Minimally Invasive Procedure for Correcting Extra-Articular Malunions of Metacarpals and Phalanges.

PURPOSE: Extra-articular malunions of metacarpals and phalanges may cause palmar pain, finger scissoring, and splaying, and interfere with function. Current treatment involves open osteotomy and fixation with plates and screws. We present a minimally invasive method using cannulated headless screws for correction of malunions and examine the outcomes in a series of patients. METHODS: Twenty malunions were operated on in 17 patients. In 16 cases, the malunion involved the metacarpal and in 4 it involved the proximal phalanx. All proximal phalanx and 3 metacarpal malunions were malrotation types, while the rest of the metacarpal malunions were dorsal angulations. The operation consisted of an opening wedge osteotomy in 8 patients; closing wedge osteotomy in 5; and a transverse osteotomy and derotation in the rest. Concomitant surgery to release tendon adhesions or contracted joints or to perform adipofascial flaps was performed in 8 cases. Fixation was achieved by means of a cannulated headless screw. Immediate range of motion was permitted in all cases. RESULTS: Correction of the malunion and osteotomy union was achieved in all cases. One patient required manipulation of a digit that was found rotated at the first follow-up visit. Eleven fingers achieved more than 280° of total active motion. In 9 digits, the total active motion was less than 280° after the operation, yet improved 76° (range, 140°-30°) from their preoperative total active motion. The mean single-assessment numeric evaluation score for the whole group was 9.1. CONCLUSIONS: The fixation provided by the cannulated headless screw is sufficient to permit immediate range of motion. Due to the minimal tissue disruption, this approach may be a reasonable alternative to the standard approach. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

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.

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.

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.

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.

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.

The stacking concept: cannulated screws for extra-articular metacarpal base fracture of the thumb.

An alternative technique to treat extra-articular fractures of the base of the first metacarpal with intramedullary canulated headless screws is presented. The principle is creating an internal fixator within the medullary canal by introducing multiple retrograde screws until they have jammed.

Dry arthroscopic 4-corner arthrodesis and other refinements to stay within a tourniquet time.

4-corner arthrodesis is a widely implanted procedure to treat degenerated joints in the wrist such as SLAC and SNAC stage II and III. Arthroscopy in combination with headless cannulated screws, permits reproducing the same intervention with the advantages of a minimally invasive surgery. This technique has already been published in the past supported by the early experience in this new exciting field. The purpose of this paper is to present new technical refinements collected over the years in order to speed up the surgery while obtaining optimum results. In this paper we also present extreme scenarios solved by combining the scope with cannulated screws.