Bilateral Plexiform Neurofibromas of the Posterior Interosseous Nerve Mimicking Dorsal Wrist Ganglions.

A 33-year-old woman presented with bilateral dorsal wrist masses associated with pain and limited range of motion. On initial presentation, the masses were believed to be ganglion cysts and the patient opted for observation. Three years later, she was found to have a chest wall mass diagnosed by biopsy to be a neurofibroma. When she later returned to seek treatment for her wrist masses, magnetic resonance imaging demonstrated posterior interosseous nerve (PIN) neurofibromas. Dorsal wrist masses situated over the scapholunate interval are commonly attributed to ganglion cysts. Neurofibromas of the PIN, although rare, should be considered in the differential diagnosis when a mass elicits pain with percussion, fails to transilluminate, fails aspiration, or if the patient has a history of neurofibromas elsewhere in the body.

Measuring Functional Outcomes After Bilateral Vascularized Composite Hand Allotransplantation: A Report of 3 Cases.

PURPOSE: Currently, numerous assessment tools are available to measure functional outcomes after bilateral hand transplantation. The purpose of this article is to present our experience utilizing quantitative assessment tools for functional evaluation and to describe our results after bilateral hand transplantation. METHODS: A single surgeon's experience with bilateral hand transplantation from 2011 to 2016 was retrospectively reviewed. Three bilateral hand transplantations were performed in 2 adults and 1 child. A minimum 2-year follow-up evaluation was available. For the adult patients, postoperative outcome measures included patient-reported pain and disability scores, return of sensation, muscle strength, range of motion, and return to work/activities of daily living, the Hand Transplant Scoring System (HTSS), the Sollerman hand function test, and complications. For our pediatric patient, postoperative outcome measures included the Functional Independence Measure for children (WeeFIM) scale, a functional independence measure for children, the 9-Hole Peg Test, the Box and Block test, and complications. RESULTS: Our 2 adult patients were age 28 and our pediatric patient was age 8 at transplantation. Follow-up ranged from 2 to 7 years. The functional assessments were performed over a period from 11 to 48 months after transplantation. Both adult patients achieved functional independence and the HTSS, Short Form-36 Health Score (SF-36), DASH, and Sollerman tests demonstrated sequential improvement compared with pretransplantation scores assessed with the use of prostheses. Our pediatric patient demonstrated improvement in his Box and Block test score for each hand at sequential visits after transplantation. His 9-Hole Peg Test demonstrated improvement, and his WeeFIM assessment at 20 months indicated a greater level of independence. CONCLUSIONS: Patient-reported outcomes and the Sollerman test when used in addition to the HTSS appear to reflect functional improvement in adult patients after bilateral hand transplantation. Although children pose a unique challenge with functional assessment, we found the WeeFIM assessment, 9-Hole Peg Test, and the Box and Block test helpful in evaluating functional outcomes in our pediatric patient. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

The Association of Clavicle Fracture With Brachial Plexus Birth Palsy.

PURPOSE: Shoulder dystocia is the strongest known risk factor for brachial plexus birth palsy (BPBP). Fractures of the clavicle are known to occur in the setting of shoulder dystocia. It remains unknown whether a clavicle fracture that occurs during a birth delivery with shoulder dystocia increases the risk of BPBP or, alternatively, is protective. The purpose of this study was to use a large, national database to determine whether a clavicle fracture in the setting of shoulder dystocia is associated with an increased or decreased risk of BPBP. MATERIALS AND METHODS: The 1997 to 2012 Kids' Inpatient Database (KID) was analyzed for this study. International Classification of Diseases, Ninth Revision (ICD-9) codes were used to identify newborns diagnosed with shoulder dystocia and BPBP as well as a concurrent fracture of the clavicle. Newborns with shoulder dystocia were stratified into 2 groups: dystocia without a clavicle fracture and dystocia with a clavicle fracture. Multivariable logistic regression was used to quantify the risk for BPBP among shoulder dystocia subgroups. RESULTS: The dataset included 5,564,628 sample births extrapolated to 23,385,597 population births over the 16-year study period. A BPBP occurred at a rate of 1.2 per 1,000 births. Shoulder dystocia complicated 18.8% of births with a BPBP. A total of 7.84% of newborns with a BPBP also sustained a clavicle fracture. Births with shoulder dystocia and a clavicle fracture incurred BPBP at a rate similar to that for newborns with shoulder dystocia and no fracture (9.82% vs 11.77%). Shoulder dystocia without a concurrent clavicle fracture was an independent risk factor for BPBP (odds ratio, 112.1; 95% confidence interval, 103.5-121.4). Those with shoulder dystocia and clavicle fracture had a risk for BPBP comparable with those with shoulder dystocia but no fracture (odds ratio, 126.7 vs 112.1). CONCLUSIONS: This population-level investigation suggests that, among newborns with shoulder dystocia, clavicle fracture is not associated with a significant change in the risk of BPBP. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

A Review on the Orthoplastic Approach to Lower Limb Reconstruction.

Just as in the craft of carpentry, a stable foundation and framework are absolutely essential to the final function of a building, but no more important than the drywall, trim, and paint that make the building functional, durable, and livable. Reconstruction of the lower extremity is similar; the orthopaedic surgeon must obtain stable fixation of the damaged or diseased bone once a thorough debridement of nonviable bone is performed, while the plastic or orthopaedic soft tissue surgeon must provide vascularized, stable coverage. These two components are complementary and both contribute to the success or failure of functional limb restoration. The stability of bone repair will predict the ultimate functional status, while the vascularized envelope will enhance the biology of bone and soft tissue healing. When both components are properly attended to, the result is often a functional limb with an acceptable appearance. While a single surgeon need not perform both of these tasks (although some may choose to do so), the orthopaedic and plastic surgeon involved in this care must have a clear understanding of each other's role and their importance for a good outcome. This is what we call the orthoplastic approach to reconstructive surgery of the extremities, that is, the application of principles and practice of both specialties applied simultaneously to optimize the outcomes in limb reconstruction. In this review article, we discuss the history of orthoplastic surgery, the key elements of orthoplastic surgery, and thoughts on factors that lead to good outcomes through select cases.

Dynamic Thumb Circumduction Measured With a Wearable Motion Sensor: A Prospective Comparison of Patients With Basal Joint Arthritis to Controls.

Purpose: The purpose of this study was to compare the active range of motion in patients with thumb carpometacarpal (CMC) arthritis to healthy controls. A secondary objective of this study was to examine the feasibility of using wearable motion sensors in a clinical setting. Methods: Asymptomatic controls and patients with radiographic and clinical evidence of thumb CMC joint arthritis were recruited. The experimental setup allowed participants to rest their forearm in neutral pronosupination with immobilization of the second through fifth CMC joints. An electromagnetic motion sensor was embedded into a thumb interphalangeal joint immobilizer, and participants were asked to complete continuous thumb circumduction movements. Data were continuously recorded, and circumduction curves were created based on degrees of motion. Peak thumb abduction and extension angles were also extracted from the data. Results: A total of 29 extremities with thumb CMC arthritis and 18 asymptomatic extremities were analyzed. Bilateral disease was present in 64% of patients. Patient age range was 35-83 years, and the control group age range was 26-83 years. The most affected extremities had Eaton stage 3 disease (38%, N = 11). The average maximum thumb abduction was 53.9° ± 19.6° in affected extremities and 70.8° ± 10.1° for controls. Average maximum thumb extension was 50.0° ± 15.2° in affected extremities and 58.4° ± 9.1° for controls. When comparing patients with Eaton stage 3 and 4 disease to controls, average maximum abduction and extension decreased with increasing disease stage (42.3°, 46.1°, and 70.8° for abduction, respectively, and 58.4°, 43.3°, and 41.3° for extension, respectively). Conclusions: We observed more severe motion limitations with increasing Eaton stage, and statistically significant differences were seen with stage 3 and 4 disease. A wearable motion sensor using a portable experimental setup was used to obtain measurements in a clinical setting. Type of study/level of evidence: Diagnostic II.

Age-Related Variations in Volar Cortical Angle of the Distal Radius.

Background: The ideal volar locking plate for the treatment of distal radius fracture should anatomically fit the volar surface of the distal radius. The purpose of this study was to measure the volar cortical angle (VCA) of uninjured adult distal radii to determine how well the VCA matches that of modern volar locking plates and whether variations in the VCA are related to demographic factors. Methods: A retrospective radiographic analysis of 273 uninjured adult distal radii was performed. Patients were stratified into age quintiles: less than 27 years, 27 to 43 years, 44 to 51 years, 52 to 64 years, and 65 years or older. The VCA was measured on lateral wrist radiographs, and patient demographics, including age and sex, were collected. Multivariable linear regression analyses were performed to determine the relationship between VCA and demographic factors. Results: The VCA ranged from 23.2° to 42.6°, with a mean of 32.2° (SD = 3.79). Mean VCA was 32.8 (SD = 4.17) in the youngest cohort (<27 years) and 30.4 (SD = 3.63) in the oldest cohort (>65 years). Mean VCA decreased with age, approximately 0.04° per year after adjusting for sex. Men had a 1.6° greater VCA than women after adjusting for age. Conclusion: Mean VCA was greater than the VCA of modern volar locking plates. The VCA decreased with age in both men and women, and men had a greater VCA than women. Such differences must be taken into account to avoid malreduction, tendon irritation, or intra-articular screw placement using current volar plate designs.

Flap Reconstruction of the Hand.

LEARNING OBJECTIVES: After studying this article, the participant should: 1. Be familiar with local, regional, and free flaps for reconstruction of the hand. 2. Be able to identify potential sources of tissue for vascularized coverage using an algorithmic approach to provide stable and functional reconstruction of the hand. 3. Recognize the controversies and complications unique to flap reconstruction of the hand. SUMMARY: The goal of this continuing medical education module is to provide the practicing reconstructive surgeon with a framework in which to think about reconstruction of the hand. The hand has unique functional and aesthetic characteristics that must be considered when choosing the optimal methods for reconstruction. There are a number of reliable local and regional flaps that can be used to treat the hand requiring soft-tissue coverage and/or vascularized bone graft. The "reconstructive ladder," originally described by Mathes and Nahai, is based on the principle of using the simplest approach that adequately restores form and ideally optimizes function. In cases where the simplest techniques prove to be inadequate, local and regional flaps and, ultimately, microsurgical tissue transfer should be considered.

Pseudoaneurysm of the popliteal artery after hardware removal in a patient with Marfan syndrome.

The formation of pseudoaneuryms after orthopaedic procedures in the setting of connective tissue disorders such as Marfan syndrome (MFS) is not well documented in the literature. We report the case of a seventy-one year old male with MFS who underwent uncomplicated distal interlocking screw removal from a femoral cephalomedullary nail for symptomatic hardware. Five weeks later, he presented with a popliteal artery pseudoaneurysm. The patient underwent successful open ligation and excision of the pseudoaneurysm. This is the first reported case of a popliteal artery pseudoaneurysm following orthopaedic hardware removal in a patient with MFS. MFS may predispose patients to peripheral vascular complications even in the most routine cases. A thorough understanding of the patient and complications associated with MFS is required prior to proceeding with elective orthopaedic surgery.

Overpowering the Previously Posterior Instrumented Cervical Spine With Cage-Assisted Anterior Cervical Discectomy and Fusion: A Cadaveric Study.

PURPOSE: Cervical spines previously posteriorly instrumented and fused with a kyphotic deformity represent a surgical challenge. Current treatment strategies include C7 pedicle subtraction osteotomy or a posterior-anterior-posterior approach, which carry the risk of significant complications. The objective of this study was to attempt to achieve lordosis with multiple anterior cervical discectomy and fusion (ACDF) cages to overpower the posterior instrumentation. METHODS: Four adult cadaveric specimens were selected and underwent C3-C7 posterior laminectomy with posterior instrumentation in a kyphotic alignment using a 3.5-mm titanium screw-rod system. Next, ACDF from C3 to C7 was performed with 15° lordotic cages to restore cervical lordosis. Posterior instrumentation was then inspected for failure. Fluoroscopic images were obtained to calculate total construct lordosis and change in segmental lordosis. CT scans were obtained after ACDF to assess for loosening, instrumentation failure, endplate damage, or impaction. Bone mineral density was calculated on CT scans. RESULTS: Age ranged from 59 to 82, and all specimens were male. No gross instrumentation failure was observed. Mean pre-ACDF lordosis between C3 and C7 was 0° (-5° to 5°). Post-ACDF lordosis increased to 37° (35°-38°). Mean segmental lordosis achieved with no endplate destruction was 13.1° (8°-17°). T scores for the cadavers were -0.5, -0.5, -3.2, and -5.1. Two levels of impaction were observed (12.5%). Failure of bone screw interface occurred in the cadaver, with a T score of -5.1 in the middle of the construct. CONCLUSION: Our study demonstrates the validity of overpowering posterior instrumentation through multiple level ACDF with lordotic cages. This may obviate the need to perform posterior-anterior-posterior procedures. LEVEL OF EVIDENCE: Level III.