How to Host A Domestic Hand Surgery Outreach Day.

Domestic outreach is an integral yet often overlooked aspect of medical volunteerism. Since 2016, the American Society for Surgery of the Hand's Touching Hands initiative has supported domestic outreach Hand Days in the United States. The purpose of this article is to provide information and guidance to hand surgeons interested in hosting their own domestic hand surgery outreach. Thorough planning is essential to a successful outreach, particularly because each outreach site will have unique considerations. Surgeon team leaders must navigate the infrastructure and legal factors specific to their practice site. Outreach patients should be screened for both financial and surgical eligibility, although there are multiple pathways for the referral and screening process. Patient evaluation also requires coordination of imaging and diagnostic testing for a low-resource population. Multidisciplinary volunteer teams are necessary to provide all perioperative services and are typically recruited from the host practice site. Some potential challenges of domestic outreach include institutional charity care policies, legal concerns, and operative space availability. Because of complex socioeconomic situations, it may be difficult to contact and coordinate care for outreach patients. Despite these potential barriers, domestic outreach offers tremendous benefit for patients who otherwise lack access to surgical care. Even one yearly outreach day can avert years of disability and can have an incredible impact on patients' functional ability and quality of life. Volunteer teams also reap the benefits of outreach by promoting intraorganizational volunteerism, renewing commitment to medical professionalism, and decreasing symptoms of burnout. Hand surgeons have a unique opportunity to provide subspecialized surgical care to underserved patients as the Touching Hands initiative continues to grow and develop. We hope that hand surgeons will consider participating in advancing the Touching Hands mission to provide life-changing surgical care in the world's poorest communities, including our own.

Meniscal allograft arthroplasty for the treatment of trapeziometacarpal arthritis of the thumb.

BACKGROUND: Arthritis at the trapeziometacarpal joint of the thumb is common. Several surgical options exist showing favorable results. We report the outcomes after interposition of allograft knee meniscus for thumb trapeziometacarpal arthritis. METHODS: Twenty-three patients (25 thumbs) had surgery for thumb trapeziometacarpal arthritis using knee meniscal allograft tissue. Eleven thumbs had a minimum follow-up of 24 months, 2 thumbs had a minimum of 12 months, and 12 thumbs had less than 6 months. Disabilities of arm, shoulder, and hand (DASH) questionnaire scores, pain levels, grip strength, pinch strength, range of motion, and radiographic measurements were performed. RESULTS: Between the preoperative and 24-month follow-up measurements, patient pain levels were reduced. There was a significant improvement in DASH scores. Comparisons between preoperative and postoperative strength measurements showed increase in grip strength and key pinch strength. Trapeziometacarpal subsidence was 5.5 %, and subluxation index measurements decreased 3.9 %. There was no clinical or radiographic evidence of foreign body reaction and no other complications occurred. CONCLUSIONS: The results of meniscal allograft arthroplasty are comparable to other surgical techniques for trapeziometacarpal arthritis with respect to pain, outcomes, strength, oppositional motion, complications, surgical time, cost, and return to work. The results suggest that meniscal allograft arthroplasty is a viable option in the surgical management of stages II and III arthritis of the TM joint. Further follow-up and clinical studies are warranted.

Time to face the healthcare challenge.

The Affordable Care Act is upon us. The success, extent, and quality of the resulting care is not fully under our control. That is surely an understatement. Healthcare is one-fifth of the United States' Gross National Product, and it is no longer ours to control. Nonetheless, we have all taken an oath, the Hippocratic Oath, and in 2012, that oath includes being advocates for our patients and helping insure that we, as a nation, "do no harm."

Engineering bi-layer nanofibrous conduits for peripheral nerve regeneration.

Trauma injuries often cause peripheral nerve damage and disability. A goal in neural tissue engineering is to develop synthetic nerve conduits for peripheral nerve regeneration having therapeutic efficacy comparable to that of autografts. Nanofibrous conduits with aligned nanofibers have been shown to promote nerve regeneration, but current fabrication methods rely on rolling a fibrous sheet into the shape of a conduit, which results in a graft with inconsistent size and a discontinuous joint or seam. In addition, the long-term effects of nanofibrous nerve conduits, in comparison with autografts, are still unknown. Here we developed a novel one-step electrospinning process and, for the first time, fabricated a seamless bi-layer nanofibrous nerve conduit: the luminal layer having longitudinally aligned nanofibers to promote nerve regeneration, and the outer layer having randomly organized nanofibers for mechanical support. Long-term in vivo studies demonstrated that bi-layer aligned nanofibrous nerve conduits were superior to random nanofibrous conduits and had comparable therapeutic effects to autografts for nerve regeneration. In summary, we showed that the engineered nanostructure had a significant impact on neural tissue regeneration in situ. The results from this study will also lead to the scalable fabrication of engineered nanofibrous nerve conduits with designed nanostructure. This technology platform can be combined with drug delivery and cell therapies for tissue engineering.

Zone-II flexor tendon repair: a randomized prospective trial of active place-and-hold therapy compared with passive motion therapy.

BACKGROUND: In order to improve digit motion after zone-II flexor tendon repair, rehabilitation programs have promoted either passive motion or active motion therapy. To our knowledge, no prospective randomized trial has compared the two techniques. Our objective was to compare the results of patients treated with an active therapy program and those treated with a passive motion protocol following zone-II flexor tendon repair. METHODS: Between January 1996 and December 2002, 103 patients (119 digits) with zone-II flexor tendon repairs were randomized to either early active motion with place and hold or a passive motion protocol. Range of motion was measured at six, twelve, twenty-six, and fifty-two weeks following repair. Dexterity tests were performed, and the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome questionnaire and a satisfaction score were completed at fifty-two weeks by ninety-three patients (106 injured digits). RESULTS: At all time points, patients treated with the active motion program had greater interphalangeal joint motion. At the time of the final follow-up, the interphalangeal joint motion in the active place-and-hold group was a mean (and standard deviation) of 156 degrees +/- 25 degrees compared with 128 degrees +/- 22 degrees (p < 0.05) in the passive motion group. The active motion group had both significantly smaller flexion contractures and greater satisfaction scores (p < 0.05). We could identify no difference between the groups in terms of the DASH scores or dexterity tests. When the groups were stratified, those who were smokers or had a concomitant nerve injury or multiple digit injuries had less range of motion, larger flexion contractures, and decreased satisfaction scores compared with patients without these comorbidities. Treatment by a certified hand therapist resulted in better range of motion with smaller flexion contractures. Two digits in each group had tendon ruptures following repair. CONCLUSIONS: Active motion therapy provides greater active finger motion than passive motion therapy after zone-II flexor tendon repair without increasing the risk of tendon rupture. Concomitant nerve injuries, multiple digit injuries, and a history of smoking negatively impact the final outcome of tendon repairs.

Arthritis of the thumb basal joint: old and new treatments for a common condition.

Arthritis of the basal joint of the thumb is a condition that is becoming even more common as longevity increases and more people have active lifestyles in later life. The role of new hyaluronase-based injectable agents is evolving. A number of surgical procedures are effective in treating early-stage arthritis; the commonly performed trapezium resection and ligament reconstruction procedures have been modified by using limited-incision approaches, arthroscopic assistance, and bioengineered materials, as well as metacarpal repositioning osteotomy.

Reconstruction after flexor tendon injury: state of the art.

The methods used to treat intrasynovial flexor tendon injuries are the result of decades of clinical experience coupled with advances in understanding the biomechanical, physiologic, and cellular milieu of the repair. Successful treatment requires optimizing the factors that can be controlled and ameliorating those that cannot be controlled.

Finger flexor motor control patterns during active flexion: an in vivo tendon force study.

An in vivo tendon force measurement system was used to evaluate index finger flexor motor control patterns during active finger flexion. During open carpal tunnel release surgery (N=12) the flexor digitorum profundus (FDP) and flexor digitorum superficilias (FDS) tendons were instrumented with buckle force transducers and participants performed finger flexion at two different wrist angles (0 degrees or 30 degrees ). During finger flexion, there was concurrent change of metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint angles, but the FDP and FDS tendon force changes were not concurrent. For the FDS tendon, no consistent changes in force were observed across participants at either wrist angle. For the FDP tendon, there were two force patterns. With the wrist in a neutral posture, the movement was initiated without force from the finger flexors, and further flexion (after the first 0.5s) was carried out with force from the FDP. With the wrist in a flexed posture, the motion was generally both initiated and continued using FDP force. At some wrist postures, finger flexion was initiated by passive forces which were replaced by FDP force to complete the motion.

Kienböck's disease: an approach to treatment.

Since its description in 1910, Kienböck's disease has continued to be a difficult problem for clinicians as well as patients. An incomplete understanding of the etiology as well as the natural history of the disease has led to an assortment of surgical treatment options. The authors present a review of Kienböck's disease and the theories behind different surgical interventions, as well as their current approach to treatment of patients with Kienböck's disease.

A device for zone-II flexor tendon repair. Surgical technique.

BACKGROUND: The stainless-steel Teno Fix tendon-repair device has improved biomechanical characteristics compared with those of suture repair, and it was well tolerated in a canine model. The purpose of this study was to compare the Teno Fix with suture repair in a clinical setting. METHODS: Sixty-seven patients with isolated zone-II flexor tendon injury were randomized to be treated with a Teno Fix or a four-stranded cruciate suture repair. There were eighty-five injured digits: thirty-four were treated with the Teno Fix, and fifty-one served as controls. A modified leinert rehabilitation technique was employed, with active flexion starting at four weeks postoperatively. Patients were followed for six months by blinded observers who determined the range of motion, Disabilities of the Arm, Shoulder and Hand (DASH) score, pinch and grip strength, and pain score on a verbal scale and assessed swelling and neurologic recovery. Adverse outcomes, including device migration and rupture, were monitored at frequent intervals. RESULTS: Nine of the fifty-one suture repairs ruptured, whereas none of the Teno Fix repairs ruptured (p < 0.01). Five of the nine ruptures were caused by resistive motion against medical advice. There were no differences between the two groups in terms of range of motion, DASH score, pinch and grip strength, pain, swelling, or neurologic recovery. The Teno Fix group had slightly slower resolution of pain and swelling compared with the control group. Of the patients who were available for follow-up at six months, sixteen of the twenty-four treated with a Teno Fix repair and nineteen of the twenty-seven treated with a control repair had a good or excellent result. One Teno Fix device migrated and extruded secondary to a wound infection. Of all eighty-five digits that were operated on, four were thought to have tendons of inadequate size to accommodate the device and nine were deemed to have inadequate exposure to allow placement of the anchors. CONCLUSIONS: The Teno Fix is safe and effective for flexor tendon repair if the tendon size and exposure are sufficient. Tendon repairs with the Teno Fix have lower rupture rates and similar functional outcomes when compared with conventional repair, particularly in patients who are non-compliant with the rehabilitation protocol.

In vivo flexor tendon forces increase with finger and wrist flexion during active finger flexion and extension.

The effects of different hand motions and positions used during early protected motion rehabilitation on tendon forces are not well understood. The goal of this study was to determine in vivo forces in human flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons of the index finger during active unresisted finger flexion and extension. During open carpal tunnel surgery (n = 12), flexor tendon forces were acquired with buckle force transducers, and finger positions were recorded on video while subjects actively flexed and extended the fingers at two different wrist angles. Mean in vivo FDP tendon forces varied between 1.3N +/- 0.9 N and 4.0 N +/- 2.9 N while mean FDS tendon forces ranged from 1.3N +/- 0.5 N to 8.5 N +/- 10.7 N. FDP force increased with active finger flexion at both wrist angles of 0 degrees or 30 degrees flexion. FDS force increased with finger flexion when the wrist was in 30 degrees flexion, but was unchanged when the wrist was in 0 degrees of flexion. Tendon forces were similar regardless of whether the fingers were moving in the flexion or extension direction. Active finger flexion and extension with the wrist at 0 degrees and 30 degrees flexion may be used during early rehabilitation protocols with limited risk of repair rupture. This risk can be further decreased for a FDS tendon repair by reducing wrist flexion angle.

Proximal row carpectomy.

Proximal row carpectomy is extremely useful as a wrist reconstructive technique for cases of degenerative joint arthritis of the radiocarpal joint cause by scapholunate advanced collapse, scapholunate advanced collapse, schaphoid nonunion advanced collapse, trans-scaphoid perilunate fracture dislocations, lunate dislocations, and Kienböck disease. It should be selected with caution for patients younger than 35 years old. The procedure can be performed with or without temporary internal fixation with with Kirschner wires, and adjunctive techniques of dorsal capsule interposition, proximal capitate excision, and radial styloidectomy can be used. The longevity of the operation is good, but the patient should be informed preoperatively that secondary procedures may be required. Based on historical series, these procedures have included addition have included of radial styloidectomy when this has not been performed at the index procedure, revision of the surgery with capitate debridement or conversion to total wrist arthodesis. Conversion of proximal row carpectomy to total wrist arthoplasty with implants can be contemplated in selected patient particularly as newer implants are designed. The technique the senior author has used on occasion has been to perform revision surgery on those patients who have chronic pain who might need further debridement of the radius in the radial styloid, the proximal capitate, or evaluation of the integrity of the interposition.

In vivo forces generated by finger flexor muscles do not depend on the rate of fingertip loading during an isometric task.

Risk factors for activity-related tendon disorders of the hand include applied force, duration, and rate of loading. Understanding the relationship between external loading conditions and internal tendon forces can elucidate their role in injury and rehabilitation. The goal of this investigation is to determine whether the rate of force applied at the fingertip affects in vivo forces in the flexor digitorum profundus (FDP) tendon and the flexor digitorum superficialis (FDS) tendon during an isometric task. Tendon forces, recorded with buckle force transducers, and fingertip forces were simultaneously measured during open carpal tunnel surgery as subjects (N=15) increased their fingertip force from 0 to 15N in 1, 3, and 10s. The rates of 1.5, 5, and 15N/s did not significantly affect FDP or FDS tendon to fingertip force ratios. For the same applied fingertip force, the FDP tendon generated more force than the FDS. The mean FDP to fingertip ratio was 2.4+/-0.7 while the FDS to tip ratio averaged 1.5+/-1.0 (p<0.01). The fine motor control needed to generate isometric force ramps at these specific loading rates probably required similar high activation levels of multiple finger muscles in order to stabilize the finger and control joint torques at the force rates studied. Therefore, for this task, no additional increase in muscle force was observed at higher rates. These findings suggest that for high precision, isometric pinch maneuvers under static finger conditions, tendon forces are independent of loading rate.

Device for zone-II flexor tendon repair. A multicenter, randomized, blinded, clinical trial.

BACKGROUND: The stainless-steel Teno Fix tendon-repair device has improved biomechanical characteristics compared with those of suture repair, and it was well tolerated in a canine model. The purpose of this study was to compare the Teno Fix with suture repair in a clinical setting. METHODS: Sixty-seven patients with isolated zone-II flexor tendon injury were randomized to be treated with a Teno Fix or a four-stranded cruciate suture repair. There were eighty-five injured digits: thirty-four were treated with the Teno Fix, and fifty-one served as controls. A modified Kleinert rehabilitation technique was employed, with active flexion starting at four weeks postoperatively. Patients were followed for six months by blinded observers who determined the range of motion, Disabilities of the Arm, Shoulder and Hand (DASH) score, pinch and grip strength, and pain score on a verbal scale and assessed swelling and neurologic recovery. Adverse outcomes, including device migration and rupture, were monitored at frequent intervals. RESULTS: Nine of the fifty-one suture repairs ruptured, whereas none of the Teno Fix repairs ruptured (p < 0.01). Five of the nine ruptures were caused by resistive motion against medical advice. There were no differences between the two groups in terms of range of motion, DASH score, pinch and grip strength, pain, swelling, or neurologic recovery. The Teno Fix group had slightly slower resolution of pain and swelling compared with the control group. Of the patients who were available for follow-up at six months, sixteen of the twenty-four treated with a Teno Fix repair and nineteen of the twenty-seven treated with a control repair had a good or excellent result. One Teno Fix device migrated and extruded secondary to a wound infection. Of all eighty-five digits that were operated on, four were thought to have tendons of inadequate size to accommodate the device and nine were deemed to have inadequate exposure to allow placement of the anchors. CONCLUSIONS: The Teno Fix is safe and effective for flexor tendon repair if the tendon size and exposure are sufficient. Tendon repairs with the Teno Fix have lower rupture rates and similar functional outcomes when compared with conventional repair, particularly in patients who are noncompliant with the rehabilitation protocol.

Carpal tunnel pressure alters median nerve function in a dose-dependent manner: a rabbit model for carpal tunnel syndrome.

BACKGROUND: An in vivo animal model for carpal tunnel syndrome (CTS) is presented which allows for graded application of pressure to the median nerve within the carpal canal. We hypothesized that such pressure would cause electrophysiologic changes in the median nerve in a dose-related manner, with NCS/EMG changes consistent with CTS in humans. METHODS: In 40 New Zealand white rabbits, ranging from 2 to 2.5 kg, angioplasty catheters were placed in the carpal tunnel in the forepaws and pressures ranging from 50 to 80 mmHg applied to one side while the contralateral side served as the control and remained uninflated. Pressure was applied until a 15% increase in distal motor latency was obtained for 2 consecutive weeks by nerve conduction studies. RESULTS: All the experimental limbs exhibited a 15% increase in distal motor latency. None of the control limbs showed a significant increase in distal motor latency. In the experimental animals the 15% delay was achieved in approximately 4-5 weeks in the 50-70 mmHg groups and in approximately 1 week in the 80 mmHg group. CONCLUSION: This new animal model for CTS demonstrates a direct cause and effect relationship between carpal tunnel pressure and median nerve dysfunction. We anticipate that this in vivo model with clinically relevant outcomes will facilitate identification of injury mechanisms, and will serve as a basis for future development of novel interventions and treatments.

Entrapment neuropathies: pathophysiology and pathogenesis.

A number of theories of pathogenesis of entrapment neuropathy, due to repeated loading, have been proposed and these theories are being actively explored with animal models. Tubes placed loosely around peripheral nerves cause delayed onset, chronic pain and changes in nerve morphology including nerve sprouting. Balloons placed around or adjacent to the nerve and inflated to low pressures, rapidly produce endoneurial edema and a persistent increase in intraneural pressure. The same models demonstrate long-term changes such as demyelination and fibrosis. The applied pressure causes a decrement in nerve function and abnormal morphology in a dose-dependent manner that appears to be linked to the amount of endoneurial edema. A new model involving involuntary, repetitive fingertip loading for 6 h per week for 4 weeks has caused slowing of nerve function at the wrist similar to that seen in patients with carpal tunnel syndrome. These models have the potential to reveal the mechanisms of injury at the cellular and biochemical level and address questions about the relative importance of various biomechanical factors (e.g. peak force, mean force, force rate, duty cycle, etc.). In addition, these models will allow us to evaluate various prevention, treatment and rehabilitation protocols.