Unplanned Reoperation After Surgery for Scapholunate Interosseous Ligament Insufficiency: A Retrospective Review of 316 Patients.

Background: The purpose of this study was to identify factors associated with unplanned reoperation after surgery for scapholunate interosseous ligament (SLIL) insufficiency. Methods: Using Current Procedural Terminology (CPT) codes from 3 hand surgery centers across 2 metropolitan areas, we identified 316 patients undergoing surgery for SLIL insufficiency from 2000 to 2014. Medical records were manually reviewed to collect data on factors that might be associated with unplanned reoperation, including age, sex, tobacco use, occupation, acuity of treatment, and reconstruction method. Results: Thirty-eight patients (12%) had an unplanned reoperation; most of them (65%) were a secondary reconstruction or salvage procedure (eg, 6 proximal row carpectomies, 9 revision reconstruction, and 10 partial carpal arthrodeses), while 5 (13%) were for unplanned screw removal. The median time between the index and second surgery was 16 months (range, 2-97 months). The type of index procedure was not associated with reoperation. The only factor associated with reoperation was cigarette smoking, and this association persisted when looking specifically at reoperations for revision or salvage. Conclusions: Patients should be counseled that smoking is associated with reoperation after SLIL surgery. Smoking cessation or decreasing nicotine usage may be beneficial prior to surgery. With the numbers available, there was no association between surgical technique and reoperation.

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.

Self-Reported Postoperative Opioid-Prescribing Practices Following Commonly Performed Orthopaedic Hand and Wrist Surgical Procedures: A Nationwide Survey Comparing Attending Surgeons and Trainees.

BACKGROUND: Although orthopaedic surgeons have been shown to prescribe excessive amounts of opioid analgesics postoperatively, the degree in which surgical trainees contribute to this trend is unknown. The purpose of this study was to compare self-reported opioid-prescribing behavior, factors influencing this behavior, and perceptions of patient opioid utilization and disposal between hand surgeons and trainees. METHODS: Attending hand surgeons and trainees in hand, orthopaedic, and plastic surgery programs were invited to participate in a web-based survey including demographic characteristics; self-reported prescribing behavior specific to 4 procedures: open carpal tunnel release, trigger finger release, thumb carpometacarpal arthroplasty, and distal radial fracture open reduction and internal fixation; and perceptions and influencing factors. Analgesic medications were converted to morphine milligram equivalents and were compared across groups of interest using independent t tests or analysis of variance for each procedure. RESULTS: A total of 1,300 respondents (266 attending surgeons, 98 fellows, 708 orthopaedic residents, and 228 plastic surgery residents) were included. Surgeons reported prescribing fewer total morphine milligram equivalents compared with residents for all 4 procedures. Personal experience was the most influential factor for prescribing behavior by surgeons and fellows. Although residents reported that attending surgeon preference was their greatest influence, most reported no direct opioid-related communication with attending surgeons. CONCLUSIONS: Residents self-report prescribing significantly higher morphine milligram equivalents for postoperative analgesia following commonly performed hand and wrist surgical procedures than attending surgeons. Poor communication between residents and attending surgeons may contribute to this finding. Residents may benefit from education on opioid prescription, and training programs should encourage direct communication between trainees and attending surgeons.

Accidental Injection of Freund Complete Adjuvant With Mycobacterium Tuberculosis.

Accidental needlestick injuries are common in laboratory and health care workers. Injection of atypical pathogens, such as those encountered in the animal laboratory setting, may pose considerable problems at the site of inoculation. We present the case of an otherwise healthy laboratory worker who accidentally self-injected Freund complete adjuvant with heat-killed Mycobacterium tuberculosis into her hand, requiring multiple debridement operations over a prolonged treatment course.

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.

Relative Contributions of the Midcarpal and Radiocarpal Joints to Dart-Thrower's Motion at the Wrist.

PURPOSE: To identify the relative contributions of the radiocarpal (RC) and midcarpal (MC) joints to dart-thrower's motion (DTM) of the wrist. METHODS: Six cadaveric upper extremities were fixed to a custom-designed loading jig allowing for pure moment-rotation analysis in 24 different directions of wrist motion. Each specimen was tested in 3 states: intact, simulated radiocarpal fusion (sRCF) and simulated pancarpal fusion (sPCF). Moments of ± 1.5 Nm were applied at each of 24 directions for each state and the resulting wrist rotation recorded. Data from each specimen were reduced to compute the range of motion (ROM) envelopes and the orientation of the ROM for the 3 different states. RESULTS: The ROM was significantly decreased in the sRCF and sPCF groups compared with the intact group in the directions of the pure extension, radial extension, ulnar flexion, and ulnar deviation. No significant difference in ROM was detected between the sRCF and sPCF groups in any direction. The ROM envelopes for the intact, sRCF, and sPCF groups were all oriented obliquely to the axis of pure wrist flexion-extension near a path of ulnar flexion-radial extension, consistent with prior reports on DTM. CONCLUSIONS: Although both simulated fusion types decreased ROM compared with the intact wrist, the principal direction of wrist motion along the path of DTM was not significantly altered by simulated RCF or PCF. CLINICAL RELEVANCE: These findings suggest that the RC and MC joints can each contribute to a similar mechanical axis of motion located along the path of DTM when the other joint has been eliminated via fusion. Surgical options such as partial wrist fusions may maintain the native wrist's mechanical axis if either the RC or the MC joint is preserved, despite significant reduction in overall ROM.

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.

Neurolysis with Amniotic Membrane Nerve Wrapping for Treatment of Secondary Wartenberg Syndrome: A Preliminary Report.

BACKGROUND: Entrapment of the superficial sensory branch of the radial nerve (SRN) commonly results in debilitating pain of the dorsoradial wrist. Symptom relief following SRN neurolysis is often incomplete or temporary due to recurrent perineural scarring. METHODS: We performed a retrospective review with prospective follow-up of all patients with SRN neuropathy who were treated with neurolysis and nerve wrapping using an amnion-based allograft adhesion barrier over a one-year interval. Measured outcomes included pain rated by Visual Analog Scale (VAS) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) functional outcome scores. RESULTS: Three females satisfied inclusion. At mean follow-up of 28.9 months, all three patients exhibited improved pain (mean VAS change -4.7 ± 0.6), function (mean QuickDASH change -40 ± 5), and subjective satisfaction. No adverse events or reactions to the implanted tissue occurred. CONCLUSIONS: SRN entrapment neuropathy was safely and effectively treated with neurolysis and amnion nerve wrapping in this small series. Use of this technique for perineural scar prevention warrants additional study in larger groups of patients and in other upper extremity entrapment neuropathies.

Prognostic Variables for Patient Return-to-Work Interval Following Carpal Tunnel Release in a Workers' Compensation Population.

BACKGROUND: We hypothesize that depressive and anxiety disorders, chronic pain conditions, and work-related factors are significant determinants of the time interval for return to work (RTW) in the workers' compensation (WC) population following carpal tunnel release (CTR) surgery. METHODS: We retrospectively reviewed records of all WC patients who underwent open CTR surgery over a 5-year period by 1 of 3 fellowship-trained hand surgeons. One hundred fifty-two wrists in 108 patients (64 unilateral, 44 bilateral) met the inclusion criteria. Demographic, medical, and surgical data were obtained from patient records. Bivariate and multivariate analyses were performed to assess predictors of RTW. RESULTS: Eighty-nine percent of all patients returned to work full-duty. Average RTW duration in all wrists was 12.5 ± 11.3 weeks. Predictors of delayed RTW in bivariate and multivariate analyses were depression with or without anxiety, chronic pain disorders including fibromyalgia, preoperative opioid use, and modified preoperative work status. Job type, motor nerve conduction velocity, and bilateral surgery were not predictive of delayed RTW interval. CONCLUSIONS: WC patients with depression, anxiety, or fibromyalgia and other chronic pain disorders were significantly more likely to have delayed RTW following CTR than were WC patients without these conditions. In addition, those who use opioid medications preoperatively and those with preoperative work restrictions were also found to have a significantly delayed RTW after CTR. Knowledge of these risk factors may help care providers and employers identify those WC patients who are most likely to have a protracted postoperative recovery period.

Dorsal versus lateral plate fixation of finger proximal phalangeal fractures: a retrospective study.

INTRODUCTION: Unstable proximal phalanx fractures are relatively common injuries but consensus of standard treatment is lacking. Outcomes following plate fixation are highly variable, and it remains unclear which factors are predictive for poorer results. The purpose of this study was to compare dorsal and lateral plate fixation of finger proximal phalangeal fractures with regard to factors that influence the outcome. MATERIALS AND METHODS: A retrospective chart review of proximal phalanx fractures treated with dorsal and lateral plating over a 6-year study interval was performed. Demographic data and injury-specific factors were obtained from review of clinic and therapy notes of 42 patients. Fractures were classified based on the OTA classification using preoperative radiographs. Outcomes investigated included final range of motion (ROM) and total active motion (TAM) of all finger joints. Complications and revision surgeries were also analyzed. RESULTS: Fracture comminution, dorsal and a lateral plate position, occupational therapy, and demographic factors did not significantly influence the outcome, complication, and revision rate after plate fixation of finger proximal phalangeal fractures. CONCLUSIONS: Based on the results of this study, no differences in the outcome of finger proximal phalangeal fractures treated by both dorsal and lateral plate fixation were observed. LEVEL OF EVIDENCE: Therapeutic, retrospective comparative, level III.

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.

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.

Distal Interphalangeal Joint Arthrodesis Complicated by Postoperative Infection: A Rare Presentation of Disseminated Herpes Simplex Virus.

Postoperative infection after elective arthrodesis of the interphalangeal joint is an uncommon complication often necessitating urgent debridement. We present the rare case of a female patient with a history of oral herpetic lesions, who underwent elective arthrodesis of the middle and index fingers for treatment of erosive osteoarthritis and subsequently developed a postoperative herpetic infection at the surgical site.

Friction Blisters on the Hands Treated Successfully Using 2-Octyl Cyanoacrylate: A Case Report.

BACKGROUND: Friction blisters on the hand are challenging to treat as conventional dressings are prone to saturation, contamination, and loosening with active hand use and other mechanical stresses. Alternative methods and materials for dressing hand blisters warrant exploration. CASE SUMMARY: A 48-year-old male surgeon presented with friction blisters over his bilateral thumbs. The patient complained of significant difficulty in keeping his dressings clean and dry, significant pain with hand hygiene, and functional limitations at work. The patient's blisters were dressed with 2-octyl cyanoacrylate (Dermabond; Ethicon US LLC, Somerville, New Jersey), applied directly onto the wound bed. The patient was able to perform his normal duties immediately, without the need for additional intervention. Six days postapplication, the Dermabond sloughed off, revealing an epithelialized surface. CONCLUSION: Dermabond is a promising agent for dressing unroofed blisters of the hand, as it provides a barrier to moisture and contamination, while allowing the wound to epithelialize, without functional cost.

Recurrent cubital tunnel syndrome treated with revision neurolysis and amniotic membrane nerve wrapping.

BACKGROUND: Perineural scarring of the ulnar nerve is a predominant cause of symptom recurrence after surgical treatment for primary cubital tunnel syndrome (CuTS). We report our preliminary experience in revision ulnar nerve decompression and nerve wrapping with an amniotic membrane allograft adhesion barrier for treatment of recurrent CuTS. METHODS: We performed a retrospective review with prospective follow-up of patients with recurrent CuTS who were treated with revision neurolysis with amniotic membrane nerve wrapping. Preoperative elbow motion, grip and pinch strengths, pain level on the visual analog scale level, and the 11-item version of the Disabilities of the Arm, Shoulder and Hand functional outcome score were compared with postoperative values using paired t testing. Symptom characteristics, physical examination findings, complications, and level of satisfaction were also obtained. RESULTS: Eight patients (mean age, 47.5 years) who had undergone at least 2 prior ulnar nerve operations satisfied study inclusion. At mean postoperative follow-up of 30 months, significant improvements were noted across all patients in visual analog scale pain levels (-3.5 vs. preoperatively; P < .0001), 11-item version of the Disabilities of the Arm, Shoulder and Hand scores (-30 vs. preoperatively; P < .0001), and grip strength (+25 pounds vs. preoperatively; P < .0001). Pinch strength and elbow motion were also significantly improved for those patients with comparative preoperative data available. All patients expressed subjective satisfaction with their results. No adverse reactions or complications occurred in any patients. CONCLUSIONS: Ulnar nerve wrapping with amniotic membrane allograft, when combined with revision neurolysis, was a safe and subjectively effective treatment for patients with debilitating recurrent CuTS.

Multifocal Neuropathy: Expanding the Scope of Double Crush Syndrome.

Double crush syndrome (DCS), as it is classically defined, is a clinical condition composed of neurological dysfunction due to compressive pathology at multiple sites along a single peripheral nerve. The traditional definition of DCS is narrow in scope because many systemic pathologic processes, such as diabetes mellitus, drug-induced neuropathy, vascular disease and autoimmune neuronal damage, can have deleterious effects on nerve function. Multifocal neuropathy is a more appropriate term describing the multiple etiologies (including compressive lesions) that may synergistically contribute to nerve dysfunction and clinical symptoms. This paper examines the history of DCS and multifocal neuropathy, including the epidemiology and pathophysiology in addition to principles of evaluation and management.