Extraskeletal Osteosarcoma of the Hand.

Extraskeletal osteosarcoma is a rare disease that uncommonly affects the upper extremity. A 46-year-old African American man presented for evaluation of a right middle finger mass. Excisional biopsy demonstrated extraskeletal osteosarcoma of the soft tissues. We performed a transmetacarpal ray resection.

Dorsal Plate Fixation of Scapular Fracture.

Scapular fractures are uncommon injuries. When they occur, they are usually treated nonsurgically. However, certain indications remain for operative intervention for the treatment of these injuries. In this article, we review some operative indications as well as the surgical technique. We present a case to demonstrate the indications and surgical technique of treatment. As with most surgical approaches, technique is critical to minimize morbidity and maximize functional outcome. Using these techniques, operative management of scapular fractures can be successful.

Smartphone-Based Goniometry Accuracy in Clinical Scenarios.

This study compared two popular iPhone-based goniometer applications to the gold standard universal goniometer for the measurement of the hip and knee joints in scenarios mimicking the normal pace of an orthopaedic clinical practice.Three physicians measured hip and knee joint angles 35 times with one of three goniometers: universal 12-inch goniometer, DrGoniometer (iPhone-5 based), and SimpleGoniometer (iPhone-5 based). Data wwere analyzed using Pearson correlation coefficient calculations. Average knee angles measured with the universal goniometer, DrGoniometer, and SimpleGoniometer measured 83.46°, 85.23°, and 80.39°, respectively. The smartphone-based goniometers had moderate agreement with the universal goniometer in the knee (r > .322). Average hip angles measured with the universal goniometer, DrGoniometer, and SimpleGoniometer measured 62.34°, 60.87°, and 59.34°, respectively. The smartphone-based goniometers had moderate agreement with the universal goniometer in the hip (r > .168). Smartphone-based goniometers gave accurate, with weak to moderate correlation, measurements for the knee and hip. (Journal of Surgical Orthopaedic Advances 26(4):223-226, 2017).

Volar capsulodesis of the thumb metacarpophalangeal joint at the time of basal joint arthroplasty: a surgical technique using suture anchors.

PURPOSE: To document the long-term results of our volar metacarpophalangeal (MCP) joint capsulodesis technique that is completed concomitantly with basal joint arthroplasty and involves a suture anchor placement, short-term pinning, and a rigid hand therapy protocol. METHODS: We conducted a retrospective chart review to examine results over a 30-month period of our volar capsulodesis technique. Follow-up results were recorded 26 to 48 months after surgery. The treatment regimen included suture anchors, joint pinning for 6 weeks, and a strict hand therapy protocol. Indications for surgery were thumb MCP joint hyperextension deformity of at least 30° and radiographic evidence of stage 3 (or greater) basal joint arthritis. We examined preoperative and postoperative range of motion, pain, pinch strength, and complications. Average patient age was 63 years (range, 55-77 y). We treated 14 thumbs in 14 patients. RESULTS: After capsulodesis, average range of motion for the MCP joint of the thumb was 4° extension and 46° flexion. The last follow-up indicated no cases of hyperextension contracture. Complications included one superficial pin track infection (treated with oral antibiotics) and one patient's report of pain at the thumb MCP joint. CONCLUSIONS: When completed as described, thumb MCP joint capsulodesis performed concurrently with trapeziometacarpal arthroplasty can be a straightforward procedure that produces positive results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Interscapulothoracic (forequarter) amputation for malignant tumors involving the upper extremity: surgical technique and case series.

BACKGROUND: Forequarter amputation (FQA) is reserved for large, multifocal, or recurrent tumors affecting the shoulder and upper extremity. Although it is performed less frequently with the advancement of limb salvage surgery, FQA remains an important treatment in select patients. The purpose of this study is to illustrate the surgical technique in a case series of 4 patients. METHODS: Between 2010 and 2012, 4 patients (mean age, 61 years; range, 36-78 years) presented with malignant disease of the upper extremity that was not amenable to or had failed limb salvage. All patients had FQA by the illustrated anterior clavicular osteotomy technique. Patient data were retrospectively reviewed from preoperative workup until last follow-up or death. RESULTS: All patients had tumors that involved major neurovascular structures of the upper extremity and shoulder girdle. One presented with neuroendocrine carcinoma and has achieved local control after FQA. Three presented with high-grade sarcoma. One of these had recurrence after prior limb salvage and neoadjuvant radiation and unfortunately succumbed to metastatic disease 6 months after FQA. An additional sarcoma patient who presented after shoulder arthroscopy for a "labral cyst" with recurrent and fulminant synovial sarcoma succumbed to her disease. The remaining sarcoma patient has had no recurrence and minimal phantom pain at last follow-up. DISCUSSION: Obtaining vascular control early in the procedure is crucial to minimize blood loss. When it is indicated, FQA is a relatively safe and reliable procedure for dealing with otherwise challenging tumors of the shoulder girdle and upper extremity. LEVEL OF EVIDENCE: Level IV, case series, treatment study.

Treatment of a type 3B hypoplastic thumb using extra phalanges from the contralateral duplicated thumb: case report.

A boy was born with a right duplicated thumb (Wassel type 6) and a left radial club hand (type 3) associated with a hypoplastic thumb (type 3B). He underwent surgical centralization of the left wrist when he was 13 months old. At age 38 months, he underwent reconstruction of the carpometacarpal joint of the hypoplastic left thumb. This procedure involved transplantation of the radial ray of the right duplicated thumb to the base of the left thumb. When he was 6 years old, the patient underwent an abductor digiti minimi muscle transfer to create opposition for the left thumb and deepening of the first web. At the final follow-up, he could grasp items in the first web space and pick up small items between the thumb and other digits of the left hand. The treatment represents a method of using otherwise discarded tissues for effective reconstruction.

Recurrent synovial chondromatosis of the distal interphalangeal joint: case report.

A 59-year-old woman presented with recurrent synovial chondromatosis of the distal interphalangeal joint at the site of removal of what was thought to be a ganglion cyst in 2003 and the subsequent excision of a recurrent synovial chondromatosis in 2005. Although synovial chondromatosis is typically described as a benign, self-limiting process, recurrent disease and local erosion of the joint of this patient required wide excision with bone grafting and arthrodesis for definitive treatment.

Regional Variations of Medicare Physician Payments for Hand Surgery Procedures in the United States.

BACKGROUND: Medicare reimbursement is known to exhibit geographic variation for inpatient orthopedic procedures. This study determined whether US geographic variations also exist for commonly performed hand surgeries. METHODS: Using the Medicare Provider Utilization and Payment Data (2012-2013) from Centers for Medicare & Medicaid Services, we analyzed regional physician charges/payments for common outpatient hand surgeries. RESULTS: The most commonly performed procedures in the United States were open carpal tunnel release (n = 21 944), trigger finger release (n = 15 345), endoscopic carpal tunnel release (n = 7106), and basal joint arthroplasty/ligament reconstruction and tendon interposition (n = 2408). A range of average Medicare physician reimbursements existed based on geographic region for basal joint arthroplasty ($669-$571), endoscopic carpal tunnel release ($400-$317), open carpal tunnel release ($325-$261), and trigger finger release ($215-$167). The latter three exhibited statistically significant variation across geographic regions with regard to both charges and physician reimbursement. However, the overall percentage physician reimbursement (70%-79%) to charges was similar across all geographic regions. CONCLUSIONS: In conclusion, further research is warranted to determine why regional or geographic variations in physician payments exist in the United States for commonly performed hand surgeries.

Treatment of primary isolated shoulder sepsis in the adult patient.

UNLABELLED: Isolated shoulder sepsis is an uncommon clinical problem with little information in the literature on causative organisms and potential sequelae. We examined the organisms involved, surgical treatments, antibiotic treatments rendered, and complications in these cases. We retrospectively reviewed the records of 19 adult patients (19 shoulders) who underwent operative treatment of isolated shoulder sepsis from 1996 to 2005. Patient age, gender, laboratory studies, previous treatment, surgical procedures, surgical findings, cultured organism, antibiotic treatment, and complications were reviewed. The organisms included methicillin-susceptible Staphylococcus aureus (five), Streptococcus B beta hemolytic (five), Staphylococcus epidermidis (three), negative cultures (two), Streptococcus viridans (one), Escherichia coli (one), methicillin-resistant S. aureus (one), and Propionibacterium acnes (one). We treated patients with intravenous antibiotics an average of 4.2 weeks (range, 3-8 weeks). One patient underwent humeral head resection with an antibiotic spacer. Another patient died during hospitalization. Open or arthroscopic débridement in conjunction with appropriate antibiotics appears effective in eradicating infection in most adults who present with shoulder sepsis. Functional outcome is poor in those patients with irreparable rotator cuff tears and/or cartilage loss. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Radius neck-to-humerus trochlea transposition for elbow reconstruction after resection of the proximal ulna: report of 2 cases.

The structural and functional deficit created after wide excision of the proximal ulna for malignant bone tumors presents a difficult reconstructive challenge. The purpose of our report was to retrospectively review the outcome of the radius neck-to-humerus trochlea transposition after wide resection of malignant forearm tumors in 2 patients. Good function was obtained using this surgical technique. This surgical option provides a durable biologic solution to a complex reconstructive problem.

Incidence and risk factors for blood transfusion in total elbow arthroplasty.

Our purpose was to determine the incidence of transfusion in consecutive patients undergoing total elbow arthroplasty and examine the risk factors for transfusion. Between January 1, 1998, and December 31, 2002, 378 primary total elbow arthroplasties were performed. Risk factors analyzed included the preoperative level of hemoglobin, age, gender, and diagnosis. Indications for transfusion and associated complications were reviewed. The overall transfusion rate was 2.9%. Men and women had a similar incidence of transfusion. The risk of transfusion was not different between patients who underwent elbow arthroplasty for sequelae of trauma, rheumatoid arthritis, or osteoarthritis. Low preoperative hemoglobin level (P = .0002) and older age (P = .015) were risk factors for transfusion. There was no statistical difference in risk of transfusion by operative time. These data demonstrate that the rate of transfusion for total elbow arthroplasty varies by patient age and preoperative level of hemoglobin.

Transverse and longitudinal osteotomy for the treatment of macrodactyly simplex congenita - a case report.

We report on a three-year-old girl with a severely enlarged right ring finger, which was diagnosed as macrodactyly simplex congenita. This was treated by epiphysial resection and osteosynthesis of the distal interphalangeal joint, longitudinal and transverse osteotomy of the phalanges, and soft tissue coverage using palmar proximal and dorsal distal flaps taken from the original oversised finger.

Endoscopic Trigger Finger Release: Surgical Technique.

Numerous surgical approaches have been described for treating patients suffering with stenosing tenosynovitis. The usual surgical descriptions differ mainly by the type of skin incision utilized. The goal of surgery is to completely release the A1 pulley, thereby allowing unimpeded motion of the flexor tendons. We describe a minimally invasive endoscopic technique to address this condition in the fingers.

Results of the Volar Approach in Proximal Interphalangeal Joint Arthroplasty.

BACKGROUND: Most hand surgeons use a dorsal approach for proximal interphalangeal (PIP) joint implant arthroplasty. However, a volar approach offers the advantage of no disturbance to the extensor mechanism, thus allowing early initiation of active range of motion. We examined our results in patients who underwent PIP joint arthroplasty via a volar approach. METHODS: Using a retrospective chart review, we evaluated the outcomes of patients undergoing PIP joint arthroplasty through a volar approach between 2001 and 2005 by 3 fellowship-trained hand surgeons at our institution. The indication for surgery was PIP joint pain with radiographic evidence of joint destruction. Variables included implant type, diagnosis, affected digit(s), preoperative and postoperative range of motion, and complications. Hand therapy was initiated on postoperative day 3 or 4. RESULTS: Over the 5 years, 25 PIP joints were replaced in 18 women and 2 men with the volar approach. Replacements consisted of 14 surface replacement prostheses, 9 pyrocarbon prostheses, and 2 silicone prostheses. The average age of patients at prosthesis implantation was 64 years (range, 39-75 years). Prostheses were placed in 1 index, 12 long, 7 ring, and 5 small digits. Average follow-up period was 33 months (range, 24-69 months). Preoperative diagnoses were osteoarthritis (14), rheumatoid arthritis (4), and posttraumatic arthritis (2). Preoperative total arc of motion averaged 42° (range, 0° extension to 80° flexion); postoperative total arc of motion averaged 56° (range, -10° extension to 90° flexion). Complications comprised 1 swan neck deformity, 1 deep infection, 1 dislocation (early), and 2 loose implants with flexion contractures. Seventeen patients had minimal or no pain at their last follow-up visit. CONCLUSIONS: PIP joint arthroplasty can be successfully implemented through a volar approach with various implant types and has outcomes similiar to the published results of the dorsal approach.

Prevalence of pulmonary embolism after total elbow arthroplasty.

BACKGROUND: Although numerous articles have addressed the risk of pulmonary embolism following total knee and total hip arthroplasty, we were unable to find comparable information for the risk following elbow arthroplasty. We therefore sought to determine the prevalence of pulmonary embolism after total elbow arthroplasty. METHODS: We conducted a retrospective review of the medical records of consecutive patients who had undergone primary elbow arthroplasty (816 procedures) or revision total elbow arthroplasty (260 procedures) at our tertiary-care academic medical institution between June 1981 and June 2001. Our purpose was to identify all patients in whom a pulmonary embolism developed after the surgery. RESULTS: Three patients had a pulmonary embolism and one died as a result of the complication during the twenty-year study period. Because of a low index of suspicion, the presenting symptoms of the pulmonary embolus were originally attributed to other causes of respiratory distress in two of the three patients. CONCLUSIONS: These findings suggest that pulmonary embolism after total elbow arthroplasty is a rare but potentially fatal complication. Surgeons should consider this diagnosis when a patient exhibits respiratory distress after total elbow arthroplasty.

Motor and Sensory Cortical Changes after Contralateral Cervical Seventh Nerve Root (CC7) Transfer in Patients with Brachial Plexus Injuries.

BACKGROUND: Previous animal studies demonstrated that the sensory and motor functions in ipsilesional upper limbs that had been reconstructed by CC7 transfer eventually associated with the contralesional brain cortices that had originally mediated the functions of the ipsilesional upper limbs before brachial plexus injury (BPI). Our hypothesis was that the same findings would be seen in humans. METHODS: Four patients with total BPI treated with CC7 transfer were included. Changes in the locations of the activated areas in the primary motor (M1) and somatosensory (S1) cortices corresponding to the motor outputs to and sensory inputs from the ipsilesional limbs were investigated using functional near-infrared spectroscopy (fNIRS) 2-3 years and 6-7 years after surgery. RESULTS: One patient was excluded from the evaluation of motor function after CC7 transfer. The motor and sensory functions of the ipsilesional upper limb in all patients were still controlled by the ipsilesional brain hemisphere 2-3 years after CC7 transfer. The reconstructed motions of the ipsilesional upper limbs correlated with the contralesional M1 in one patient and the bilateral M1s in another patient (both of whom demonstrated good motor recovery in the ipsilesional upper limbs) and with the ipsilesional M1 in a third patient with poor motor recovery in the ipsilesional upper limb. Sensory stimulation of the ipsilesional hands 6-7 years after CC7 transfer activated the contralesional S1 in two patients who achieved good sensory recovery in the ipsilesional hands but activated the ipsilesional S1 in the other two patients with poor sensory recovery of the ipsilesional hands. CONCLUSIONS: Transhemispheric transposition of the activated brain cortices associated with the recovery of motor and sensory functions of the ipsilesional upper limbs was seen in patients with CC7 transfer as has been reported for animal models of CC7 transfer.

High frequency of K-ras codon 12 mutations in bronchoalveolar lavage fluid of patients at high risk for second primary lung cancer.

A high frequency of K-ras mutations may indicate preneoplastic changes in the bronchial epithelium as a result of genotoxic injury. With the use of sensitive detection techniques, we report a higher prevalence of K-ras mutations in bronchoalveolar lavage than has been reported previously for lung cancer. A PCR/ligase chain reaction technique was used to determine K-ras codon 12 mutations in a group of 52 bronchoalveolar lavage specimens from patients at risk of a second lung cancer. Of the specimens examined, 84% contained at least one mutation in K-ras codon 12, corroborated by an allele-specific hybridization method. These results suggest that point mutations in K-ras codon 12 are widespread in the bronchial epithelium. Based on these preliminary findings, further evaluation of this efficient sensitive assay to monitor K-ras status should be conducted in larger clinical cohorts where clinical outcomes will ultimately be available. Such a trial will define the utility of K-ras codon 12 mutation status as a marker of lung cancer.

Extrusion of a NeuroTube: A Case Report.

BACKGROUND: Peripheral nerve injury is a common result of trauma. In cases of nerve gap, treatment may involve placement of a nerve conduit. This case involves a polyglycolic acid nerve conduit tube that was extruded through soft tissue. To our knowledge, this reactive process has only been previously documented in one article. This complication is not commonly known among hand surgeons, hence our interest in documenting it. CASE REPORT: We present the case of a 33-year-old male who injured his right nondominant thumb in a workplace saw accident. His complex wound involved the radial digital nerve, and the nerve was repaired using a polyglycolic acid nerve conduit. By postoperative week 4, part of the nerve conduit was extruding through the wound. No signs of infection were noted, and the remainder of his wounds had healed. The patient declined a nerve graft, so his wound was debrided with no further attempts at nerve repair. The wound healed uneventfully, and the patient returned to full duty without restrictions. CONCLUSION: We believe this is the first documented case of extrusion of a nerve conduit through healthy soft tissue. Recent advancements in nerve allografts and conduits hold promise but are not yet in widespread use. We recommend the use of a collagen conduit to avoid extrusion of polyglycolic acid-based materials.