Nonvascularized Toe Joint Transfers to the Hand in Young Children: Technique Revisited.

BACKGROUND: Small joint reconstruction of the hand poses a significant challenge, especially in children where both functional motion and preservation of the epiphysis are desired. Auto-transplantation of whole joints is the only way to reconstruct a functional joint that maintains growth potential. Historically, nonvascularized toe-to-finger joint transfer has been criticized for high rates of avascular necrosis and joint dissolution, while vascularized transfers seemingly resulted in increased durability of the joint space and epiphysis. However, certain populations remain poor candidates for microvascular reconstruction, such as those with congenital deformities or sequelae from trauma or infection. In our case series, we demonstrate that a simplified nonvascularized surgical technique and careful patient selection can produce stable, functional joints. METHODS: Nonvascularized toe-to-finger joint transfer was performed in 3 children between the ages of 4 and 6. Reconstructed joints included 2 proximal interphalangeal (PIP) joints and 1 metacarpophalangeal (MCP) joint. Donor grafts consisted of second toe PIP joints harvested en bloc to include the epiphysis of the middle phalanx, collateral ligaments, volar plate, and a diamond-shaped island of extensor tendon with its central slip attachment. RESULTS: Follow-up ranged from 7 to 29 months. Each patient demonstrated functional improvements in joint motion and stability. Postoperative radiographs confirmed adequate joint alignment and persistence of the joint spaces. Epiphyseal closure was observed in 1 patient as early as 25 months postoperatively. CONCLUSIONS: Nonvascularized joint transfer should remain a practical consideration for small joint reconstruction of the hand in certain pediatric patients.

Update on Thumb Basal Joint Arthritis Surgery.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Comprehend anatomy and biomechanics of the normal and arthritic trapeziometacarpal joint. 2. Evaluate best evidence for diagnosis and for operative and nonoperative treatment of thumb osteoarthritis. 3. Understand treatment pitfalls of basilar joint arthritis and complication avoidance. SUMMARY: Articular and ligamentous anatomy of the trapeziometacarpal joint enables complex motions. Disability from arthritis, common at the trapeziometacarpal joint, is debilitating. Furthering the understanding of how trapeziometacarpal arthritis develops can improve treatment. The authors provide current best evidence for diagnosis and treatment of basilar joint arthritis. Pitfalls in treatment are discussed.

Targeted Muscle Reinnervation for Symptomatic Neuromas Utilizing the Terminal Anterior Interosseous Nerve.

Sensory nerve trauma at the level of the wrist can lead to debilitating neuromas. Targeted muscle reinnervation (TMR) is an effective therapy for the treatment of neuromas. Here we propose the use of the terminal anterior interosseous nerve (AIN) as a viable recipient for TMR. All superficial sensory nerves around the wrist, including the dorsal ulnar sensory nerve, the distal lateral antebrachial cutaneous nerve, the distal branches of the superficial branch of the radial nerve, and the palmar cutaneous branch of the median nerve were dissected in 2 cadaver specimens. The AIN branch to pronator quadratus was divided just distal to the final branch of flexor pollicis longus to preserve adequate length for TMR. The sensory nerves at the wrist were fully dissected to identify a viable location for coaptation to the AIN. After the cadaveric concept was demonstrated, the technique was successfully used in a clinical case. In summary, the distal AIN is a versatile recipient for TMR as a treatment of painful sensory neuromas at the level of the wrist, with minimal donor-site morbidity.

Current indications for abdominal-based flaps in hand and forearm reconstruction.

Extensive soft tissue loss or injury of the hand and upper extremity is a challenging reconstructive problem traditionally treated with abdominal-based pedicled flaps. Options for coverage included the groin flap based on the superficial circumflex iliac artery, the Scarpa's fascia flap based on the superficial inferior epigastric artery, and the paraumbilical perforator flap from the deep inferior epigastric artery perforators. Despite the ability to provide consistent and pliable soft tissue coverage with ease of elevation, these flaps have several disadvantages including restriction of mobility, requirement for multiple procedures, bulkiness and patient discomfort. With the advent of microsurgery, pedicled regional flaps, and off-the-shelf skin substitutes, the applications for these flaps have narrowed. However several indications still remain. These include: patient and facility factors which deter microsurgery, the absence of recipient vessels after injury, prior surgical use of recipient vessels, the need to preserve major vessels for future reconstruction, and large multi-surface wounds requiring coverage. In this review we detail these indications and provide case examples for each.

Recurrent Schwannomatosis of the Hand.

Background: Peripheral nerve sheath tumors (PNSTs) are neoplastic soft tissue masses generated from the abnormal proliferation of Schwann cells. Often, these tumors occur in isolation and are known as schwannomas or neurilemmomas. The presence of multiple schwannomas is known as schwannomatosis. The purpose of this article is 2-fold: (1) to review the relevant literature and describe a unique case of this rare condition; and (2) to emphasize salient clinical considerations in the diagnosis and treatment of schwannomatosis. Methods: In this report, we describe the case of a 52-year-old white man who presented with multiple recurrent soft tissue masses of the right hand. On initial presentation, he described pain across his right hand and index finger, which persisted despite numerous prior operations. The index finger had a flexion contracture around the location of the proximal interphalangeal joint, and there were multiple tender masses along the length of the finger and palm. Results: Segmental excision of the affected radial digital nerve was performed. A pulp flap based on contralateral neurovascular bundle resulted in a sensate, pain-free digit. Tissue pathology confirmed the diagnosis of multiple neurilemmomas. Conclusions: We report the success of a radial digital neurectomy in a patient with widespread neurilemmomas, who had previously excluded that painful digit from use. It was through careful consideration of the preoperative differential diagnosis, by valuing the preoperative imaging, and by considering all surgical options with specific attention paid to skin flap design that this good outcome of a fully sensate, pain-free, mobile index finger was achieved.

Reliability of the Dorsal Tangential View in Assessment of Distal Radioulnar Joint Reduction in the Neutral, Pronated, and Supinated Positions in a Cadaver Model.

PURPOSE: Intraoperative assessment of distal radioulnar joint (DRUJ) alignment is often based on lateral radiographs whose interpretation is dependent upon positioning the forearm in neutral rotation. The dorsal tangential view (DTV) is a near-axial view of the dorsal wrist used in assessing dorsal screw penetration during radius fixation. The purpose of this study was to determine whether the DTV can also reliably assess DRUJ alignment in multiple forearm positions. METHODS: Four transhumeral cadaveric specimens were used to simulate an unstable DRUJ. The stabilizing soft tissue structures of the DRUJ were sectioned. Fluoroscopic DTV images were obtained with the DRUJ of each specimen held in 5 positions: dorsally dislocated, dorsally subluxated, reduced, volarly subluxated, and volarly dislocated. In each position, images were taken with the forearm in neutral rotation, full pronation, and full supination. Three observers independently assessed DRUJ position on DTV images. Intra- and interobserver reliability were assessed in each forearm position. RESULTS: Observers correctly identified DRUJ position as reduced, volarly malreduced, or dorsally malreduced on 94% of the DTV images (97%, 95%, and 92% in the neutral, supinated, and pronated forearm positions, respectively). Weighted kappa values for intraobserver reliability were 0.965, 0.964, and 0.965 for the 3 observers. The mean kappas for intraobserver reliability were 1.000, 0.967, and 0.930 with the forearm in neutral, supinated, and pronated positions, respectively. Weighted kappa values for interobserver reliability between paired observers were 0.948, 0.912, and 0.929. The mean kappa for interobserver reliability was 0.926, 0.931, and 0.930 for the forearm in neutral, supinated, and pronated positions, respectively. CONCLUSIONS: The DTV reliably demonstrated the position of the DRUJ independent of forearm rotation in a cadaveric model. CLINICAL RELEVANCE: Surgeons may consider the DTV as another tool for fluoroscopic verification of the DRUJ reduction in the operating room or clinic.

Impact of Septated First Dorsal Compartments on Symptomatic de Quervain Disease.

BACKGROUND: The authors conducted this study to determine whether septation of the first dorsal compartment is more prevalent in de Quervain tenosynovitis, and whether this contributes to failure of corticosteroid injection therapy. METHODS: A retrospective review of 79 consecutive patients (85 wrists) with symptomatic de Quervain tenosynovitis treated with surgical release was performed. The number of corticosteroid injections performed preoperatively and the presence of first dorsal compartment septation determined intraoperatively were recorded. Correlation between the number of steroid injections and the presence of septation was evaluated. In addition, 48 matched cadaver upper extremities (96 wrists) that had not previously undergone surgery for de Quervain disease were evaluated for the presence of first dorsal compartment septation. The prevalence of septation was compared between matched wrists and against the surgically treated clinical cohort. RESULTS: In the clinical cohort, 61.2 percent of wrists contained a septated first dorsal compartment. There was no correlation between the presence of a septated first dorsal compartment and the number of steroid injections before surgical release. In the cadaver portion of the study, 72.9 percent of wrists contained septa. There was no significant difference in the prevalence of septated first dorsal compartments between groups. CONCLUSIONS: In the present study, the majority of wrists contained a septated first dorsal compartment, with no difference in the prevalence of septa between surgically treated patients and a cadaver sample that had not undergone prior surgical release. Furthermore, there was no correlation between the presence of septa and the number of preoperative corticosteroid injections administered. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The Impact of Suture Caliber and Looped Configurations on the Suture-Tendon Interface in Zone II Flexor Tendon Repair.

PURPOSE: To evaluate the impact of suture caliber and looped configurations on the integrity of 4-strand modified Kessler zone II flexor tendon repairs during progressive cyclic loading. METHODS: Seventy-two flexor digitorum profundus tendons from 18 fresh human cadaver hands were divided into 4 repair groups. Thirty-six matched tendons underwent repair using either a 4-0 looped or 4-0 single-stranded suture, and an additional 36 tendons underwent 3-0 looped or 3-0 single-stranded repairs. Repair strength was tested by progressive cyclic loading. The force generating 2-mm gap formation, ultimate failure, and the mechanism of failure were recorded for each test. The impact of looped versus single-stranded configurations and the effect of tendon cross-sectional area on repair integrity were analyzed for each suture caliber. RESULTS: There was no statistically significant difference between groups regarding the force to 2-mm gap formation or ultimate failure, and all values exceeded the minimum threshold of 27 N required to withstand an early active range of motion rehabilitation protocol. The use of a 3-0 caliber suture resulted in a significantly higher proportion of repairs failing by suture pullout through the tendon substance, including 63.5% of looped and 38.9% of single-stranded core sutures. By comparison, this occurred in 11.1% of 4-0 looped and 0% of 4-0 single-stranded sutures. Larger tendon cross-sectional areas were associated with more robust repairs, particularly in the 3-0 looped group. CONCLUSIONS: In a human cadaver flexor tendon repair model, there was no significant difference in the mean force to failure between all 4 flexor tendon repair constructs under progressive cyclic loading. However, the 3-0 caliber suture failed more frequently by suture pullout, particularly with the use of a looped suture. CLINICAL RELEVANCE: Four-strand flexor tendon repairs using a 3-0 caliber suture are more prone to early failure by suture pullout under progressive cyclic loading compared with a 4-0 caliber suture.

Correlation of the Lateral Wrist Radiograph to Ulnar Variance: A Cadaveric Study.

PURPOSE: Both positive and negative ulnar variance have been implicated in a variety of wrist disorders. Surgery aims to correct the variance in these pathologic conditions. This necessitates accurate and reproducible measuring tools; however, the most accurate radiographic measurement technique remains unclear. The purposes of this study were to evaluate 3 methods for determining ulnar variance and to compare each with direct anatomic measurement in a cadaver model. METHODS: We fixed 10 fresh above-elbow cadaver specimens in neutral rotation and obtained standardized fluoroscopic posteroanterior and lateral wrist images. A dorsal approach was performed and two independent investigators directly measured ulnar variance using digital calipers with the cartilage both intact and denuded. Ulnar variance was measured radiographically using the lateral, perpendicular, and central reference point methods. The reliability of each set of measurements (within a 1-mm cutoff) was assessed by the intraclass coefficient; agreement between radiographic and direct measurements was evaluated by the Bland-Altman method. RESULTS: Each method of determining ulnar variance demonstrated near perfect agreement by the intraclass coefficient. The lateral radiograph method correlated highly with the directly measured ulnar variance with the cartilage denuded with an average measurement difference of 0.06 mm. No radiographic measurement technique demonstrated consistent agreement within 1 mm of the measured ulnar variance with the cartilage intact. CONCLUSIONS: Ulnar variance measured by the lateral wrist radiograph technique correlates highly with the directly measured osseous ulnar variance. The remaining measurement techniques did not correlate reliably to within 1 mm of the directly measured ulnar variance with 95% confidence. No method was able to account accurately for the articular cartilage thicknesses at the lunate facet of the radius or the distal ulnar head, which we found to vary in an unpredictable manner. Whereas the lateral radiograph has been shown to allow for more reliable standardization of wrist position compared with the posteroanterior view, this study also highlights the inherent limitations of using static radiographic images in evaluating ulnar variance. CLINICAL RELEVANCE: The results of the current study demonstrate the utility of the lateral wrist radiograph for assessing bony ulnar variance.

The Dorsal Aponeurosis of the Thumb.

PURPOSE: To evaluate the thumb dorsal aponeurosis anatomy. Consideration of structural differences between the fingers and thumb will provide an improved clinical understanding of the thumb dorsal aponeurosis anatomy. METHODS: Ten fresh cadaver hands from 5 patients with an average age of 31.6 (range, 22-41) years were dissected. The thenar muscles were identified and insertion sites were documented. The fibers of the dorsal aponeurosis and contributions were identified. RESULTS: The flexor pollicis brevis superficial head contributed to the radial fibers of the dorsal aponeurosis in 8 specimens and contributed to the deep head in 1 specimen. The abductor pollicis brevis provided fibers to the radial dorsal aponeurosis in all 10 specimens. The oblique and transverse heads of the adductor pollicis contributed to the ulnar dorsal aponeurosis in 8 and 9 hands, respectively. The fibers of the intrinsic apparatus were composed of 3 major types: transverse, oblique, and long. CONCLUSIONS: This investigation provides a detailed anatomic study of the dorsal aponeurosis of the thumb with observation of both intrinsic and extrinsic contributions. CLINICAL RELEVANCE: Understanding the anatomy of the dorsal aponeurosis of the thumb remains important not only for evaluation of the classic Stener lesion, but also for the appropriate treatment of deformity, contracture, and neuromuscular disorders involving the thumb.

Finger Injuries in Ball Sports.

Finger injuries are common in athletes playing in professional ball sports. Understanding the intricate anatomy of the digit is necessary to properly diagnose and manage finger injuries. Unrecognized or poorly managed finger injuries can lead to chronic deformities that can affect an athlete's performance. Multiple factors and treatment options should be considered to provide the best functional outcome and rapid return to play for an athlete. This article discusses the mechanism of injury, diagnosis, treatment, and return-to-play recommendations for common finger injuries in ball sports.

A Cadaver Investigation of Screw Purchase With 2 Retrograde Techniques for Capitolunate Arthrodesis.

PURPOSE: To examine the hypothesis that the amount of bone purchase within the lunate is greater when using a technique for intermetacarpal retrograde screw placement across the capitolunate joint than when using a dorsal capitate technique. METHODS: Seven fresh cadaver limbs were dissected. We exposed the carpus and scaphoidectomy and performed selective capitolunate decortication. We compared the technique of dorsal capitate placement of headless compression screws with intermetacarpal placement by measuring the depth of purchase in the lunate. RESULTS: Drill hole depths in the lunate were greater using the intermetacarpal technique versus the dorsal capitate technique; the average depth was 9.0 and 6.4 mm, respectively. The calculated number of threads was also greater with the intermetacarpal technique than with the dorsal capitate technique (15 vs 9 threads, respectively). CONCLUSIONS: The intermetacarpal technique for retrograde headless compression screw placement in a capitolunate arthrodesis provided a greater depth of purchase in the lunate portion of the construct. It also afforded more ease of placement than previously described antegrade techniques without the risk of hardware migration into the radiocarpal joint. CLINICAL RELEVANCE: The knowledge gained from this study may help guide surgeons to choose a technique for retrograde placement of headless compression screws in capitolunate arthrodesis to gain better purchase within the lunate.

Soft-Tissue Surgery for Camptodactyly Corrects Skeletal Changes.

BACKGROUND: This study demonstrates the potential for radiographic and clinical improvement with surgical correction of camptodactyly. Although historically these radiographic changes have been held to be permanent, the authors encourage surgical intervention for digits with severe flexion contracture or progressive radiographic changes before skeletal maturity is reached. METHODS: The authors assessed 18 consecutively operated fingers in nine skeletally immature patients in whom advanced radiographic articular changes had occurred. Mean preoperative flexion contracture was 63 degrees (range, 35 to 105 degrees). The average age of the patients was 11 years (range, 4 to 15 years) at the time of surgery. Clinical response to surgery was studied, but radiographic articular changes were followed postoperatively as a primary outcome. RESULTS: Each patient demonstrated the classic preoperative radiographic joint changes on radiographic films at the affected proximal interphalangeal or distal interphalangeal joint. All patients had substantial clinical improvement postoperatively. Two digits had extensive radiographic damage, requiring proximal interphalangeal joint arthrodesis. Fifteen of the remaining 16 digits (94 percent) had substantial improvement or full restoration of radiographic articular congruency at average follow-up of 9 months (range, 3 to 18 months). The only joint that did not remodel fully was the one that did not have complete clinical correction. CONCLUSIONS: Even in patients with severe radiographic changes from camptodactyly, surgery can effectively improve range of motion. Once radiographic articular changes become apparent, surgical correction should be undertaken not only to prevent further joint damage but also to reverse these radiographic changes before skeletal maturity is reached. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Vascularized Heterodigital Island Flap for Fingertip and Dorsal Finger Reconstruction.

A heterodigital vascularized island flap can functionally restore large soft tissue defects to the injured fingertip in a single stage. It is optimally used for digits of unequal length so that the donor fingertip is not violated, and the skin island is best taken from the less dominant side of the donor finger. Because it is a transposition flap with a proximal axis of rotation, its transposition arc can also reach the dorsum of an adjacent digit. This article describes how the heterodigital arterialized flap preserves the donor finger digital nerve and distal pulp, thus reducing donor site morbidity. Indications, method of flap elevation, and flap design will be reviewed to optimize case selection, minimize donor site morbidity, and enhance safety of flap elevation and transposition.

Biomechanical evaluation of double-strand (looped) and single-strand polyamide multifilament suture: influence of knot and suture size.

BACKGROUND: Flexor tendon repair in zone II remains a vexing problem. Repair techniques have been developed to strengthen and optimize the number of core strands crossing a repair. A polyamide looped suture doubles the number of core strands for every needle path. This simplifies repairs, but the knot remains a potential weakness. The purpose of our study was to create a biomechanical model used to evaluate the bulky knot of a looped suture as it may be weaker, resulting in greater deformation. METHODS: Using machined steel rods to hold our suture constructs, we compared four different knot configurations using looped and non-looped sutures in 3-0 and 4-0 varieties using a four-core strand technique. The constructs were tested under increased cyclic loading recording both forces applied and suture construct lengthening ("clinical gapping") and ultimate breaking strength. RESULTS: During continuous periods of cyclic loading, we measured permanent deformation and ultimate breaking strength. Permanent deformation results when there is no recoverable change after force removal defined as a permanent rod separation (or gapping) of 2 mm. Four-strand 3-0 and 4-0 looped sutures failed at 39.9 and 27.1 N faring worse than a four-strand non-looped suture which reached a rod separation of 2 mm at 60.7 and 41.3 N. The ultimate breaking strength demonstrated absolute failure (construct rupture) with the 3-0 looped suture breaking at the knot at 50.3 N and the non-looped suture at 61.5 N. For the 4-0 suture, these values were 32.4 and 41.76 N. CONCLUSION: Within the constraints of this model, a looped suture fared worse than a non-looped suture especially when comparing 4-0 and 3-0 sutures. However, two-knot 3-0 looped suture constructs did resist the force generally accepted as occurring with early non-resistive tendon motion protocols, while two-knot 4-0 looped suture constructs did not. CLINICAL RELEVANCE: This paper provides a description of a model to evaluate various suture materials and knot strengths in isolation of the tendon itself. This allowed us to evaluate mechanical differences between looped and non-looped sutures for polyamide, which are commonly used in flexor tendon repair. These differences between sutures may impact choices for a suture type selected for these repairs.

Severe camptodactyly: A systematic surgeon and therapist collaboration.

INTRODUCTION: Although common, the treatment of camptodactyly is controversial. PURPOSE: Our purpose is to delineate a logical stepwise treatment plan based on corresponding components of the pre-operative and intraoperative evaluation of camptodactyly. In addition, describe structure rehabilitation plan utilizing the same stepwise evaluation. METHODS: With the use of a retrospective cohort study design, we reviewed 18 consecutively operated digits in twelve patients with camptodactyly affecting the proximal interphalangeal (PIP) joint. There were five girls and eight boys, averaging eight years of age (range: 9 months to 15 years) at surgery. RESULTS: Surgery corrected flexion contractures with mean post-operative flexion contracture of 3° (range 0-25°) at mean follow-up of 11 months (range 3-32 months). 15 of 18 digits achieved full active PIP extension. DISCUSSION: By employing a detailed clinical assessment to guide surgical treatment followed by focused therapy, we have markedly improved flexion contractures in digits with moderate to severe camptodactyly. CONCLUSIONS: Hand therapy is essential to maintain and further surgical improvement of passive extension and to regain active extension following surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Evaluation of a stepwise surgical approach to camptodactyly.

BACKGROUND: Camptodactyly is common, but its treatment remains controversial. Multiple deforming forces have been implicated in its pathogenesis. This study evaluates a logical clinical assessment and corresponding stepwise surgical plan. METHODS: Eighteen consecutive fingers (12 children) had surgery to treat camptodactyly of the proximal interphalangeal joint at a mean age of 8 years (range, 9 months to 15 years). The little (n = 13), ring (n = 2), and middle fingers (n = 3) were involved. Mean preoperative flexion contracture was 57 degrees (range, 35 to 75 degrees). All digits had moderate to severe contracture with functional impairment and were offered surgery. Preoperative and postoperative active range of motion was recorded. The sequential treatment steps correspond to the clinical examination and potentially involve volar skin release with flap, fascial release, flexor digitorum superficialis tenotomy, sliding volar plate release, extension lag correction, and Fowler extensor tenotomy. RESULTS: Mean postoperative flexion contracture resolved to 3 degrees (range, 0 to 25 degrees) at a mean follow-up of 11 months (range, 3 to 32 months). Mean proximal interphalangeal joint flexion was 88 degrees (range, 50 to 100 degrees). Fifteen of 18 fingers achieved full active proximal interphalangeal joint extension. The remaining digits had residual contractures of 5, 20, and 25 degrees. All digits had soft-tissue release with flap and flexor digitorum superficialis tenotomy, 16 had volar plate release, two had intrinsic transfers, and three had Fowler tenotomy release performed. CONCLUSIONS: This stepwise surgical approach effectively treats severe camptodactyly and appears to confirm the authors' suspected pathogenesis of the disorder. Lumbricals and interossei were not involved. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Closed flexor tendon ruptures.

We review different causes, diagnoses, and treatment options of closed flexor tendon disruptions in the hand. A classification of closed tendon ruptures based on their mechanism includes traumatic tendon avulsion, spontaneous midsubstance rupture, attrition rupture, infiltrative tenosynovial rupture, and iatrogenic. Certain conditions result in tendon disruption inflicted by more than 1 of these etiologies. In rheumatoid arthritis, tendon rupture may result from attrition on an exposed rough surface, proliferative tenosynovial tendon infiltration, or steroid use.