Total Elbow Arthroplasty Historical and Current Concepts.

The evolution of total elbow arthroplasty (TEA) has laid the groundwork for modern day TEA and has contributed to our understanding of elbow biomechanics. Trends in the usage of TEA have also varied significantly over time. This article aims to review the history and evolution of the TEA implant with a focus on modern day implant biomechanics and the trends in TEA indications. Additionally, this review discusses various complications that can occur with modern day TEA and looks toward the future to identify innovation and future trends.

Endoscopic Carpal Tunnel Release Past, Present, and Future Directions.

Carpal tunnel release is a safe and reliable option for the surgical treatment of carpal tunnel syndrome. It has traditionally been performed under direct visualization through an open approach. Endoscopic carpal tunnel release (ECTR) was developed as a minimally invasive alternative with the goals of decreasing soft tissue trauma and accelerating functional recovery. Endoscopic carpal tunnel release continues to increase in popularity from both a surgeon and patient perspective. Endoscopic carpal tunnel release has been shown to result in earlier functional improvement compared to traditional open techniques but with no meaningful differences in long-term outcomes. The cost-effectiveness of ECTR remains unclear. This review highlights the history of ECTR, the current literature regarding outcomes and cost, and the future directions of carpal tunnel surgery.

Demystifying the Radial Nerve The Management of Radial Nerve Palsy in the Setting of Humeral Shaft Fracture.

The association of radial nerve palsy and humeral shaft fracture is well known. Primary exploration and fracture fixation is recommended for open fractures and vascular injury while expectant management remains the standard of care for closed injuries. In the absence of nerve recovery, exploration and reconstruction is recommended 3 to 5 months following injury. When direct repair or nerve grafting is unlikely to achieve a suitable outcome, nerve and tendon transfers are potential options for the restoration of wrist and finger extension.

Postoperative Elbow Instability: Options for Revision Stabilization.

Persistent and recurrent postoperative elbow instability includes a spectrum of pathologies ranging from joint incongruity and subluxation to dislocation. Restoration of osseous anatomy, particularly the coronoid, is a priority in restoring elbow alignment and maintaining ulnohumeral joint stability. After managing bony deficiencies, soft-tissue and ligamentous structures are typically addressed. When required, both static and dynamic adjunctive stabilization procedures have been described, which aid in maintaining a concentric reduction. In these complex procedures, both complication avoidance and early recognition of postoperative complications assist in obtaining a good result. In this review, we discuss current treatment options for revision stabilization for patients with persistent and recurrent elbow subluxation or dislocation after primary stabilization.

Determining the Optimal Dosage of Corticosteroid Injection in Trigger Finger.

BACKGROUND: Corticosteroid injection is the mainstay of nonoperative treatment for trigger finger (stenosing tenosynovitis), but despite substantial experience with this treatment, there is minimal available evidence as to the optimal corticosteroid dosing. The purpose of this study is to compare the efficacy of 3 different injection dosages of triamcinolone acetonide for the treatment of trigger finger. METHODS: Patients diagnosed with a trigger finger were prospectively enrolled and treated with an initial triamcinolone acetonide (Kenalog) injection of 5 mg, 10 mg, or 20 mg. Patients were followed longitudinally over a 6-month period. Patients were assessed for duration of clinical response, clinical failure, Visual Analog Scale (VAS) pain scores, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores. RESULTS: A total of 146 patients (163 trigger fingers) were enrolled over a 26-month period. At 6-month follow-up, injections were still effective (without recurrence, secondary injection, or surgery) in 52% of the 5-mg group, 62% of the 10-mg group, and 79% of the 20-mg group. Visual Analog Scale at final follow-up improved by 2.2 in the 5-mg group, 2.7 in the 10-mg group, and 4.5 in the 20-mg group. The QuickDASH scores at final follow-up improved by 11.8 in the 5-mg group, 21.5 in the 10-mg group, and 28.9 in the 20-mg group. CONCLUSIONS: Minimal evidence exists to guide the optimal dosing of steroid injection in trigger digits. When compared with 5-mg and 10-mg doses, a 20-mg dose was found to have a significantly higher rate of clinical effectiveness at 6-month follow-up. The VAS and QuickDASH scores were not significantly different between the 3 groups.

Reducing Tourniquet Pressures in Hand Surgery: Are Lower Pressures as Effective?

Background Pneumatic tourniquets are widely used in hand surgery. Elevated pressures can be associated with complications, and thus, guidelines based on patient-specific tourniquet pressures have been recommended. The primary aim of this study was to determine whether lower tourniquet values based on systolic blood pressure (SBP) could be effectively applied in upper extremity surgery. Methods A prospective case series of 107 consecutive patients undergoing upper extremity surgery with use of a pneumatic tourniquet was performed. Tourniquet pressure used was based on the patient's SBP. The tourniquet was inflated based on our predetermined guidelines: 60 mm Hg was added for SBP < 130 mm Hg, 80 mm Hg for SBP between 131 and 190 mm Hg, and 100 mm Hg for SBP > 191 mm Hg. The outcome measures included intraoperative tourniquet adjustment, surgeon-rated quality of bloodless operative field and complications. Results The mean tourniquet pressure was 183 ± 26 mm Hg with a mean tourniquet time of 34 minutes (range: 2-120 minutes). There were no instances of intraoperative tourniquet adjustment. The surgeon-rated quality of bloodless operative field was excellent in all patients. No complications were associated with the use of a tourniquet. Conclusion Tourniquet inflation pressure based on SBP is an effective method to provide a bloodless surgical field in upper extremity surgery at significantly lower inflation pressures than are the current standards.

Carpometacarpal Arthroplasty What's the Rule of Thumb?

Carpometacarpal (CMC) arthritis of the thumb is one of the most common pathologies encountered in clinical hand and orthopedic surgery practices. Anatomy of the CMC joint and its biomechanics are theorized to predispose the articulation to laxity and subsequent degenerative changes. Diagnosis of CMC arthritis is primarily based on history, physical examination, and imaging findings, all of which coalesce to guide treatment. There are a multitude of treatment options for CMC arthritis, each with its own set of pearls and pitfalls with treatment decision making shared by surgeon and patient. Continued research and longitudinal data on outcome measures will assist in determining the ultimate "rule of thumb" for the treatment of CMC arthritis.

Late Repair of Flexor Tendon Lacerations Within the Digital Sheaths.

PURPOSE: This article presents the outcomes of repairs of flexor tendon lacerations within digital sheaths performed more than 2 weeks after injury. METHODS: A retrospective review of 46 patients; 37 with finger lacerations involving a total of 54 severed tendons in 42 fingers and nine with thumb lacerations of the flexor pollicis longus (FPL). In those patients with finger lacera- tions, 30 lacerations were isolated to the flexor digitorum profundus (FDP; 17 in Zone I and 13 in Zone II), and 12 involved both FDP and flexor digitorum superficialis (FDS) for a total of 24 tendon lacerations. RESULTS: The delay in surgery for finger lacerations ranged from 2 to 96 weeks (average: 8.5 weeks) and for thumb lacerations, 2 to 17 weeks (average: 5.5 weeks). In Zone I finger lacerations, postoperative flexion of the distal interphalangeal (DIP) joint averaged 35° with 82% of patients regaining total active motion (TAM) in the good to excellent range. In Zone II injuries isolated to the FDP tendon, postoperative DIP joint flexion averaged 36.5° with 73% of patients regaining good to excellent TAM. In Zone II injuries involving both flexor tendons, final average DIP flexion was 37° with only 45% of patients regaining good to excellent TAM. All patients with FPL lacerations regained at least 30° (average: 46°) of active interphalangeal joint flexion. CONCLUSION: When certain conditions exist that are deter- mined at surgery, delayed repairs of isolated FDP lacera- tions in fingers and FPL lacerations in thumbs can restore satisfactory mobility. Results are less favorable when both flexor tendons in the finger are lacerated and only the FDP repaired.

Penlight versus Smartphone: Diagnostic Efficacy of Transillumination.

Background: The purpose of this study was to compare the diagnostic accuracy of a smartphone flashlight to a conventional penlight with regards to transillumination of simulated soft tissue masses of the hand and wrist. Methods: Eight participants performed transillumination assessments in a fresh frozen cadaver upper extremity model. Spheres measuring 9.5 mm were used to simulate fluid-filled or solid soft tissue masses. Two spheres were placed on the volar aspect and two on the dorsal aspect of the wrist. These were then evaluated with either a smartphone flashlight or penlight. Participants noted whether each sphere did or did not transilluminate. Each participant performed two evaluations at an interval of 3 weeks. Results: The overall sensitivity, specificity and accuracy of the smartphone were 100%, 44% and 72%, respectively. The overall sensitivity, specificity and accuracy of the penlight were 100%, 75% and 88%, respectively. The difference in accuracy between the smartphone group and penlight group was statistically significant (p = 0.029). The kappa value, indicating intra-observer agreement, for the smartphone group and penlight group was 0.76 and 0.76, respectively. Conclusion: In conclusion, transillumination with a penlight is a viable adjunct to the examination of soft tissue masses of the hand and wrist. The use of a smartphone flashlight, while convenient, is less accurate than a penlight and can lead the examiners to misinterpret the composition of soft tissue masses. Level of Evidence: Level IV (Diagnostic).

Targeted Muscle Reinnervation (TMR) and Other Considerations in Upper Extremity Amputation.

Targeted muscle reinnervation (TMR) is a procedure in which amputated nerves are transferred to motor branches of functionally expendable muscles, which can then serve as "biological amplifiers" of neurologic information. It is a technique that was developed with the primary intent of improving myoelectric prosthesis control in high level upper extremity amputees. Over time, TMR has been shown to confer significant benefits in terms of both residual and phantom limb pain and as such has become a powerful tool in neuroma management in amputees and non-amputees. This review first discusses general principles of amputation management in the upper extremity, including the different types of prosthetics that are available for these patients. The history, rationale, and evolution of TMR will then be outlined, followed by several relevant surgical principles. Finally, the current evidence for and against TMR will be reviewed. Robust data on the functional benefits are still needed, and future studies will continue to clarify its role in both upper and lower extremity amputees.

Updates on Distal Radius Fractures Past, Present, and Complications.

Before the 1900s, distal radius fractures were misdiagnosed as radiocarpal dislocations and most were treated nonoperatively. Between the 1900s and 1920s there were several anesthesia and antiseptic advancements that led to the advancement of surgical interventions. Then after the continued use and implementation of radiographs in orthopedics, radiographic parameters allowed for a critical analysis of treatment and patient outcomes that led to the further advancement of distal radius fracture treatment. This review will detail the historical content that led us to current practices. Additionally, current methods are critiqued, and common complications are reviewed in order to allow orthopedic surgeons to avoid these complications today.

Extensive Tumoral Calcinosis of the Hand.

Tumoral calcinosis is a rare and benign subtype of calcinosis cutis, a group of disorders involving soft tissue calcium deposition. Only 250 cases have been described since 1898; hand involvement is exceedingly rare. We report a case of extensive calcinosis within the flexor sheath of the little finger. Presentation included a painful mass over the volar aspect of the little finger, restricted digit motion, and skin compromise at the site of the mass. Surgical debulking was performed resulting in restoration of finger function.

Cerclage Wire Fixation for Fracture-Dislocations of the Proximal Interphalangeal Joint.

Proximal interphalangeal (PIP) joint fracture dislocations are challenging injuries to treat. Multiple and varied treatments have been proposed. We present the use of cerclage wiring as a helpful technique in these challenging scenarios. The technique has the benefit of securing fracture fragments from the volar or dorsal base of middle phalanges or a comminuted fracture involving the entire articular surface. We report on the use of cerclage wires in eight patients (average: 43 years of age). Three patients had volar base fractures, three dorsal base fractures, and two impacted fractures involving the entire articular surface. All fractures healed, and average postoperative PIP active flexion motion arc was 21° to 95° (functional arc of 74°). We believe cerclage wire fixation is an effective and reproducible method to treat intra-articular fractures of middle phalanges, especially comminuted fractures involving the entire articular surface, and should be available to hand surgeons treating these difficult injuries.

Crossed K-Wires Versus Intramedullary Headless Screw Fixation of Unstable Metacarpal Neck Fractures: A Biomechanical Study.

Background: Intramedullary headless screw (IMHS) has shown promise as an alternative to other fixation devices for metacarpal neck fractures. The purpose of this study was to assess the biomechanical performance of IMHS versus the commonly-used crossed K-wire technique. We hypothesized that IMHS fixation provides superior stability to K-wires. Methods: A metacarpal neck fracture model in 23 human cadaveric metacarpals was created. The specimens were divided into two groups based upon fixation method: Group 1, 3 mm intramedullary headless screw; and Group 2, 0.045 inch crossed K-wires. A cantilever bending model was used to assess load-to-failure (LTF), maximum displacement, energy absorption, and stiffness. Results: The mean LTF was 70.6 ± 30.1 N for IMHS and 97.5 ± 34.7 N for crossed K-wires. Mean stiffness was 11.3 ± 3.4 N/mm and 17.7 ± 7.8 N/mm for IMHS and crossed K-wires, respectively. The mean maximum displacement was 20.2 ± 4.6 mm for IMHS and 24.1 ± 3.7 mm for crossed K-wires. Moreover, mean energy absorption was 778.3 ± 528.9 Nmm and 1095.9 ± 454.4 Nmm, respectively, for IMHS and crossed K-wires. Crossed K-wires demonstrated significantly higher stiffness and maximum displacement than IMHS (p < 0.05). Conclusions: IMHS fixation of unstable metacarpal neck fractures offers less stability compared to crossed K-wires when loaded in bending. Clinical Relevance: Crossed K-wires offer superior stability for the treatment of metacarpal neck fractures. These results reveal that IMHS fixation is less favorable biomechanically and should be cautiously selected with regards to fracture stability.

The Relationships Between Surface Measurements and Underlying Tendon Autograft Length for Upper Extremity Reconstructive Surgery.

PURPOSE: The availability of tendon grafts is an important consideration for successful upper extremity reconstructive surgery, including flexor or extensor tendon reconstructions, tendon transfers, and ligament reconstructions. Graft selection is based on availability, expendability, ease of harvest, and length. Given variations in patient height and extremity length, existing average values may provide suboptimal insight into actual tendon lengths available. The purpose of this study is, therefore, to pursue a method of estimating available donor tendon lengths based on easily measured anatomical surface landmarks. METHODS: Thirty cadaveric upper and lower extremity limbs were dissected and the length of commonly harvested tendon grafts including the palmaris longus, extensor indicis proprius, extensor digiti minimi, plantaris, and second long toe extensor was measured. Surface forearm length (from finger tip to cubital fossa) and surface fibular length (from lateral malleolus to fibular head) were also measured. Correlations between surface measurements and underlying tendon lengths were analyzed, and linear models were generated that predicted tendon length as a function of surface measurements. RESULTS: Surface measurements were correlated with underlying tendon length (R = 0.46 - 0.66). Linear models could predict tendon lengths based on surface measurements. A ratio of donor tendon length compared with the limb segment measured was established for each tendon and can be applied to estimate donor tendon length. For the upper extremity tendons, the multipliers for the palmaris longus, extensor indicis proprius, and extensor digiti minimi were 0.51, 0.20, and 0.18, respectively. Lower extremity tendon ratios for the plantaris and extensor digitorum longus were 0.69 and 0.60, respectively. CONCLUSIONS: Although length of available donor tendon can be a limiting variable at the time of surgery, surgeons may be better able to estimate underlying tendon lengths using easily obtained superficial measurements. CLINICAL RELEVANCE: Information obtained from these cadaveric measurements may aid in preoperative planning in hand and upper extremity surgery.

Dorsal Plating of Distal Radius Fractures Historical Context and Appropriate Use.

The management of distal radius fractures has evolved over time from a largely nonoperative paradigm to a more commonly performed operative procedures today. Surgical trends have similarly developed, with dorsal plating falling out of favor due to complications involving extensor tendon pathology as well as due to the ubiquity of the volar plate along with the advent of locking plate technology. However, with the improvement in design of newer generation dorsal plates, this technique should be used in the appropriate clinical situation, including dorsal comminution and angulation with concomitant carpal pathology. Outcome data supports dorsal plating and has been shown to be comparable to that of volar plating, with some unique advantages. As such, the technique of dorsal plating should have a role in surgical management of these injuries.

Volar-Ulnar Approach for Fixation of the Volar Lunate Facet Fragment in Distal Radius Fractures: A Technical Tip.

The volar Henry approach is most commonly used for surgical fixation of distal radius fractures. However, this approach is limited in achieving adequate exposure for the fixation of the volar-ulnar portion of the distal radius, rendering it difficult for the ideal placement of the fixation construct. We propose the use of the extensile volar-ulnar approach for fixation of distal radius fracture involving a small volar-ulnar fragment. This approach allows optimal reduction of the sigmoid notch and the volar lunate facet, which anatomically reduces both the radiocarpal joint and the sigmoid notch. In addition, extension of this approach may safely be performed if concomitant carpal tunnel release is necessary.

Combined Palmer Type 1A and 1B Traumatic Lesions of the Triangular Fibrocartilage Complex A New Category.

We present a series of eight patients who underwent wrist arthroscopy for presumed solitary tears of the triangular fibrocartilage (TFC) and were, instead, found to have combined 1A (central tear) and 1B (ulnar avulsion) tears. The Palmer Classification does not currently categorize this combined pattern. All but one patient had a traumatic injury. Each subject had preoperative radiographs and MRI scans. TFC tears were evident on all MRI scans, though only one was suggestive of a combined tear pat - tern. Surgical management included arthroscopic central tear debridement and ulnar peripheral repair. Average follow-up was 22 months. Grip strength in the affected hand improved from 16% deficit as compared to the unaffected side, to 3.5% deficit postoperatively (p = 0.003), and visual analog scores (VAS) decreased from an average of 7.1/10 preoperatively to 2.3/10 postoperatively (p < 0.001). There was no statistically significant change in wrist range of motion (ROM), however. Arthroscopic debridement of the central perforation (1A lesion) with concomitant repair of the ulnar detachment (1B lesion) resulted in functional and symptomatic improvement. This combined 1A/1B TFC injury is not reliably diagnosed preoperatively and should be considered a new subset in the Palmer classification, as this will raise awareness of its presence and assist in preoperative planning of such lesions.

Concomitant Ulnar Styloid Fracture and Distal Radius Fracture Portend Poorer Outcome.

The literature on the effect of ulnar styloid fractures (USFs) on concomitant distal radius fractures (DRFs) is mixed. We conducted a study to determine if associated ipsilateral USFs affect outcomes of DRFs. We retrospectively evaluated 315 DRFs treated (184 operatively, 131 nonoperatively) over a 7-year period. Concomitant USFs were identified. Mean follow-up was 12 months. Disabilities of the Arm, Shoulder, and Hand (DASH) and 36-Item Short Form Health Survey (SF-36) outcome scores, and grip strength and wrist range of motion data, were collected. Statistical analysis was performed with Student t test and analysis of variance. Incidence of concomitant USF and DRF was higher (P < .0002) in the operative group (64.6%) than in the nonoperative group (39.1%). Patients with USFs had worse mean (SD) pain score, 1.80 (2.43) versus 0.80 (1.55) (P = .0001), DASH score, 17.03 (18.94) versus 9.21 (14.06) (P = .001), and SF-36 score, 77.16 (17.69) versus 82.68 (16.10) (P = .022). In the operative group, patients with USFs had more pain and poorer DASH Functional scores than patients without USFs. Results were similar in the nonoperative group. There was no difference in healing time between intra-articular and extra-articular fractures or between presence and absence of USFs. Concomitant occurrence of USFs and DRFs-which is associated with worse pain scores and lower functioning compared with USFs without DRFs-should prompt clinicians to counsel patients about delayed recovery.

Impact of Joint Position and Joint Morphology on Assessment of Thumb Metacarpophalangeal Joint Radial Collateral Ligament Integrity.

PURPOSE: A 2-part biomechanical study was constructed to test the hypothesis that coronal morphology of the thumb metacarpophalangeal joint impacts the assessment of instability in the context of radial collateral ligament (RCL) injury. METHODS: Fourteen cadaveric thumbs were disarticulated at the carpometacarpal joint. Four observers measured the radius of curvature of the metacarpal (MC) heads. In a custom jig, a micrometer was used to measure the RCL length as each thumb was put through a flexion and/or extension arc under a 200 g ulnar deviation load. Strain was calculated at maximal hyperextension, 0°, 15°, 30°, 45°, and maximal flexion. Radial instability was measured with a goniometer under 45 N stress. The RCL was then divided and measurements were repeated. Analysis of variance and Pearson correlation metrics were used. RESULTS: The RCL strain notably increased from 0° to 30° and 45° of flexion. With an intact RCL, the radial deviation was 15° at 0° of flexion, 18° at 15°, 17° at 30°, 16° at 45°, and 14° at maximal flexion. With a divided RCL, instability was greatest at 30° of flexion with 31° of deviation. The mean radius of curvature of the MC head was 19 ± 4 mm. Radial instability was inversely correlated with the radius of curvature to a considerable degree only in divided RCL specimens, and only at 0° and 15° of flexion. CONCLUSIONS: The RCL contributes most to the radial stability of the joint at flexion positions greater than 30°. The results suggest that flatter MC heads contribute to stability when the RCL is ruptured and the joint is tested at 0° to 15° of metacarpophalangeal flexion. CLINICAL RELEVANCE: The thumb MC joint should be examined for RCL instability in at least 30° of flexion.