Effectiveness of an Arthroscopic Technique to Correct Supination Losses of 90° or More.

PURPOSE: To present a new arthroscopic method for treating supination losses. METHODS: Six patients (15-71 y) were eligible for this study. All had a history of trauma to the wrist more than 6 months previously. Five of them had sustained a distal radius fracture: 3 had been treated with a volar plate (1 of them for an extra-articular malunion), 1 with an external fixator and K-wires, and 1 had been treated in a cast. One of these patients underwent a further operation for correcting an intra-articular malunion. The last patient underwent an open reduction of a transscaphoid perilunate dislocation. During a standard radiocarpal arthroscopy, a curved periosteal elevator was inserted through the 6R portal into the volar-radial corner of the triangular fibrocartilage complex and advanced proximally gliding on the anterior ulnar head surface. The volar capsule was then distended with the periosteal elevator and by means of gentle sweeping motion adherences between them, the volar capsule and the ulnar head were freed. Finally, the arthroscopic release was combined with a gentle passive supination force applied by the surgeon. Full supination was maintained in an orthosis for 2 to 3 days. Afterward, regular physical therapy was instituted. Concomitant surgery, arthroscopic or open, was performed in all to treat associated conditions. RESULTS: Full supination (90°) was achieved in all intraoperatively. At a mean follow-up of 3.3 years, mean supination was 76° in the latest follow-up (range, 50° to 90°). Mean improvement in supination was 80° (range, 50° to 100°). No distal radioulnar instability or other complications were noted. CONCLUSIONS: The method presented proved effective in severe forms of supination deficits. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Foot web free flaps for single-stage reconstruction of hand webs.

PURPOSE: To present a method for reconstructing the digital web in posttraumatic defects using a free tissue transfer of the web from the foot and to present the functional and aesthetic results. METHODS: Nine web free flaps were performed; 8 were used to reconstruct posttraumatic web losses and 1 was used to reconstruct a defect resulting from to infection. All cases involved the first (3) or second (6) webs of the hand. Web flaps were taken from the foot first web (2 patients), from the second (6 cases), and from the third (1 case) in a patient with congenital syndactyly of second foot web space. The donor site was managed by skin grafting from the instep (1 case), creation of a syndactyly (7 cases), or both (1 case). RESULTS: All flaps survived without complications. Finger abduction and flexion-extension were similar to the contralateral side. No functional limitations, pain, or contracture were reported. One donor site healed with hypertrophic scars; otherwise, no donor site complications occurred. On a visual analog scale (0-10), the patient assessed appearance of the hand and the donor foot as 9.0 and 9.0, respectively, on average. One web was not well-positioned in the first operation and required revision. CONCLUSIONS: The foot web free flap reconstructs the hand web by replacing it with a similar functional subunit rather than attempting to recreate the complex geometry, and allows for full function and excellent appearance of the hand. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Minimally invasive fixation of fractures of the phalanges and metacarpals with intramedullary cannulated headless compression screws.

PURPOSE: To present the technique, indications, and outcomes of metacarpal and phalangeal fractures fixed with intramedullary cannulated headless screws (CHS). METHODS: We retrospectively reviewed all charts of patients whose metacarpal and phalangeal fractures had been treated with intramedullary CHS in our practice. A total of 69 fractures (48 metacarpal and 21 phalangeal) were identified in 59 patients. Seventeen were open fractures. Eleven patients had multiple fractures (29 in total); of those, 21 were managed with CHS. In 4 other fractures the method was abandoned intraoperatively. The defect created by the entrance of the screw in the proximal phalanx was identified by computed tomography in 20 patients. RESULTS: In 63 fractures a single screw was used; in 6 fractures 2 screws were used to provide stronger fixation. All patients returned to full duties or sport activities at an average of 76 days (range, 3 wk to 15 mo). At the latest follow-up (range, 5-54 mo; average, 19 mo) total active motion was on average 247° (range, 150° to 270°) for all fractures, 249° (range, 210° to 270°) for metacarpal, and 243° (range, 150° to 270°) for proximal phalangeal fractures. All fractures were healed and within acceptable radiological parameters. A comminuted basilar phalangeal fracture displaced secondarily yielding a poor functional result. Two patients required tenolysis and further procedures before the final result was achieved. The screw hole represents around 20% of the proximal phalanx distal articular surface. CONCLUSIONS: Unstable transverse fractures in the phalanx and metacarpal are amenable to single intramedullary CHS fixation. Comminuted fractures require more complex configurations. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Arthroscopic reduction of comminuted intra-articular distal radius fractures with diaphyseal-metaphyseal comminution.

PURPOSE: In the setting of severely comminuted diaphyseal-metaphyseal fractures of the distal radius, arthroscopic reduction of the joint surface is difficult and often results in shortening and collapse. Yet, several authors have shown the benefits of arthroscopy in articular distal radius fractures. We present a method that safely allows a combination of arthroscopic reduction and rigid fixation and describe the outcomes in a small group of patients. METHODS: Four consecutive patients with severely comminuted diaphyseal-metaphyseal articular fractures of the distal radius were treated using the stable reference fragment technique. For all cases, we used an extra-long volar locking plate applied to the diaphysis of the radius. Preoperative computed tomography scanning was used to identify the largest articular fragment. This reference fragment was reduced and stabilized with locking pegs or screws to the volar plate under fluoroscopic guidance. The articular reduction continued arthroscopically, using the reference fragment as a guide. Once the articular reduction was complete, the comminuted metaphysis was addressed and secured to the plate. RESULTS: All patients achieved excellent clinical and radiological results. Flexion-extension averaged 124° and pronation-supination averaged 174°. One patient showed minor signs of radiocarpal osteoarthritis on radiographs at 3 years. CONCLUSIONS: By securing the reference fragment before addressing the metaphyseal comminution, a stable platform was created. Thus, intra-articular reduction was achieved while maintaining extra-articular alignment. Although the results were excellent, the number of cases was small. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Outcomes of free adipofascial flaps combined with tenolysis in scarred beds.

PURPOSE: To review our outcomes of transferring vascularized free adipofascial flaps used to change the local tissue conditions at the time of tenolysis in adhesion-prone beds. METHODS: Eleven free adipofascial flaps were transplanted in 10 patients after tenolysis on the forearm (3 cases), the dorsum of the hand (5 cases), or the dorsum of the proximal phalanx (3 cases). All recipient areas had badly scarred beds, 7 of which had previously failed tenolyses. In addition to tenolysis (10) or the insertion of bridging tendon grafts (1), arthrolysis of several involved joints and bone fixation for nonunion (3 cases) were carried out simultaneously. The adipofascial flap was then wrapped around the tendons or interposed between the scarred tissue and the freed tendons. In 8 cases, the flap was the lateral arm adipofascial flap, whereas adipose flaps from the toes were used for the fingers. RESULTS: All flaps survived without vascular crisis. In all cases, total active motion was similar to the passive motion obtained at surgery. Average Disabilities of the Arm, Shoulder, and Hand score improved from 69 to 10, and average Patient-Rated Wrist Hand Evaluation score improved from 65 to 9. Secondary surgery was needed to reduce the bulk of the flap in 3 patients. One patient required an additional procedure to obtain an optimum result. CONCLUSIONS: Free adipofascial flaps provided satisfying results in this group of patients. The flaps should be considered when the bed is scarred or after a failed tenolysis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Onycho-osteo-cutaneous defects of the thumb reconstructed by partial hallux transfer.

PURPOSE: To present our experience in distal thumb amputations reconstructed by partial toe to hand transfers with special emphasis on manual workers. METHODS: Twenty-five patients who experienced amputation of the thumb distal to the interphalangeal joint, excluding pure soft tissue losses, were included in the study. All but 2 were manual workers. Twenty were reconstructed within 2 weeks after injury. The other 5 were referred late. In all patients, the ipsilateral hallux was used as donor, based on the proper digital artery (18 cases), the intermetatarsal artery (6 cases), and the dorsalis pedis artery (1 case). RESULTS: All transferred flaps survived. At a minimum follow-up of 1 year (range, 1-14 y), active range of motion at the interphalangeal joint was more than 55° in 23 patients. Two had an interphalangeal joint arthrodesis, 1 of them before referral. Pinch and grip were similar to the contralateral side. Two-point discrimination was normal in the dorsal oblique amputations and 7 to 11 mm in the rest. Patient satisfaction was high from a functional and aesthetic standpoint (9.5 out of 10 on a visual analog scale for both outcomes). All patients returned to work 2 to 4.5 months after the operation. Delayed donor site healing was noticed in 4 cases. CONCLUSIONS: In contrast to classic teaching that recommends stump closure for cases of distal thumb amputation, we attained excellent results with partial toe transfer in manual workers. In our experience, the thumb can be restored to nearly normal with an acceptable donor site sequela. The best indication is for cases of dorsal oblique amputations, because thumb sensibility is unaffected, and for amputations where the germinal matrix is preserved, because nail regrowth occurs. Early transfer is strongly recommended. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Vascularized graft from the metatarsal base for reconstructing major osteochondral distal radius defects.

PURPOSE: To present our experience of reconstructing distal radius articular defects with a vascularized osteochondral graft from the metatarsal base and to present the mid-term outcomes. METHODS: Seven patients (average age, 36 y; range, 26-55 y) who had reconstruction of major defects of the articular surface of the radius are presented. In 5, the lunate facet and sigmoid notch were reconstructed; in 1, an isolated defect on the surface of the lunate facet was reconstructed; and in 1, the scaphoid facet was reconstructed. In 6, the base of the third metatarsal was transferred, and in 1, the base of the second was transferred. RESULTS: All flaps survived without complications. At the latest follow-up (range, 20 mo to 8 y), the flexion-extension arc improved an average of 50°, and the pain on a visual analog scale decreased from 8 to 1 on average. Disabilities of the Arm, Shoulder, and Hand score improved from 54 to 11 on average. One patient did not improve. No major complaints related to the donor site were mentioned (average American Orthopedic Foot and Ankle Society score of 96/100). CONCLUSIONS: Our mid-term results are promising; however, the decision-making process and the operation are complex. The operation is not indicated when the carpals are devoid of cartilage or when the defect involves the whole radius surface.

Arthroscopic resection arthroplasty for malunited intra-articular distal radius fractures.

PURPOSE: Cartilage damage of the carpals is a contraindication for corrective osteotomy of the malunited intra-articular distal radius fracture and typically is treated in the symptomatic patient with a salvage procedure. Here, we present our experience and early results with arthroscopic resection arthroplasty of the radiocarpal joint. METHODS: We treated 10 patients (age, 17-68 y; average, 53 y) who had intra-articular malunion of the distal radius with mirror erosion on the carpals. The original fracture occurred 4 to 36 months (average, 9 mo) before our intervention. We performed arthroscopic arthrolysis and resected the offending portion of the radial malunited fragment, eliminating the stepoff and creating a smoother joint surface. Range of motion was started immediately after the operation, except in 2 patients. RESULTS: The locations of the malunions were evenly distributed between the scaphoid fossa, the lunate fossa, or both. Stepoffs varied from 2 to 6 mm. We resected up to 60% of the entire radial articular surface to obtain a smooth surface (average, 28%; range, 20% to 60%). All patients reported immediate relief of pain and improvement in motion (particularly extension). At the latest follow-up (average, 28 mo; range, 13-42 mo), average extension improved from 24° to 54°, average grip strength improved from 47% to 89% of the contralateral wrist, average Disabilities of the Arm, Shoulder, and Hand score improved from 74 to 18, and average Patient-Rated Wrist Hand Evaluation score improved from 79 to 15. CONCLUSIONS: The aim of the operation was to relieve patients' pain by providing a smooth, although fibrocartilaginous, surface for the carpus to glide on the radius. The follow-up was short and the results may be short-lived. However, for the younger patient, it may provide a temporary alternative to partial wrist arthrodesis with minimal morbidity, and for the less demanding patients, it may be a definitive procedure.

Early experience with (dry) arthroscopic 4-corner arthrodesis: from a 4-hour operation to a tourniquet time.

PURPOSE: Scaphoidectomy and 4-corner arthrodesis (4CA) is an effective procedure for treating several degenerative conditions of the wrist. Recently, the arthroscopic approach to this operation was described. Although it is conceptually appealing, certain aspects make its application difficult. We present our technique for dry arthroscopic scaphoidectomy and 4CA, which reduces the operative time to less than 2 hours. METHODS: Four consecutive patients underwent scaphoidectomy and 4CA. In each case, we performed the operation with a dry arthroscopic technique using cannulated screws for rigid fixation. We performed bone grafting from the distal radius in 2 patients and from the scaphoid itself in the other two. The relevant operative details are the use of a scapholunate portal, the resection of the scaphoid with a pituitary rongeur, and the placement of bone graft in a dry arthroscopic environment. Range of motion exercises are started 2 to 3 weeks after the operation. RESULTS: The first operation took 4 hours. The last 2 were completed in 1 hour 45 minutes and 1 hour 55 minutes, respectively. No complications occurred. No operations were converted to an open procedure. CONCLUSIONS: Although the operation has a steep learning curve, it is conceptually appealing. It is too early to prove that the arthroscopic procedure has better results than the open 4CA; nevertheless, in our opinion it represents the future of wrist surgery.

Reconstruction of the ulnar head with a vascularized second metatarsal head: case report.

A case of a young patient with avascular necrosis of the ulnar head following a severely displaced ulnar head fracture is presented. Treatment included debridement of the entire ulnar head, leaving the ulnar styloid, sigmoid notch, triangular fibrocartilage, and both distal radioulnar ligaments intact. The head of the ulna was reconstructed by transferring a vascularized second metatarsal head. At 4-year follow-up, the patient had a pain-free wrist with 45° active pronation and 65° supination. He resumed working without limitations as a manual laborer. We conclude that ulnar head reconstruction with a vascularized second metatarsal head is worthwhile in the setting of an unreconstructable traumatic defect, particularly when the sigmoid notch and distal radioulnar ligaments are preserved.

Effects of collagen prosthesis cross-linking on long-term tissue regeneration following the repair of an abdominal wall defect.

Collagen prostheses used to repair abdominal wall defects, depending on their pretreatment (noncross-linked vs. cross-linked), besides repair may also achieve tissue regeneration. We assessed the host tissue incorporation of different bioprostheses using a new tool that combines immunofluorescence confocal microscopy with differential interference contrast images, making it possible to distinguish newly formed collagen. Partial hernial defects in the abdominal wall of rabbits were repaired using cross-linked/noncross-linked bioprostheses. Expanded polytetrafluoroethylene (ePTFE) was used as control. After 14/30/90/180 days of implant, specimens were taken for microscopy, immunohistochemistry, and quantitative-reverse transcription-polymerase chain reaction to determine host tissue ingrowth and collagen I/III protein and 1a1/3a1 gene expression. Shrinkage and stress resistance were also examined. At 14 days, cross-linked prostheses had suffered significantly less shrinkage than ePTFE or noncross-linked prostheses. Significantly higher shrinkage was recorded for ePTFE in the longer term. Microscopy revealed encapsulation of ePTFE by neoformed tissue, while the bioprostheses became gradually infiltrated by host tissue. Noncross-linked prosthesis showed better tissue ingrowth, more intense inflammatory reaction and more rapid degradation than the cross-linked prostheses. At 14 days, cross-linked prostheses induced up-regulated collagen 1a1 and 3a1 gene expression, while noncross-linked only showed increased collagen III protein expression at 90 days postimplant. At 6 months, the tensile strengths of cross-linked prostheses were significantly greater compared with ePTFE. Our findings demonstrate that despite the cross-linked collagen prostheses promoting less tissue ingrowth than the noncross-linked meshes, they became gradually replaced by good quality host tissue and were less rapidly degraded, leading to improved stress resistance in the long term.

Sigmoid notch reconstruction and limited carpal arthrodesis for a severely comminuted distal radius malunion: case report.

We present the case of a young patient with a severely comminuted, malunited, intra-articular distal radius fracture and complete disruption of the sigmoid notch. We reconstructed the malunited distal radioulnar joint by osteotomy and repositioning the displaced sigmoid notch fragments through a combined dorsal and volar approach. At the same time, we carried out a radioscapholunate arthrodesis with distal scaphoid excision. We used a free vascularized corticoperiosteal flap from the medial femoral condyle to span the massive bone defect in the radius to obtain union. At the 2.5-year follow-up, the patient had essentially normal function of the distal radioulnar joint (painless, with 85° of active pronation and 75° of supination). He resumed work as a bricklayer without limitations. We conclude that sigmoid notch reconstruction by osteotomy is worthwhile in the setting of malunited distal radius whether or not the radiocarpal joint is reconstructable.

Vascular anatomy of the dorsum of the foot.

BACKGROUND: The authors' purpose was to study the anatomy of the dorsum of the foot and determine the distribution and caliber of all vascular branches that nourish the skin and the extensor hallucis longus and extensor digitorum longus tendons. METHODS: The authors performed 20 cadaver dissections. The skin paddle was designed within the dorsum of the foot. Dissection continued until all vascular branches that nourished the skin and tendons were identified. The authors measured the caliber of the vascular connections and the distance to the proximal end of the extensor retinaculum. RESULTS: The dorsalis pedis artery was the continuation of the anterior tibial artery in all cases. A mean of five cutaneous perforators irrigated the cutaneous paddle with a mean caliber of 0.53 mm. The paratenon of the extensor hallucis longus tendon was vascularized by a mean of 8.1 vascular branches with a mean diameter of 0.71 mm. The paratenon of the extensor digitorum longus tendon was nourished by a mean of 5.4 vascular branches, and the mean caliber of those branches was 0.65 mm. CONCLUSION: The dorsum of the foot presents a constant vascular anatomy that is well suited for the elevation of different types of compound flaps which, in turn, would adapt to the needs of the defect.