of the first and second metacarpals that was successfully treated with button removal and an antibiotic regimen. CONCLUSIONS: ATBS is a safe, minimally invasive procedure for treatment of symptomatic stages II through IV thumb CMC arthritis.

Single Incision Distal Biceps Repair With Hemi-Krackow Suture Technique: Surgical Technique and Early Outcomes.

BACKGROUND: Many surgical methods exist for distal biceps repair. We present the technique and early outcomes of a series of distal biceps repairs completed with a novel suturing technique utilizing a hemi-Krackow locking stitch at the tendon-bone interface. METHODS: A retrospective review was performed of patients who underwent primary distal biceps repair using a single anterior incision with 2 suture anchors utilizing a hemi-Krackow stitch. With both anchors, a locking stitch along the tendon edge was complimented by the other strand passing through the central aspect of the distal tendon and advanced to pull the tendon edge down to the bone with appropriate tension. Patients with revision surgery and the use of allograft were excluded. Clinical outcomes included elbow range of motion and grip strength. All patients completed a Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire and reported satisfaction level, pain level, and any postoperative complications. RESULTS: Fourteen patients with an average age of 51.3 years (range, 27.8-66.4 years) were included in the study. The dominant arm was injured in 9 cases. At an average of 16.4 months' follow-up (range, 6.8-34.3 months), all patients had elbow range of motion of 0° to >130°, and grip strength was 101.5% of the uninjured arm (range, 70.6%-121.4%). The Average QuickDASH score was 6.5 (range, 0-36.5). CONCLUSION: Single incision biceps repair with suture anchor fixation using our hemi-Krackow stitch provided a strong repair allowing easy tensioning of the biceps tendon to bone and showed satisfactory functional outcomes at early follow-up. No patients required revision surgery, and there was only 1 case of transient nerve complaints.

Central Band Interosseous Membrane Reconstruction For Forearm Longitudinal Instability.

BACKGROUND: The Essex-Lopresti injury results from injuries to the stabilizing structures of the forearm, the radial head, the interosseous membrane, and the triangular fibrocartilage complex. CASE DESCRIPTION/LITERATURE REVIEW: We describe principles in approaching the patient with an acute or chronic Essex-Lopresti injury and describe surgical techniques to address these challenging cases both in the acute and chronic setting and describe outcomes of these techniques. CLINICAL RELEVANCE: Further research into the role of the interosseous ligament in providing longitudinal and transverse stability to the forearm is likely to change our understanding of the Essex-Lopresti injury and alter management strategies.

Osteochondral Autograft Transfer for Treatment of Metacarpophalangeal and Interphalangeal Cartilage Defects.

There is no general consensus regarding the optimal surgical treatment for cartilage defects of the metacarpophalangeal and interphalangeal joints in active patients who wish to preserve motion and functionality. We describe our technique of arthroscopically harvested femoral osteochondral autograft for treatment of metacarpophalangeal and interphalangeal cartilage defects.

Concomitant Total Wrist and Total Elbow Arthroplasty in a Rheumatoid Patient.

Background Concomitant arthroplasty has been described to have several benefits over multistage procedures. Ipsilateral total elbow and total shoulder arthroplasty has been reported with good outcomes in upper extremity concomitant arthroplasty. Case Description A 65-year-old woman presented with ipsilateral left-sided wrist and elbow joint degeneration as a result of longstanding rheumatoid arthritis. Concomitant total wrist and total elbow arthroplasty was performed with satisfactory results at both joints. She tolerated the procedure well and had an uneventful clinical course postoperatively. Literature Review Currently, no literature exists that describes one-stage total wrist and total elbow arthroplasty. Individually, total wrist and total elbow arthroplasty have both been reported to result in good outcomes and patient satisfaction. Previous studies have reported the utility of concomitant ipsilateral upper extremity procedures with a one-stage total elbow and total shoulder arthroplasty having been identified as a cost-saving procedure with expedited return to functionality versus a two-stage procedure. Clinical Relevance Patients with ipsilateral degenerative changes in the wrist and elbow should be considered on an individual case basis for concomitant total wrist and total elbow arthroplasty.

Complications Following Partial and Total Wrist Arthroplasty: A Single-Center Retrospective Review.

PURPOSE: To describe our institution's experience with complications following partial and total wrist arthroplasty (TWA). METHODS: We performed a retrospective review of 105 wrist surgeries in 100 patients who underwent surgery with prosthetic replacement of the distal radius, the proximal carpus, or both at a single institution. Patient factors including age, sex, body mass index, handedness, underlying disease, and previous injury were recorded. Outcomes focused particularly on postoperative complications and need for revision surgery. RESULTS: Forty-seven TWAs, 52 distal radius hemiarthroplasties, and 6 proximal carpal hemiarthroplasties were reviewed with a mean follow-up duration of 35 ± 28 months. Overall complication and revision rates were 51% (53 of 105) and 39% (41 of 105), respectively. Postoperative contracture accounted for the largest number of complications needing additional surgery (20%), followed by component failure (15%). Deep infections occurred in 2 TWAs and 1 distal radius hemiarthroplasty and required removal of hardware, antibiotic spacer placement, and a prolonged course of intravenous antibiotics prior to a definitive operation. Of those patients requiring additional surgery, 41% (n = 10) underwent at least 2 procedures, and 10% (n = 4) underwent at least 6 additional surgeries. CONCLUSIONS: Although TWA and partial wrist arthroplasty are attractive treatment options for the painful arthritic wrist, there remains a noteworthy potential for complications requiring additional surgery. A detailed understanding of these risks is essential for surgeons so that patients may be counseled accordingly and that alternative treatment options may be considered. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Little finger carpometacarpal arthroplasty technique and result in 3 cases.

PURPOSE: To present our surgical technique and results for the treatment of posttraumatic arthritis of the little finger carpometacarpal (CMC) joint. METHODS: We performed a retrospective review of 3 patients who underwent our surgical technique. All patients had previously sustained intra-articular fractures of the base of the little finger metacarpal and presented with painful posttraumatic arthritis of the fifth metacarpal-hamate joint. Patients were treated with little finger CMC arthroplasty and extensor carpi ulnaris suspensionplasty. RESULTS: We observed the 3 patients in the office over a mean of 21 months and by telephone for a mean for 51 months postoperatively. They had improvements in wrist motion and grip strength. Finger motion remained stable. Pain and tenderness at the little finger CMC joint were eliminated. CONCLUSIONS: Our technique provided satisfactory pain relief and motion preservation for posttraumatic arthritis of the little finger CMC joint. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The tenosynovial flap for recalcitrant carpal tunnel syndrome.

Operative intervention for recalcitrant carpal tunnel syndrome often utilizes local vascularized tissue to provide coverage of the median nerve in an attempt to limit scarring or adherence of the nerve to its surrounding structures. Although the hypothenar fat pad is the most commonly cited source of vascularized tissue, alternative options do exist. We review the technique of utilizing a pedicled tenosynovial flap as the source of local vascularized tissue for coverage of the median nerve in cases of recalcitrant carpal tunnel syndrome.