Removal of a Portion the Dorsal Lip of the Radius during Proximal Row Carpectomy
Institution where the work was prepared: Siu Com, Springfield, IL, USA
D.S. Cooney, MD, PhD; N. Engineer; B. Wilhelmi
Southern Illinois University
Introduction Proximal row carpectomy (PRC) results in good range of motion and pain relief with a moderate loss of grip strength. After PRC, the proximal capitate articulates with the radio-scaphoid fossa. Intraoperative dynamics and cadaver dissections suggested that the dorsal rim of this surface may interfere with wrist extension following PRC. Therefore, the authors began resecting a portion of the dorsal lip of the radius during PRC.
Methods We retrospectively analyzed the results of 15 wrists treated consecutively with PRC modified by resection of the dorsal lip of the radio-scaphoid fossa. All surgeries were performed by a single surgeon between May 2001 and December 2004. Patients' ages ranged from 26 to 61, with a mean of 46.8 years; 7 of the patients were female, and 7 were male. Indication for the procedure was scapholunate advanced collapse (SLAC), SNAC, or Kien-bock's disease. Seven of the 15 patients had a history of trauma. Fourteen patients received PIN ablation and 12 underwent radial syloidectomy at the time of PRC. Follow-up ranged from 5 to 122 weeks, with a mean follow-up of 27.4 weeks.
Results Our experience with this modification of proximal row carpectomy has resulted in excellent reduction in pain and preservation of ROM. The results of testing after 20 weeks reveal an average wrist flexion of 39°, extension of 43°, and arc of 92°, and grip strength of 76% of the contralateral side. Key and pinch strengths were 85% and 90% of the contralateral side, respectively. Average radial and ulnar deviations were 11° and 25°, respectively. These results compare favorably with reports in the literature. Published reports of flexion-extension arcs ranged from 70° to 84°. Oddly, the increase noted in our patients' arc of flexion-extension came from flexion (31–36° in the literature) as opposed to extension (36–40° in the literature) as we had expected. Although any increase in ROM is welcome, further studies will be required to fully understand the biomechanical changes following proximal row carpectomy, with and without resection of the dorsal rim of the radius. Grip strengths and radial–ulnar deviation values from our patient population are within the range noted in the literature.
Autologous Iliac Crest Bone Graft Versus Demineralized Bone Matrix Allograft for Intercarpal Fusions
Institution where the work was prepared: Allegheny General Hospital, Pittsburgh, PA, USA
Nickolaos Darlis, MD, PhD1; Todd R. Wurth, MD2; S.M. Patel1; Robert A. Kaufmann, MD3; D.G Sotereanos1
1Allegheny General Hospital
2The Bone and Joint Clinic
3University of Pittsburgh Medical Center
Experimental studies on the osteoinductive properties of demineralized bone matrix (DBM) allografts have led to their widespread use in recent years. However, there are only a few clinical studies that compared DBM to the “gold standard” of iliac crest bone grafting (ICBG). A comparison of DBM to ICBG is presented in two groups of patients who underwent four-corner fusions of the wrist by the one surgeon using identical operating technique.
The senior author's first 10 consecutive patients in which DBM with a glycerol courier was used for four-corner fusion were compared with 10 patients selected from a total of 48 patients in whom ICBG was performed. The ICBG group was matched for age, indication, and healing impairing comorbidities (mainly smoking) to the DBM group. A series of radiographs from each patient consisting of the 8, 12, and 24 postoperative week follow-up were digitized and blinded. Three orthopedic surgeons who were not involved in patient care were asked to rate the degree of bony union in a scale of 0 (no evidence of healing) to 3 (solid bony healing). The operating technique included scaphoid removal, decortication of the midcarpal articular surfaces of the lunate, capitate, hamate, and triquetrum, and fixation with three K-wires in identical configuration. The mean age of patients was 37.8 years (range 25–50 years) for the DBM group and 40.2 years (range 25–55 years) for the ICBG group. Indications were either SLAC or SNAC wrist for all patients. There were two smokers in each group.
All patients had a minimum follow-up of 1 year. All fusions healed both radiographically and clinically without complications. In the retrospective review of the radiographs there was significantly less visible healing at 8 weeks in the DBM group (mean score 1.47 versus 1.73 of the ICBG group, p < .05). Lower scores were also obtained for the DBM group at 12 and 24 weeks but they did not reach statistical significance.
In this study, DBM and ICBG were equally effective in achieving solid bone union for intercarpal fusions. However, the radiographic appearance of bridging bone lagged behind in the DBM group. Such a delay may be significant in graft choice for patients with healing impairment.
Long-Term Outcome and Evaluation of the Radiolunate Joint Following Scaphoidectomy and Four-Corner Fusion
Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA
David G. Dennison, MD; Coen Wijdicks, BS; Steven L.
Moran, MD; Alexander Y. Shin, MD
Mayo Clinic
Purpose The effect of four-corner fusion and scaphoidectomy on the lunate fossa has not been well studied. The purpose of this study was to evaluate our experience with four-corner arthrodesis, specifically focusing at the development of radiolunate arthritis and functional outcome.
Methods A retrospective review was conducted on all patients who underwent a scaphoidectomy and four-corner arthrodesis between January 1974 and July 2002. The Disabilities of the Arm, Shoulder and Hand, Patient Rated Wrist Exam, and a questionnaire were sent to all surviving patients. Medical records and radiographs were reviewed. Type of fixation, carpal indices, arthritic changes in the radiolunate fossa, and complications were recorded. Statistical significance was set with an alpha less than or equal to 0.05.
Results A total of 177 procedures (170 patients) were reviewed. Average survey follow-up was 9.0 years. The average flexion-extension arc was 56°. Eighty-four percent of patients reported an improvement in pain. Grip strength was reported as the same or better in 61% of patients, and 77% of them returned to work. The type of fixation (k-wires, staples, circular plate) had no effect on union rate (p = 0.72). Thirty-eight percent of patients required at least one additional procedure. Progression of radiolunate arthritis was visible in 10.6% of radiographs; however, 70% of these patients required further surgery, but only one required total wrist arthrodesis. Overall, eight wrists required revision to a total wrist arthrodesis or arthroplasty and six of these occurred within 1 year from index surgery.
Conclusions Four-corner fusion provides a reliable solution for SLAC and SNAC arthritis with preservation of the radiolunate articulation and wrist function. The majority of revisions to total wrist arthrodesis occurred within 1 year from index surgery.
A Prospective Outcomes Study of Four-Corner Wrist Arthrodesis Using a Circular Limited Wrist Fusion Plate for Stage II Scapholunate Advanced Collapse Wrist Deformity
Institution where the work was prepared: University of Michigan, Ann Arbor, MI, USA
Michigan, Ann Arbor, MI, USA
Kevin Chung, MD, MS; AJ Watt; SV Kotsis
University of Michigan
Purpose Scapholunate advanced collapse (SLAC) wrist deformity is a common pattern of degenerative arthrosis of the wrist. This study prospectively evaluated a series of patients who underwent four-corner fusion via a circular plate internal fixation technique.
Methods Patients with symptomatic Stage II SLAC wrist deformity were treated with scaphoid excision and four-corner fusion using the Spider™ Limited Wrist Fusion Plate (KMI, San Diego, CA). Patients were prospectively evaluated at 6 months and 1 year with a standard study protocol with radiographs, functional tests, and an outcomes questionnaire.
Results Eleven patients were enrolled and 10 patients completed their 1-year follow-up. Grip strength, lateral pinch strength, and Jebsen–Taylor test scores at 1 year were not significantly different from preoperative values. Mean active range of motion was 87° preoperatively and 74° at 1 year follow-up (p = 0.19). The Michigan Hand Outcomes Questionnaire showed no significant improvement in function, activities of daily living, work, pain, or patient satisfaction. The mean pain scores decreased from 54 preoperatively to 42 one year postoperatively (p = 0.30), which indicated persistent wrist discomfort. Three patients had broken screws; one was asymptomatic, one required 3 months of strict wrist immobilization, and one was reoperated for symptomatic nonunion.
Conclusions Four-corner fusion using the first generation Spider™ plate technique has the advantage of earlier mobility and increased patient comfort from lack of protruding K-wires. Patients in this series, however, continued to have disabling pain, functional limitations, work impairment, and low satisfaction scores after this procedure. Although limited by a small patient sample, this series presents outcomes data that may be useful in counseling patients who are contemplating four-corner fusion using this internal fixation device. Further investigation is necessary to evaluate the biomechanical properties of the Spider™ plate. Our data suggest that better implants should be designed to avoid implant failure, which occurred in 3 out of the 11 patients in this series.
Modified Brunelli Procedure for the Treatment of Chronic Scapholunate Instability
Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA
Steven L. Moran, MD; Kerry Ford; Correy Wulf; William Cooney, MD
Mayo Clinic
Purpose The ideal treatment for chronic scapholunate (SL) instability is not yet established. Several soft tissue procedures have been described to limit scaphoid flexion in the hopes of preventing further rotary subluxation and the progression to radiocarpal arthritis. The modified Brunelli procedure utilizes the flexor carpi radialis, passed through the distal palmer scaphoid, and then attached to the dorsum of the lunate, as a means of limiting scaphoid rotation. We wished to examine our long-term results with the use of the modified Brunelli procedure.
Methods A retrospective chart review was conducted that examined all modified Brunelli procedures performed at our institution since 1995. Patient's wrist pain had to have been present for more than 3 months to be included in the study. Wrist motion and grip strength were compared to the normal wrist pre- and postoperatively. Radiographs were reviewed for changes in SL angle, SL diastasis, and radiolunate angle following surgery. Seventeen patients with a diagnosis of chronic scapholunate instability underwent a modified Brunelli procedure. Average patient age was 40 years, and pain had been present for an average of 20 months. Nine patients presented with static scapholunate instability and 8 presented with dynamic instability. Average follow-up was 22 months.
Results The flexion–extension arc decreased from 90% of the normal wrist preoperatively to 60% postoperatively. Radial and ulnar deviation remained stable at 88% before and after surgery. Grip strength also remained unchanged at 85% of normal following surgery. Pain was significantly improved in 77% of patients. Frank failures occurred in 2 patients in the static group, one due to infection requiring fusion and the second failure was due to persistent pain. There were no failures in the dynamic group. Average Mayo wrist score was 74, with 2 excellent, 5 good, 7 fair and 3 poor results. Follow-up films revealed evidence of radiocarpal arthritis in one patient and midcarpal arthritis in another. Abnormalities in scapholunate distasis were not consistently corrected by the surgery. Conclusion The modified Brunelli procedure provided improvement for patients with chronic SL instability. Although wrist motion was decreased, most of the patients experienced significant pain relief and were able to return to work. In selected patients the modified Brunelli procedure may provide a reliable alternative for the treatment of chronic scapholunate instability.
Arthritis
Report of Total Joint Replacement of the Pip Joint with a Pyrolitic Carbon Implant
Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA
Cesar J. Bravo, MD; Robert Beckenbaugh, MD; Kirsten Hormel, RN
Mayo Clinic
Purpose The purpose of this paper is to report preliminary patient outcomes and to review the surgical technique and postoperative therapy/splinting protocols with a new type of prosthetic implant for correction of arthritic disease of the proximal interphalangeal joint.
Methods Following FDA approval in March 2002, a 2-year consecutive series of 68 implants (136 components) in 43 patients have been performed. Of these patients, 17 had osteoarthritis, 11 had rheumatoid arthritis, and 15 presented with posttraumatic osteoarthritis. Preoperatively, pain was a significant factor, as well as decreased range of motion, deformity, and joint instability.
Results Preoperative range of motion averaged 40°, whereas postoperative range of motion averaged 52°. A total 6% of total components were loose at final follow-up. Nine implants subsided. Forty-two percent of the components implanted upon review slightly shifted from original position with bone remodeling, but were not loose. Eleven patients have required additional procedures to improve/ maintain joint motion/function from index procedure.
Conclusions Results for 6, 12, and 24 months follow-up are presented by using a pyrocarbon semiconstrained surface replacement arthroplasty. Reduction of pain, improved range of motion, and patient satisfaction are noted.
Excision of the Trapezium and Interposition Arthroplasty with Gelfoam for the Treatment of Trapezial Metacarpal Osteoarthritis
Institution where the work was prepared: Orthopedic Institute of Illinois, Peoria, IL, USA
Ronald E. Palmer, MD1; Yassine Kanaan, BS2
1Orthopedic Institute of Illinois
2University of Illinois College of Medicine at Peoria
Background Several approaches exist for trapeziometacarpal osteoarthritis. The most common procedure is the anchovie procedure where the trapezium is excised and a forearm tendon, usually the flexor carpi ulnaris, is sacrificed and interposed in place of the trapezium. Because the procedure requires the sacrifice of a tendon, we used a gelfoam for the treatment of trapeziometacarpal osteoarthritis to spare the tendon. To our knowledge, only one prior study was performed using the gelfoam technique on 35 patients in Israel.
Objective To examine the results of gelfoam interposition for the treatment of trapeziometacarpal osteoarthritis after excision of the trapezium on a sample of 139 patients.
Methods and Results Excision of the trapezium with gelfoam interposition was performed on 139 thumbs, which were evaluated on average after 2 months. The follow-up examination included a clinical evaluation and questionnaire. Pain relief was achieved in all cases. All patients were satisfied with their postoperative result. All patients achieved improved function and strength as measured by the following: thumb carpal–metacarpal extension and abduction; thumb opposition; grip strength; pinch tip; palmar pinch; and lateral pinch. The first web span did not atrophy after the procedure. No particular complications were noted.
Conclusion We feel gelfoam interposition is an effective alternative to the anchovie procedure with no particular complications or morbidity, while sparing the flexi carpi ulnaris.
Comparison of Trapeziometacarpal Joint Reconstruction by Alternate Methods of Tendon Arthroplasty
Institution where the work was prepared: Siu Com, Springfield, IL, USA
D.S. Cooney, MD, PhD; N. Engineer; B. Wilhelmi
Southern Illinois University
Introduction Arthritis of the carpo-metacarpal joint of the thumb is a common ailment that leads to debilitating pain, weakness, and disability when left untreated. Surgical treatment has included numerous techniques that have evolved over the years. The current study reviews the use of two such techniques by a single surgeon at our institution. These techniques are the Thompson suspensionplasty and the modified Weilby interposition arthroplasty.
Methods We retrospectively analyzed the results of 44 thumbs with follow-up ranging from 4 months to 3.54 years, with a mean follow-up of 1.46 years. A modification of the Weilby FCR suspensionplasty was performed in 25 cases and the Thompson APL sling arthroplasty in 19. All surgeries were performed by a single surgeon between October 2001 and December 2004. Patients' ages ranged from 43 to 79, with a mean of 57.2 years. Thirty-seven of the patients were female, and 7 were male. There were no significant differences in the technique used based on age, sex, or indication.
Results All patients had improvement in ROM at last follow-up, and 37 of 44 patients (84%) had complete resolution of pain at last follow-up. Time to resolution of symptoms and return to work were significantly shorter in the APL suspensionplasty group (14 and 10 weeks vs. 26 and 16 weeks). Results were significant with a p value of 0.004 and 0.029, respectively. Functional evaluation of grip, key, and pinch strength demonstrated return of more than 85% of the strength of the nonoperated side in 86% of patients at last follow-up. Average grip strength at more than 24 weeks was 97% on the contralateral side, with no significant difference between the two groups. Two patients failed treatment with the modified Weilby due to recurrent pain, and both were successfully treated with the Thompson technique. Two patients with bilateral disease were treated with both techniques, one on each side. Both stated that they preferred the Thompson side. Overall, both surgeries are excellent options for reconstruction of trapeziometacarpal arthritis. Both give full ROM and restoration of grip strength and resolution of pain in the majority of patients. However, in our experience, the Thompson technique is preferred by patients and results in faster recovery times.
MPJ Tenodesis for Swan-Neck Adduction Collapse Secondary to Thumb Basilar Joint Arthritis
Institution where the work was prepared: Baylor College of Medicine, Houston, TX, USA
Morgan Edward Norris, MD, DDS1; Salem Samra, BA1; Tuppen H. Bourianoff, PT, MOT, OTR, CH2; Jeffrey DeMercurio, MD1; David T Netscher, MD1
1Baylor College of Medicine
2Healthsouth Houston Hand Rehabilitation Center
Compensatory thumb metacarpophalangeal joint (MPJ) hyperextension may occur with basilar joint arthritis and subluxation. We have implemented a simple surgical procedure that provides correction of the thumb MPJ hyperextension problem through use of an anchored free palmaris longus tendon graft tenodesis volarly.
Purpose The purpose of this study is to report the results of thumb MPJ tenodesis for swan neck deformity, performed in conjunction with trapezial resection arthroplasty. We believe the MPJ tenodesis preserves range of motion and also promotes stability in cases where an arthrodesis might otherwise have been chosen.
Methods Twelve patients (14 extremities) were evaluated at a minimum of 11 months postoperatively (range 11–72 months). Outcome analysis was performed by using the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire, the McGill Pain Questionnaire (MPQ), and a patient satisfaction survey. Clinical assessments, performed by a certified hand therapist, evaluated thumb appearance, range of flexion and extension at the MPJ, opposition, span, cylindrical grip strength, and pinch strength. Special attention was devoted to the stability of the MPJ based on assessment of range of motion and strength.
Results The DASH questionnaire revealed an average score of 13.0 (indicating good return of function) and the McGill Pain Questionnaire revealed mild to no postoperative pain. Overall, patient satisfaction was high postoperatively. Eleven out of 14 responses indicated patients were very happy with their results, with the remaining three indicating patients were satisfied. In addition, 12 out of 14 responses indicated the operated thumb was stronger than preoperative condition, while two noted no change. Clinical assessment revealed good preservation of range of motion at the MPJ (-35 to 65° range of extension and flexion; mean extension 2°, mean flexion 44°). Assessment of thumb strength revealed mean tip pinch strength of 6.8 lb, mean key pinch strength of 8.7 lb, and mean chuck pinch strength of 8.2 lb. Firm thumb stability was maintained and demonstrated during the above measurements. There were no complications.
Conclusions Thumb MPJ tenodesis can be an alternative to arthrodesis in patients who have swan neck deformity of the thumb secondary to basilar joint arthritis. The procedure provides high patient satisfaction as well as good thumb function, strength, and range of motion. It is easily performed simultaneously with trapezial resection arthroplasty without complications.
Reasons Why Rheumatoid Arthritis Patients Seek Surgical Treatment for Hand Deformities
Institution where the work was prepared: University of Michigan, Ann Arbor, MI, USA
Kevin C. Chung, MD, MS1; Sandra V. Kotsis1; Hyungjin M. Kim1; Frank D. Burke, FRCS2; EF Shaw Wilgis, MD3
1University of Michigan,
2Pulvertaft Hand Centre,
3Raymond M. Curtis National Hand Center at the Union Memorial Hospital
Purpose Previous studies have found that function and pain are the main factors that persuade physicians to recommend surgical reconstruction to rheumatoid arthritis (RA) patients. However, the factors that influence patients to undergo surgical reconstruction are not fully known. The purpose of this study is to determine how function, pain, and aesthetics rank in order of importance to RA patients who are considering metacarpophalangeal (MCP) joint arthroplasty for rheumatoid hand deformities.
Methods Study participants were part of a larger National Institutes of Health sponsored study. Participants who were eligible to undergo MCP joint arthroplasty were enrolled into the study via defined inclusion and exclusion criteria. All patients had RA and MCP joint extensor lag and/or ulnar deviation. Study participants chose whether they wanted to enroll into a surgical group to undergo MCP joint arthroplasty or a nonsurgical group. At enrollment, all participants completed the Michigan Hand Outcomes Questionnaire (MHQ). Function, pain, and aesthetics domains from the MHQ were used in a logistic regression model as predictors to determine the factors associated with patients choosing reconstruction for rheumatoid hand deformities.
Results The sample consisted of 33 surgical patients and 28 nonsurgical patients. Younger age and female gender were significantly associated with increased likelihood of choosing MCP joint arthroplasty surgery. The age- and sex-adjusted odds ratio of choosing MCP joint arthroplasty was 0.50 (p = 0.001) for function, 1.47 for pain (p = 0.002), and 0.83 for aesthetics (p = 0.13). Patients with less function and greater pain were more likely to undergo MCP joint arthroplasty. Aesthetic consideration was not a statistically significant predictor.
Conclusions Impaired function had the strongest association with patients choosing reconstruction, while pain relief was the next most important factor. Although aesthetic consideration is less important, it may prove to be an important factor in determining patient satisfaction after surgery. Understanding patient expectations is an essential component of preoperative counseling for patients regarding surgical options for the rheumatoid hand.
Trauma
A New Capsular Based Vascularized Distal Radius Graft for Proximal Pole Scaphoid Pseudarthrosis
Institution where the work was prepared: Allegheny General Hospital, Pittsburgh, PA, USA
D.G. Sotereanos1; Nickolaos Darlis, MD, PhD1; Zoe H. Dailiana, MD2; K Malizos2
1Allegheny General Hospital
2University of Thessalia, Greece, School of Health Sciences
Pedicled or free vascularized bone grafts (VBGs) are established in the treatment of proximal pole scaphoid nonunions. Microsurgical dissection of the pedicle has been essential for all VBGs. A new distal radius VBG is described, from the floor of the fourth extensor compartment supported by a rectangular, distally based strip of dorsal capsule. Latex injection studies confirmed that vascularization of this graft is not random, but is based on the artery of the fourth extensor compartment. The pedicle of the artery is included in the capsule attached to the bone graft thus eliminating the need for microsurgical dissection.
Thirteen patients, mean age of 26.2 years (range 19–43 years) with nonunion of the proximal pole of the scaphoid were treated. The mean time from injury was 25 months (range 12–48 months) and the patients had no prior procedures. Ten of the patients were diagnosed with avascular necrosis of the proximal pole based on radiographic appearance and on the absence of punctuate bleeding intraoperatively. Through a dorsal approach, the VBG was harvested and the nonunion was debrided and fixed with a Herbert screw in 11 patients and with 2 K-wires in two. A longitudinal trough was then created across the nonunion site and the VBG was impacted. The procedure was supplemented by radial styloidectomy in three patients.
Mean follow-up was 19 months (range 12–40 months). Solid bony union was observed in 10 patients both radiographically and clinically after a mean of 12.6 weeks (range 6–23 weeks). Three patients had persistent nonunions (one fibrous union diagnosed by CT). The mean range of motion was 68° of extension to 55° of flexion with full pronosupination. None of the patients demonstrated progression of arthritic changes. No complications occurred.
The results from the use of a capsular-based VBG compare favorably to the results of pedicled VBGs for proximal pole scaphoid nonunions. Its advantages include a simple and time-sparing harvesting technique without the need for microsurgical dissection of the pedicle. No donor site morbidity was observed.
Arthroscopic Fixation and Percutaneous Bone Morphogenic Protein Injection of Cystic Scaphoid Nonunions—A New Technique
Institution where the work was prepared: University of Mississippi Medical Center, 2500 North State Street, MS, USA
William Geissler, MD
University of Mississippi Medical Center
Arthroscopic management and percutaneous reduction of acute scaphoid fractures has recently gained wide acceptance. Arthroscopic management of scaphoid nonunions is controversial. Recent reports of arthroscopic reduction and percutaneous fixation for stable fibrous nonunions of the scaphoid without bone grafting yielded a 100% success rate. However, the management of cystic scaphoid nonunions arthroscopically has not been previously reported. The purpose of the study was to evaluate the healing rate for arthroscopic stabilization and percutaneous injection of bone morphogenic protein for cystic scaphoid nonunions without a humpback deformity. Fifteen patients underwent arthroscopic fixation and percutaneous injection of bone morphogenic protein for cystic nonunions of the scaphoid. There were 14 males and one female. The average age was 21 years (range 15–29 years). A new arthroscopic technique is described. The arthroscope was placed in the 6-R portal and the proximal pole of the scaphoid was impaled with a 14-gauge needle right at the junction of the scapholunate interosseous ligament at the middle third of the proximal pole of the scaphoid. A new traction tower has been designed that can be flexed at its base. Fluoroscopic confirmation of the starting point was confirmed. The guide wire was then aimed toward the thumb and inserted into the scaphoid. The scaphoid is drilled with a cannulated drill. A cannulated putty pusher was inserted over the guide wire and 1 cm of bone morphogenic protein was inserted into the cystic nonunion site after being percutaneously curetted. A headless cannulated screw was placed. Cystic nonunions healed in 14 patients. Average time to union was 3 months (range 2–6 months). Average flexion was 60°, extension 50°, radial deviation 15°, and ulnar deviation 20°. The one patient with radiographic signs of a persistent fracture line had improved pain relief following the surgery. A new arthroscopic technique was developed to reproduce reliably and simplify the starting point for insertion of a cannulated screw in the proximal pole of the scaphoid to stabilize the fracture. Arthroscopic evaluation of the wrist postinjection, both of the radial carpal and midcarpal space, showed no leakage of the bone morphogenic protein into the joint. Use of bone morphogenic protein yielded a high success rate for cystic scaphoid nonunions and avoided increased surgical morbidity of bone graft harvest either from the distal radius or the iliac crest.
A Cine-MRI Study on Dynamic Changes of the Triangular FIbrocartilage Complex during Radioulnar Deviation
Institution where the work was prepared: Department of Orthopaedic Surgery, School of Medicine, Keio Univ, Tokyo, Japan
Purpose Changes in shape of the triangular fibrocartilage complex (TFCC) during radial–ulnar deviation were studied by using cine-mode MRI.
Materials and Methods We examined 10 right wrists of healthy volunteers: five wrists of traumatic TFCC tear and five wrists of nonunion of ulnar styloid process. The wrist was fixed in a custom acrylic device, which only allows radial and ulnar deviation. Coronal MR images of nine radial–ulnar deviated positions (every 5° from 15° radial deviation to 25° ulnar deviation) were obtained by using a 1.0-Tesla superconductive MR device. Three serial coronal slices with thickness of 1 mm and slice gap of 1 mm were scanned at middle coronal plane of the wrist in each position. Three different pulse sequences of fast spin echo (SE) T1weighted (TR 150 ms, TE 18 ms), fast SE T2-weighted (TR 3000, TE 125), and fat-suppression fast SE T1-weighted (TR 200, TE 18) images were compared. Field of view (FOV) of 16 cm, matrix of 256 × 256, repetition of 2 times were used. Acquisition time was 8–10 s for one position and total imaging time was 90 s for whole positions. Cine-mode MRI was assembled and output to video.
Results The TFCC was delineated as a low-intensity structure between the carpus, radius and ulna in all three sequences. Due to contrast with the joint cartilage, the TFCC was delineated best on fat suppression MRI. Cine-MRI demonstrated the lunate rotated approximately 22° around the capitate during radial–ulnar deviation. The ulnar side of the TFCC (the so-called meniscus homolog and ulnar collateral ligament) was elongated by 15 mm at maximum radial deviation and compressed by 8 mm at maximum ulnar deviation. The changes in shape of the fibrocartilaginous disk were very small during radial–ulnar deviation in 10 healthy volunteers and in two patients with radial slit tear of the TFCC. In contrast, the wavy deformities on the disk in ulnar deviation were observed in three patients with horizontal tear or foveal detachment of the TFCC. In two patients of ulnar styloid nonunion, snapping of the ununited fragment was demonstrated at maximum ulnar deviated position. In the other three patients, elongation between the ulnar styloid fragment and ulnar head was seen in radial deviation.
Conclusion These findings suggest that the abnormal dynamic changes of the TFCC may be seen in maximum ulnar deviated position, which are related to positive ulnocarpal stress test with the wrist forced ulnar deviation.
Functional Outcome after Minimal Invasive Screw Fixation and Early Mobilization of Acute Scaphoid Fractures in the Middle Third
Institution where the work was prepared: Department of Hand, Plastic and Reconstructive Surgery, Ludwigshafen, Germany
Miriam Mueller, MD; Kai Megerle, MD; Günter Germann, MD, PhD; Michael Sauerbier, MD, PhD
Heidelberg University
Differentiation between stable and unstable fractures cannot always be precisely assessed with conventional X-rays and thus should be additionally evaluated by CT scan with sagittal cuts parallel to the scaphoid axis. Based on these findings, unstable fractures (Herbert B1, B2) can be operatively stabilized to speed up the healing process, thereby avoiding prolonged immobilization. Minimal invasive surgery with cannulated screws is currently the treatment of choice under most circumstances. A cast immobilization is not necessary, when using this surgical technique.
In this retrospective study, bony consolidation as well as bilateral measurement of grip strength, active range of motion and subjective outcome data are analyzed. Assessment included AROM, grip strength measurement (JAMAR), and a DASH questionnaire. Forty-five patients with acute scaphoid fractures were treated with minimal invasive screw fixation (HBS, Martin Medizintechnik, Tuttlingen, Germany) in our department between February 2001 and June 2004. All patients received a CT scan for fracture classification. Prior to surgery, the average patient age was 25 years; 40 of 45 patients were men. Full range of motion and full activity were noted 6 weeks postoperatively. Bone consolidation was found in 44 cases, and one patient required reosteosyntesis. The average grip strength after 6 weeks was 90% of the contralateral hand. The DASH score was 7.35 points. The results demonstrate that minimal invasive screw fixation of the scaphoid leads to satisfying functional outcomes. Due to early mobilization, patients were highly pleased to attain full function and were able to return to work early. We also offer this technique to patients with stable scaphoid fractures (Herbert A2) with the advantage of early mobilization and reintegration into ADLxs. As compared with conservative treatment, the perspective of early return to daily activities and/or sports activities leaves patients very satisfied.
Open Reduction and Internal Fixation of Acute Scaphoid Fractures via a Limited Dorsal Approach
Institution where the work was prepared: University of Michigan Medical Center, Ann Arbor, MI, USA
Asheesh Bedi, MD; Radford Hayden, PA; Martin K. Gelbke, MD; Peter J.L. Jebson, MD
University of Michigan
Objective To evaluate the clinical and radiographic outcome of a consecutive series of patients who underwent ORIF of acute scaphoid fracture via a limited dorsal approach.
Summary of Background Data ORIF of scaphoid fractures can be challenging secondary to the complex anatomy of the scaphoid, its extensive articular surface, and its tenuous blood supply. Regardless of the selected surgical approach, clinical and biomechanical studies have demonstrated the importance of central screw placement with fixation of these fractures. Recent cadaveric studies have demonstrated more reliable and accurate central screw placement with a dorsal approach.
Methods Between 2000 and 2005, 19 patients underwent ORIF of an acute, scaphoid fracture; these procedures were performed by a single surgeon. Indications for surgery were an acute, unstable fracture in 17 cases and a delayed primary diagnosis (>4 weeks) in two cases. Each fracture was classified by using the modified Herbert system. An open, limited dorsal approach was utilized, and fracture fixation achieved with a headless Accutrak (Acumed, Beaverton, OR, USA) compression screw in all cases. Patients were followed postoperatively until clinical and radiographic union was confirmed. DASH score, visual analog pain score, grip strength, wrist range-of-motion, and plain radiographs were obtained at the final visit. Radiographs were evaluated in a blinded fashion to assess fracture union, screw position, the presence of avascular necrosis, or hardware failure.
Results Eighteen males and 1 female, with age ranging from 16 to 32 years (mean 21.1 years), were included in the study. One patient was lost to follow-up and excluded. Thirteen B2 and five B3 fracture patterns were noted. All patients progressed to radiographic union without complication or the need for a secondary procedure. Mean duration to radiographic union was 9.3 weeks. Central-third screw position, as defined by Trumble et al., was confirmed in 17 of 18 cases. No cases of proximal pole AVN or hardware failure were noted. DASH scores and visual analog pain analysis revealed a high degree of patient satisfaction and minimal morbidity. Seventeen patients were satisfied and returned to their usual activities without restrictions. No patient complained of incisional hypersensitivity.
Conclusions ORIF of an acute scaphoid fracture via a limited dorsal approach is safe and effective. The technique does not violate the palmar radiocarpal ligaments and the limited exposure avoids injury to the critical dorsal vasculature. The limited dorsal approach allows reliable and accurate screw insertion in the central axis of the scaphoid, which is biomechanically advantageous and permits reliable healing with minimal morbidity.
AAHS Concurrent Scientific Paper Session A-2
Hand
Factors Affecting Efficiency and Patient Satisfaction in Hand Surgery Clinics
Institution where the work was prepared: University of Pittsburgh, Pittsburgh, PA, USA
Frederick G. Weniger1; Nikola Zivaljevic, MD, MBA, MHA2; Jason R. Dudas, BA1; W.P Andrew Lee1; Joseph E. Imbriglia1
1University of Pittsburgh,
2Hand and Upper Extremity Center
Introduction Cost and access have been cited as the main problems with health care today. By maximizing efficiency, both issues are addressed, but it is essential to preserve patient satisfaction, as physicians depend on patients' recommendation to maintain practice volume. Improving efficiency in the clinical setting is a desirable approach to health-care cost control, because it empowers physicians, rather than governmental agencies or insurance carriers, to determine practice growth. The purposes of this study were to determine which aspects of hand surgery clinics are predictors of efficiency, what contributes to patient satisfaction, and how efficiency affects patient satisfaction.
Methods Two data sets were collected: (1) physician efficiency data and (2) patient satisfaction data. Indices of physician efficiency were evaluated and scored by an observer. Patient flow through the clinic was also calculated. Linear regression was performed between physician scores and patient flow to determine which efficiency indices predicted patient flow. Patients completed satisfaction surveys, including likelihood to recommend the physician. Each survey item was regressed with the likelihood to recommend, in order to determine which aspects of the clinic visit predicted overall patient satisfaction. Finally, the patient flow was regressed with likelihood to recommend, so as to correlate efficiency and patient satisfaction.
Results There was a statistically significant inverse relationship between time spent on administrative tasks and patient flow (R2 = 0.73; p = 0.031), as well as a positive relationship between clinic preparedness and patient flow (R2 = 0.87; p = 0.006). Among satisfaction survey items, only overall experience with the physician was statistically significantly related to likelihood to recommend (R2 = 0.94; p = 0.001). Finally, patient flow and likelihood to recommend also exhibited a statistically significant positive relationship (R2 = 0.87; p = 0.021).
Conclusion We have identified aspects of hand surgery clinics that are predictive of their efficiency: time spent on administrative tasks and clinic preparedness. Overall, experience with the physician is most predictive of patient recommendation. Even when time spent with the patient is relatively brief, as is often necessitated, a physician can still provide an encounter of high quality with which the patient will be satisfied. In fact, our data indicate that patients not only tolerate, but prefer, an efficient clinic experience. It is possible that these findings are unique to a problem-focused specialty clinic, such as hand surgery. Nonetheless, efficiency and patient satisfaction are applicable to all areas of medicine.
Utility Measurement in Upper Extremity Disorders
Institution where the work was prepared: School of Public Health, University of Louisville, Louisville, KY, USA
Steven J. McCabe, MD, MSc; A. Scott LaJoie, PhD, MSPH; J Myers; A Tregaskiss; A Goodwin; Bart Brown;
University of Louisville
Purpose Clinical problems of the upper extremity are common and cause significant disability. In spite of this, there is very little published literature on utility measurement in patients with upper extremity pathology or injury. Most of these problems will have utilities close to 1.0, which may present difficulties with utility measurement. We present our overall experience in measuring utilities in upper extremity problems.
Methods We measured the utility by using the Visual Analogue Scale (VAS) and various forms of the Standard Gamble (SG) in surrogates and patients with upper extremity problems including Carpal Tunnel Syndrome (CTS), basal joint arthritis, and fracture of the distal radius. We measured the relationship of disease severity to utility by comparing scores with health status measures such as the carpal tunnel disease-specific instrument and the Disabilities of the Arm Shoulder and Hand (DASH) where appropriate.
Results Using the SG, we found the utilities associated with upper extremity pathology to lie between 0.9 and 1.0 on a scale of 0 to 1. For example, the average utility of CTS was found to be 0.97, and the most severe form of median nerve dysfunction 0.93. The VAS consistently yielded lower utility ratings than the SG. Patients most often provided higher utility ratings than surrogates. While the SG and VAS utilities both correlated with symptom severity measures in CTS patients, only the VAS correlated with a disability score in basal joint arthritis patients. Most patients who had experienced a distal radius fracture were not willing to gamble, providing utility estimates of 1.0 with the SG, but 0.808 with the VAS. The chained version of the paper SG was found to be a useful method to expand the upper end of the utility scale to discriminate within a pathologic entity.
Conclusion Through our experiences at measuring utility close to 1.0, we recommend the chained version of the paper form of the standard gamble as an efficient method to perform these measurements in conjunction with the VAS in a clinical population or in surrogates. Our results and experience will help the clinical researcher to embark on utility measurement for conditions with utilities close to 1.0 and are directly applicable to decision analysis and economic analysis for upper extremity pathology.
What Does 3D Computer Modeling of Muscle Offer Hand Surgeons?
Institution where the work was prepared: University of Toronto, Toronto, ON, Canada
Nancy H. McKee, MD; Karan S. Singh, PhD; Winnie Tsang, MSc; Anne M. Agur, PhD
University of Toronto
Digitization in 3D of muscle anatomical details and clinical 3D imaging can lead to creation of anatomically accurate 3D computer modeling of the functioning 42 muscles of the hand and forearm. The authors have created an interactive, anatomically based 3D computer model of the hand and forearm with 42 muscles capable of creating unconstrained joint movements. This is an example of but one of the dynamic optimization models that have been created by different teams to explore body movements. How can hand surgeons use these capabilities? The following is an exploration of possibilities. Video examples of some will be presented. (1) Gesturing—improving our understanding and ability to document deficits. Exploration of hypotheses: For example, the “inability” to gesture is not just a lack of input to create a movement but frequently represents excess input to some muscles to maintain a lack of movement. This can be explored with the model and with clinical tools such as EMG and ultrasound (US) as well as image motion capture. (2) Coordination/discoordination exploration. While dystonia is diagnosed relatively rarely, its components of central nervous system alterations and peripheral manifestations are probably present in many frustrating situations where a patient struggles “excessively” and abnormally to achieve a given movement. (3) Nerve and/or tendon and/or muscle injury exploration. For example, image motion capture could study patients with a specific nerve injury at a specific level (e.g., ulnar nerve above the elbow) and create data about the limits and range of unconstrained movements with such an injury. The computer model can be set up to create lack of stimulation to the appropriate muscles and asked to demonstrate how other muscles achieve specific unconstrained movements of the joints. (4) Reconstructive and therapeutic intervention analysis. For example, (a) tendon transfers and free functioning muscle operations could be planned and explored on a model that mimicked the deficit of an individual patient (via integrated use of data mining of image motion capture data); (b) therapeutic modalities of integrating muscle function—relaxation and contraction—could be better focused on the individuals clinical problems; (5) educational tools: videos, websites can be created to demonstrate the function of the muscles that create wrist and finger movement.
This model will benefit from refinements. The challenges are many but the benefits are numerous. Creative ingenuity on many fronts is advancing the capabilities and applications of computer modeling.
Epinephrine in Hand and Finger Surgery
Institution where the work was prepared: SIU COM, Spingfield, IL, USA
Purpose The purpose of this study was to expand our investigation since our prior reports on the use of epinephrine in the hand and finger by examining a larger number of patients to further elucidate the complication risk of epinephrine with local anesthesia in procedures involving the hand and finger.
Methods This is a retrospective review on the use of epinephrine for 1,556 hand and finger procedures performed over 5 years. Epinephrine was not used for replant or revascularization procedures or in patients with peripheral vascular disease.
Results Epinephrine was used in conjunction with local anesthetic for 1,111 finger and 445 hand procedures. Of these 1,391 patients, 875 were men and 516 were women with an average age of 41 years. There were no cases of digital gangrene or other complications solely attributed to the use of epinephrine in the hand or finger.
Conclusion In this review on the use of epinephrine in hand and finger surgery, no patients went on to develop digital gangrene.
Randomized Double Blinded Comparison of Duration of Anesthesia between Three Commonly used Agents in Digital Nerve Block
Institution where the work was prepared: Queen Elizabeth II Health Sciences Centre, New Halifax Infirmary, Halifax, Canada
Christopher J. Thomson, MD; Donald H. Lalonde
Dalhousie University
Background Three local anesthetics are commonly employed for digital nerve block; 2% lidocaine with 1:100,000 epinephrine, 2% lidocaine, and 0.5% bupivicaine. We have not identified a study that has compared these three agents in digital nerve block in a randomized fashion. The goal of this study was to determine which of the three agents provided the longest duration of digital nerve blockade.
Methods Thirty volunteers had the long finger of each hand along with one of their small fingers anesthetized with one of the above agents, respectively. The local anesthetic agent to be used in each finger was randomized. A double-blind design was employed. Volunteers reported the time that each of their fingers returned to normal sensation at the tip. An ANOVA was used to detect significant differences between the three groups and subsequent pairwise comparisons were performed with post-hoc Tukey tests. Bonferroni corrections were employed to account for multiple comparisons. We also calculated the 95% confidence intervals surrounding each mean.
Results The duration of anesthesia was as follows: 0.5% bupivicaine (mean = 24.9 h), 2% lidocaine with epinephrine (1:100,000) (mean = 10.4 h), 2% lidocaine (mean = 4.9 h). In both the Bonferroni and Tukey tests, all three agents provided significantly different durations of digital nerve blockade (p = 0.01).
Conclusions Bupivicaine (0.5%) provides significantly longer digital anesthesia than 2% lidocaine with epinephrine (1:100,000), which in turn provides longer anesthesia than 2% lidocaine.
Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA
Umar Hasan Choudry, MD; Steven L. Moran; William P. Cooney, MD
Mayo Clinic
We present our experience with children (up to age 16 years) presenting to the Mayo Clinic with CTS from 1974 to 2005. Thirty-two patients were diagnosed with CTS, either on history or nerve conduction tests (NCT) and electromyography (EMG). There were 21 females (66%) and 11 males (34%), with a mean age of 14 years (range: 5–16 years). Twenty (63%) complained of bilateral symptoms. The presenting symptoms were numbness (n = 25, 63%), pain (n = 15, 47%), paresthesias (n = 8, 25%), and weakness-clumsiness (n = 4, 13%). The etiologies for the CTS were overuse syndrome (n = 14, 44%), genetic conditions (n = 8, 25%), familial CTS (n = 5, 16%), trauma in = 4, 13%), and ganglion cyst (n = 1, 3%).
Among the overuse syndrome patients, 7 (50%) had bilateral symptoms, 12 (86%) had positive findings on nerve irritation tests (Tinnel's, Phalen's, and carpal compression tests), no patient had thenar wasting, and only 2 patients (14%) had decrease in 2-point discrimination (2-pd). Ten (71%) underwent NCT/EMG, with 4 (40%) NCT and 1 (10%) EMG being abnormal. Eleven (79%) had resolution of symptoms with splint or injections, with only 2 (14%) requiring surgery. The genetic causes for CTS were Mucolipidosis Type III (n = 2), Hurler Syndrome (n = 1), Multiple Epiphyseal Dysplasia (n = 1), Albright Syndrome (n = 1), Juvenile Rheumatoid Arthritis (n = 1), Myasthenia Gravis variant (n = 1), and Klippel–Trenauny–Weber Syndrome (n = 1). Among these patients, all 8 (100%) had bilateral symptoms, 2 (25%) had positive nerve irritation tests, 4 (50%) had thenar wasting, and 6 (75%) had decreased 2-pd on examination. All (100%) had NCT/ EMG, with 5 (63%) NCT as well as EMG being abnormal. Six (75%) had improvement of symptoms with surgery after failing conservative management.
Among the familial cases of CTS, all 5 (100%) had bilateral symptoms, positive nerve irritation tests and decrease in 2-pd on examination. However, only 1 (20%) had thenar wasting. All patients had abnormal NCT and EMG. Due to loss of follow-up, no conclusion on therapy could be ascertained.
All (100%) posttraumatic CTS patients exhibited unilateral symptoms, the same side as their injury, 3 (75%) had abnormal nerve irritation tests, 1 (25%) had thenar wasting, and 2 (50%) had abnormal 2-pd. The only NCT performed was abnormal; however, the EMG was normal. Three (75%) had complete resolution with surgery and 1 (25%) with steroid injection. The intracarpal ganglion cyst caused unilateral symptoms, with positive nerve irritation tests; however, the objective 2-point discrimination and thenar muscle mass were normal. Removal of the cyst was curative.
Fourteen-Year Follow-Up of the Distal Single Incision Scope Assisted Carpal Tunnel Release
Institution where the work was prepared: Ather Mirza M. D., Smithtown, NY, USA
Ather Mirza, MD; Mary Kate Reinhart, CNP; Ather Mirza, MD
Introduction This study reports the 14-year follow-up study on scope-assisted carpal tunnel release using the distal single incision technique.
Methods This technique of CTR has been performed on 1,855 cases since 1991. A 1.5-cm longitudinal distal single incision in the palm allows for direct visualization of the distal edge of the transverse carpal ligament, median nerve, abnormal structures (aberrant motor branch variants and communication branch of the ulnar nerve), and the superficial palmar arch. A specially designed knife/sleeve unit mounted on a standard 4-mm endoscope allows for division of the transverse carpal ligament with a distal-to-proximal pass. The interthenar fascia is usually preserved.
Results Postoperative pinch and grip strengths were near or greater than the preoperative level by 8 weeks. Patients whose interthenar fascia were preserved had lateral pinch strengths significantly higher postoperatively compared to patients who did not have an intact interthenar fascia. Mean overall return to work was 21 days. Twenty-seven percent of patients required no postoperative analgesics, with minimal scar, ulnar pillar, and radial pillar tenderness. There were no permanent neurovascular injuries to the median nerve or superficial palmar arch.
Discussion and Conclusion This technique allows for a small cosmetically appealing scar and direct identification of key anatomy. Patients have less loss of strength and function in the early postoperative periods and an overall early return to work and full activities. This technique has shown good long- and short-term results.
The Scratch Collapse Test for Carpal and Cubital Tunnel Syndrome
Institution where the work was prepared: Washington University in St. Louis School of Medicine, St. Louis, MO, American Samoa
Brendan Patterson, BS; Christine Cheng; Susan E. Mackinnon
Washington University in St. Louis School of Medicine
Purpose This prospective study evaluated the clinical usefulness of a new provocative test for carpal and cubital tunnel syndrome.
Methods A total of 135 patients (63 males, 72 females) and 108 controls (47 males, 61 females) were evaluated for carpal syndrome and/or cubital tunnel syndrome (98 patients were evaluated for carpal tunnel syndrome and 54 patients for cubital tunnel syndrome). Electrodiagnostic studies confirmed the diagnosis. Provocative tests included Tinel's sign, Phalen's test, elbow flexion, and a new test, the Scratch Collapse Test. This test involves scratching over the carpal or cubital tunnel syndrome and then testing for reflex weakness in external rotation of the arm.
Results The mean age of the group with carpal tunnel was 51.6 years; cubital tunnel (50 years); and the control group (52.3 years). In the control group, scratch collapse testing, Tinel's sign, Phalen's test, or elbow flexion was rarely positive. In 157 extremities with carpal tunnel syndrome, 122 had a positive scratch collapse test, 62 positive Tinel's sign, and 80 positive Phalen's test. In 79 extremities with cubital tunnel syndrome, 62 had a positive scratch collapse test, 46 positive Tinel's sign, and 42 positive elbow flexion. Sensitivity of the scratch collapse test in subjects with carpal tunnel syndrome was 0.82, Tinel's sign 0.38, and Phalen's test 0.53. Subjects with cubital tunnel syndrome sensitivities were as follows: scratch collapse test 0.80, Tinel's sign 0.64, and elbow flexion 0.56.
Conclusion The scratch collapse test is a useful provocative test to evaluate patients for carpal tunnel and cubital tunnel syndromes.
Anatomic Relationship Among Median Nerve Thenar Branch, Superficial Palmar Arch and Transverse Carpal Ligament
Institution where the work was prepared: University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Justin Michael Sacks, MD; Yur-Ren Kuo; Kia McLean; Ronit Wollstein; W.P Andrew Lee
University of Pittsburgh Medical Center
Complications from open, limited incision or endoscopic carpal tunnel release (CTR) are at times related to the transection of the thenar branch of the median nerve (TBMN) or the superficial palmar arch (SPA). Knowledge of the anatomy of these structures in relationship to the transverse carpal ligament is critical. We investigated these anatomical relationships by using cadaveric dissections to provide information that could be used by surgeons to minimize potential complications when operating in this region of the hand. Forty-eight fresh cadaver hands were analyzed in this study. Skin flaps were designed by intersecting Kaplan's cardinal line and a longitudinal line from the third web space along the course of the ring finger to the distal wrist crease. Skin flaps were elevated to expose neurovascular structures. Measurements included (1) distance between the distal transverse carpal ligament (DTCL) and the SPA, (2) distance between the DTCL and the origin of the TBMN, and (3) length of the transverse carpal ligament all using the longitudinal line from the third web space as a reference point. Distances were measured in millimeters and obtained with calipers using 2.5x loupe magnification. The thenar branches of the median nerve were extraligamentous in 44/48 (92%) and transligamentous in 4/48 (8%) specimens. The TBMN contained one branch in 28/48 (58%) and multiple branches in 20/48 (42%) specimens. The average distance from the DTCL to the SPA was 18.8 ± 0.6 mm (95% CI: 17.6–20.0 mm). The average distance from the DTCL to the TBN was 6.9 ± 0.4 mm (95% CI: 6.5–7.3 mm). The average distance of the TCL was 28.5 ± 0.8 (95% CI: 26.9–30.1 mm). Critical neurovascular structures lie in close proximity to the TCL, and are liable for injury during CTR. Thus, knowledge of these special anatomical relationships would help the clinician avoid complications regardless of the method of CTR.
Acute Compression Neuropathy of the Median Nerve in the Wrist and Forearm Following Trauma
Institution where the work was prepared: Wayne State University, Detroit, MI, USA
Wayne State University
A rise in the interstitial pressure within a compartment above the critical threshold pressure causes hypoxia of the nerves within the compartment. This leads to symptoms of compression neuropathy. Acute and chronic carpal tunnel syndrome is the most commonly described compression neuropathy of a peripheral nerve.
Over a 3-year period, 15 patients were treated with symptoms suggestive of acute median nerve neuropathy. This included seven isolated burns to hand and forearm, foreign body in the wrist or forearm, one thrombosed median artery, one gunshot wound of the forearm, and three patients with crush injury. There were two women in this group. The etiology of the burn injuries included contact burns (2), electrical burns (1), fire cracker (1) and flame burns (3). The mean surface area of burn was 4% (range 0.5–10%).
All patients presented within 12 h of their injury except for the patient with the foreign body in the forearm. The symptoms were slow onset of numbness over the median nerve distribution and excruciating pain on passive stretch of the fingers. Diagnosis was made from clinical findings, compartment pressures, and radiographs were carried out in patients to rule out any fractures. Nerve conduction studies were not routinely carried out.
Early decompression of the compartment with excision of burns in burn patients and removal of foreign body in two patients. At the time of decompression, the median nerve was found to be congested with edema fluid within the carpal tunnel in burn patients. Burn patients either underwent skin grafting or flap coverage at the time of decompression or the following day. All patients were followed up clinically by two-point discrimination and by nerve conduction studies postoperatively.
Acute compression neuropathy seem to occur in trauma patients. The compartment pressures were unreliable in burn patients. There was clinical evidence of increased compartmental pressures in all patients. Early decompression resulted in good clinical recovery in most patients. Patients with electrical injury had the slowest clinically recovery probably from the conduction defect from the injury.
American Association for Hand Surgery
Concurrent Scientific Paper Session A-2
“High Definition” 3D Imaging of Mechanoreceptors in Dorsal Radiocarpal Ligament of Human Wrist: A Basis for New Classification
Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA
Kazunari Tomita, MD1; Richard A. Berger, MD, PhD2; Evelyn J. Berger1; Kai-Nan An, PhD1
1Orthopedic Biomechanics Laboratory
2Mayo Clinic
Purpose Among the conventional staining methods, silver or gold chloride staining with light microscopy has been mostly used in the studies of the mechanoreceptor to date. Freeman and Wyke developed the first classification scheme that has become the standard for categorizing mechanoreceptors. However, the specificity and resolution of this technique has made interpretation and classifications of mechanoreceptors suspect and has been limited to 2D analysis. Utilizing a new protocol of nerve-specific fluorescent immunohistochemistry and confocal laser microscopy, we have observed a quantum leap in the analysis of joint mechanoreceptors. With three-dimensional information available, we are seeing a large number of receptors that defy the Freeman and Wyke scheme, thus pressing a review and possible revision of current mechanoreceptor classifications. This study reports “high-definition” three-dimensional characteristics of mechanoreceptors found in the human dorsal radiocarpal ligament.
Methods Twenty dorsal radiocarpal (DRC) ligaments were harvested from 10 fresh cadavers (5 males, 5 females; average age 75.3 years). The tissues were fixed, serially sectioned with a cryostat at 50 μm, collected on glass slides, then processed for fluorescence immunohistochemistry by using antibody to protein gene product 9.5 (PGP9.5), followed by a secondary antibody conjugated to a fluorescent tag (Alexa Fluor 488). Sections were evaluated with an LSM-510 confocal laser microscope and a Kontron KS 400 image analyzer. Labeled mechanoreceptors were mapped, measured, and categorized.
Results A total of 202 mechanoreceptors were found in the 20 DRC ligaments. Many mechanoreceptors observed had similar characteristics. Of these, 31.3% were olive shaped, 28.8% oval, 18.5% fusiform, 7.7% spherical, 6.4% cylindrical, 1.7% rectangular, and 5.6% unclassifiable. The average size of the olive, spherical, and oval shape mechanoreceptors along their long axis length averaged 222 μm (55–650 μm). The average size of the long axis length of the rectangular, cylindrical, and fusiform shape was 365 μm (80–900 μm). Although the shape of mechanoreceptors was consistent with the type I and type III categories described by Freeman and Wyke, there is a large discrepancy in the sizes. More than 25% of the total number of DRC mechanoreceptors fell into a category we called NOTT (nontype one, two, three).
Conclusion Combined fluorescent immunohistochemistry and confocal technology provide “high-definition” imaging that significantly increases the analysis of the morphology and the 3D measurements of joint mechanoreceptors, afferent nerves, and terminal fibers. Our ability to more accurately define similar characteristics and thus categorize joint mechanoreceptors will be greatly enhanced.
Wrist Denervation and the Anterior Interosseou
Nerve: Anatomic Considerations
Institution where the work was prepared: Columbia University Medical Center, New York, NY, USA
Robert J. Strauch, MD; Michael W. Grafe; Paul D. Kim; Melvin P. Rosenwasser
Columbia University
Purpose Wrist denervation via resection of the distal anterior (AIN) and posterior interosseous (PIN) nerves is an effective treatment for chronic wrist pain. When performing this procedure through a dorsal approach, we have been impressed by anatomic variations of the AIN. This has raised concerns about potential denervation of the pronator quadratus (PQ). The purpose of this study is to elucidate the anatomy of the AIN and PIN as encountered through a dorsal distal forearm incision.
Methods Ten fresh-frozen cadavers were dissected. Prior to dissection, radiographs were performed to ensure accurate localization of the proximal ulnar head with a radiopaque marker. A dorsal forearm approach, as described by Weinstein and Berger (1), was performed to identify the anatomy of the PIN and AIN. The location and diameter of all AIN branches were noted by using an operating stereoscopic microscope at 25x magnification and a precision caliper. The PIN anatomy and size was also noted.
Results The anatomy of the AIN was variable. The average AIN diameter proximal to the PQ was 1.5 mm. The average number of AIN motor branches was 4.2 (range 2–7). The largest PQ motor branch (1.0 mm average diameter) was the first motor branch and was located 37.9 mm from the proximal ulnar head. The last motor branch was found an average of 23.9 mm (range 17.9–30.5 mm) from the proximal ulnar head. In 9/10 specimens, the sensory branch tunneled radially through the distal PQ and innervated the periosteum of the volar distal radius (0.6 mm average diameter). In 4/10 specimens, a separate branch to the DRUJ was present (0.4 mm average diameter). We found the average PIN diameter to be 0.87 mm.
Conclusion Resection of the AIN at a point 4 cm proximal to the proximal point of the ulnar head will completely denervate the PQ. Division of the AIN 2 cm proximal to the ulnar head will spare most of the PQ motor branches.
Psychological Profile of a Group of Chronic Limb Pain Patients in a Hand Surgery Clinic
Institution where the work was prepared: Hand and Microsurgery Center of E1 Paso, E1 Paso, TX, USA
Jose Monsivais, MD
Hand & Microsurgery Center
Introduction The psychological profile of chronic pain patients is unclear in the current literature. Some evidence suggests there is a personality type that is prone to develop a chronic pain condition, and other studies suggest there is no such evidence. This study showed major depression was a consistent associated finding in this group with chronic pain.
Materials and Methods Thirty-five patients were randomly selected from a pool of patients with chronic pain who had been seen in a specialty clinic over a 5-year period. There were 26 females and 9 males. Criteria for inclusion were presence of a neuropathic condition and chronic pain present for a period longer than 1 year. Diagnoses included CRPS I and II (15 patients) and myofascial pain (20 patients). Evaluation consisted of a detailed history and physical examination, sensory motor evaluation, and electrodiagnostic and imaging studies. Physical fitness was assessed initially and monitored throughout the study period. Pain scales were assessed initially, and in every subsequent visit. Body mass index was also recorded. Pain questionnaires and psychological battery were also administered. The psychological battery consisted of MPI, SEL-90-R, BAPSI, Oswestry pain questionnaire, BPR, behavioral health questionnaire, pain survey, MBHI, and MCI-2.
Results Ulnar entrapment at the elbow and cervical radiculopathy were the neuropathic conditions most frequently seen. The most frequent psychological diagnosis was major depression in over 90% of the patients. The group had a mean BMI of 30. Statistical analysis was performed by using the contingency coefficient C.
Conclusion The most common cause of chronic pain was secondary to a neuropathic condition (P < 0.001). Associated findings were major depression and deconditioning (P < 0.001). Litigation (24%), worker's compensation (96%), and symptom magnification (96%) were also commonly associated. This study indicates that major depression is a consistent finding in this patient population, and depression should be treated to increase chances of a successful outcome.
Results of Reinnervation of the Biceps and Brachialis Muscles with a “Double Fascicular Transfer” for Elbow Flexion
Institution where the work was prepared: Washington University, St. Louis, MO, USA
Thomas H. Tung, MD; Susan E. Mackinnon; Christine B. Novak, PT, MS
Washington University
Introduction In 1994, Oberlin reported transfer of a redundant FCU fascicle of the ulnar nerve to the biceps branch of the musculocutaneous nerve to restore elbow flexion after brachial plexus injury. We report a modification of Oberlin's procedure with a second fascicle transfer to also reinnervate the brachialis muscle, a more powerful elbow flexor, in addition to the biceps.
Methods Seven patients underwent direct transfer of a redundant motor fascicle from the ulnar and median nerves to the biceps and brachialis branches of the musculocutaneous nerve. Assessment included degree of recovery of elbow flexion, and ulnar and median nerve function including pre- and postoperative pinch and grip strength, and 2-point discrimination.
Results Patients in this study consisted of 4 men and 3 women with a mean age of 34 years (standard deviation, 19 years; range, 18–61 years). Surgery was undertaken at a mean of 4 months postinjury (standard deviation 2 months, range 1–5 months). Mean recovery of elbow flexion was MRC grade 4+/5. Clinical evidence of reinnervation was noted at a mean of 5.5 months (standard deviation 1 month, range 3.5–7 months) postoperatively and the mean length of follow-up was 20.5 months (standard deviation, 11.2 months; range, 13–43 months). No permanent motor or sensory deficits related to the ulnar or median nerves were noted. All patients maintained good hand function and had no complaints of weakness or impairment. At last follow-up for all patients, pinch and grip strength, and 2-point discrimination were unchanged or better.
Conclusion Transfer of redundant motor fascicles from both the ulnar and median nerves can successfully reinnervate the biceps and brachialis muscles with restoration of strong elbow flexion. The time for reinnervation and recovery was minimized by the proximity of the donor fascicles to the motor endplates. The reinnervation of the brachialis muscle, the primary elbow flexor, as well as the biceps muscle provides an additional biomechanical advantage that accounts for the excellent elbow flexion strength obtained using this technique. Direct coaptation of the nerve fascicles was performed without the need for nerve grafts and there was no functional or sensory donor morbidity. No additional secondary procedures to further improve elbow flexion have been required. Advantages with this approach also include less dissection and shorter operative time compared to more proximal nerve transfers and grafts, and dissection in uninjured and unscarred tissue planes.
Outcomes of Suprascapular Nerve Neurotization in 125 Patients with Brachial Plexus Injuries
Institution where the work was prepared: EVMS, Microsurgical Research Center, Norfolk, VA, USA
Julia K. Terzis, MD, PhD; Ioannis Kostas, MD
Eastern Virginia Medical School
Objectives Shoulder stabilization is of utmost importance in upper extremity reanimation. The purpose of this study is to present our experience on suprascapular nerve reconstruction in 125 cases of obstetrical and adult brachial plexus lesions. Outcomes will be analyzed in relation to various factors including age of the patient, denervation time, donor nerve used, and functional restoration achieved in the supraspinatus versus the infraspinatus muscles.
Methods The medical records of 165 patients who had suprascapular nerve reconstruction were reviewed. A total of 125 patients operated upon by a single surgeon between 1978 and 2000 had adequate follow-up. Eighty-five patients were adults, and 40 patients suffered from obstetrical brachial plexus palsy (OBPP). Direct neurotization of the suprascapular nerve was performed in 59 patients, whereas in 26, interposition nerve grafts were used. In 93 patients the distal spinal accessory was used as the motor donor nerve for suprascapular nerve neurotization, whereas in 25 cases intraplexus donors were used. In seven cases cervical plexus donors were used.
Results The overall results in adult plexopathies were good or excellent in 75% of the patients for the supraspinatus muscle and in 55% for the infraspinatus muscle. In OBPP, the results were good or excellent in 82% for the supraspinatus muscle and 65% for the infraspinatus muscle. The mean postoperative muscle grading for the distal accessory to suprascapular nerve neurotization was 3.31; for intraplexus to suprascapular neurotization was 3.37; and for cervical plexus to suprascapular neurotization was 3.19. There was statistically significant difference between direct accessory to suprascapular neurotization versus accessory to suprascapular via a nerve graft. Early surgery, less than 6 months, yielded significantly better results than late surgery, more than 12 months.
Conclusions Suprascapular nerve reconstruction is a worthwhile procedure that stabilizes the glenohumeral joint, avoids shoulder arthrodesis, and restores shoulder abduction from 20° to 80°. The best results are observed in OBPP patients, when direct neurotization of the suprascapular nerve is carried out soon after injury (6 months or less).
AAHS Concurrent Scientific Paper Session B-1
Trauma and Microvascular
Fingertip Reconstruction with the Laterally Based Thenar Flap: Indications and Long-Term Functional Results
Institution where the work was prepared: University of Kentucky, Lexington, KY, USA
Brian Rinker, MD
University of Kentucky
The thenar flap is a reliable and time-tested method of fingertip reconstruction. It has been criticized for causing flexion contractures and tender, unsightly scars, yet the literature contains very little objective functional outcome data. The purpose of this study is to analyze the long-term functional results following fingertip reconstruction using the laterally based modified thenar flap and to compare these results with other accepted reconstructive methods. Nineteen patients underwent reconstruction of a fingertip amputation with a laterally based modified thenar flap between January 2001 and April 2004. Ages ranged from 3 to 48 years, with median age of 19.5 years. There were 15 males and 4 females. The series included 5 index, 8 long, 3 ring, and 2 small fingers. The angle of PIP immobilization ranged from 30° to 85° of flexion (mean, 66°) and was consistently greater for the more radial digits. Time to division ranged from 11 to 15 days (mean 12.8). Seventeen patients were available for follow-up evaluation, which consisted of range of motion testing, static and dynamic two-point discrimination, and Semmes-Weinstein monofilament testing. The contralateral hand was assessed as a control. A questionnaire measured patient satisfaction regarding sensibility, function, and appearance. Follow-up ranged from 12 to 32 months with a mean of 20 months. The reconstructive goals were met in all cases. Two patients reported cold intolerance; one reported painful hyperesthesia in the fingertip. The mean MP motion in the affected finger was 96°, versus 102° in the unaffected side. The PIP range of motion averaged 89° (range 80–95°), compared to 92° in the unaffected side. The DIP motion was 42°, compared to 55° in the contralateral side. Only the difference in DIP motion was statistically significant. The mean static 2-point discrimination in the flap was 6.8 mm (range 3–10 mm), compared to 3.8 mm in the contralateral side. Upon monofilament testing, 14 patients had sensory thresholds of 2 gf or less, implying intact protective sensation. Three patients had a sensory threshold of 4 gf. There were no hypertrophic or tender donor scars, and thumb ROM was full in all cases. This study does not support the contention that thenar flaps are associated with problematic donor scars and postoperative flexion contractures, even in the adult population and ulnar digits. Functional results in this series compare favorably to those in published series of cross-finger and homodigital flaps. When sound principles of flap design, timing of division, and early mobilization are followed, excellent outcomes can be expected.
Vascular Basis of the Metacarpal Flaps Without Sacrificing the Dorsal Metacarpal Artery
Institution where the work was prepared: UMF luliu Hatieganu, Cluj Napoca, Romania
The dorsal skin of the hand is well known to be a real donor area for dorsal intermetacarpal arteries. Apart from the indisputable advantages, these flaps have also some major disadvantages, the most important ones being: they are useful only in covering the soft tissue defects located in the proximal half of the long fingers, and because the flap's vascular pedicle is situated proximal to the metacarpophalangian joint, the early finger mobilization after the surgery is impossible. We describe a type of flap similar as design and donor area with the metacarpal classical flap, but that can be used in covering soft tissue defects very distal, both volar and dorsal in the long fingers, and that allows an early functional postoperative recovery, because the situation of the vascular pedicle distal to the MP joint.
Material and Methods We present a study made on fresh cadavers, using ink infusions, in which we observed the different types of vascular anasthomotic arches between the dorsal and palmar circulation. We observed some well-developed vascular anasthomosis in the proximal half of the long fingers first phalanx, between the dorsal metacarpal arteries and the palmar common digital arteries or the collateral digital arteries. We mapped the length, sizes, caliber, design, and anasthomosis of these vessels. We also studied the clinical usefulness of these arteries, by harvesting two types of flaps—fasciocutaneous pedicled flaps and fasciocutaneous island transposition flaps—and blood supplied by these perforator vessels.
Results In 25% of the cases, we observed some temporary venous congestion that diminished and spontaneously subsided. In 5–6% of the cases, we lost the flaps, due to persistent venous congestion, or because the pedicle was tunnelized. For the rest of the cases, the flap's integration was very good and the functional recovery begun 24 h postoperatively, with improved results.
Conclusions The main advantages of these flaps are as follows: (1) they do not sacrifice the dorsal metacarpal artery; (2) because of the long pedicle, they can be used to cover the distal regions of the fingers, both dorsal and volar; (3) the pedicle is located distal to the metacarpophalangian joint, thus the functional postoperative recovery can begin very early, at 24 h after the procedure.
Nailfold Reconstruction for Correction of Burn Fingernail Deformity
Institution where the work was prepared: Shriners Burns Hospital, Massachusetts General Hospital, Boston, MA, USA
Jesus A. Garcia, MD, PhD; Matthias B. Donelan
Harvard Medical School
Background Fingernail deformities frequently occur following burn injury to the hand. Frequently, the deformity is secondary to contracture of soft tissues proximal to the eponychium and is not the result of injury to the nailbed or germinal matrix. Following scar contracture, the roof of the nailfold peels away from the nail and causes abnormal nail growth and appearance. Abnormal appearance can range from slight changes in contour and location of the eponychium to complete destruction of germinal matrix and absence of nail growth. The majority of burn fingernail deformities fall into a midrange category that includes multiple symptoms. However, the important concept is that in many cases the complex structure of the nailfold is only displaced by the proximal contracture and is not destroyed by the injury.
Methods The burn fingernail deformity is readily treatable with a simple, reliable procedure that releases the proximal scar contracture with a distally based bipedicled flap and resurfacing of the flap donor defect with a skin graft.
Results Complete contracture release allows the everted and displaced roof of the nailfold to slide distally without tension and reliably restores normal nailfold anatomy. This restores the contribution of the dorsal nail matrix to nail growth and improves fingernail appearance and function. This procedure has been used in over 100 digits with burn fingernail deformities over the past 20 years, and there have been no instances of flap loss.
Conclusions This procedure is simple and straightforward to perform with few complications that relieves many symptoms associated with burn fingernail deformity. Thousands of burned digits would benefit by this procedure.
Management of Vasospastic Disorders with Botulinum Toxin A
Institution where the work was prepared: Allina Medical, University Minnesota, Minneapolis, MN, USA
Paul K. Lim, MD1; Allen L. Van Beek, MDP1,2; Andrew J.L. Gear, MD1; Marc R. Pritzker, MD2
1University Minnesota
2Allina Medical
Following digital artery sympathectomy, recurrence or persistence of vasopasm may compromise hand function and ultimately result in amputation of all or portions of both lower and upper extremities. At the 2004 AAHS meeting, the authors presented their very early results using Botulinum toxin A (BTA) (Botox®; Allergan) to control Raynaud-type vasospasm associated with mixed collagen diseases. This report outline methods of treatment, long-term follow-ups, and the continuing treatment of this expanding group of patients.
We present a case series of 11 patients with profound vasospasm producing intractable rest pain, digital ulcerations, and digit infarctions that failed aggressive medical therapy, and which were then treated by perivascular injections of BTA. In most patients both hands were involved. Proximal vascular disease and the extent of digital artery flow were documented with high-resolution magnetic resonance imaging. Prior to BTA injection, the level of pain, cutaneous temperatures, color, and ulcerations and infarctions were documented. The most symptomatic hand was injected with a total 100 units of BTA. In some patients with bilateral impending or active infarction, simultaneous injection of both hands were performed with 100 units into each hand.
Our longest follow-up is 28 months. All patients reported highly significant pain reduction from a scale of 10/10 to 0–2/10 within 24–48 h following injection. Relief persists for months following the injection. Nine of 11 patients with nonhealing ulcers spontaneously healed small ulcers and also healed areas of infarction after surgical debridement and in two cases small skin grafts. Nine of 11 patients reported decreased severity and frequency of vasospastic episodes. Long-term follow-up reveals that patients required repeat injection to control pain, ischemia, and superficial ulcerations 3–11 months after their first injections.
BTA, when injected into the perivascular tissues of the hand, appears to be an effective treatment for intractable digital ulcerations and rest pain in patients with severe vasospastic disorders. BTA probably produces a prolonged chemical sympathectomy by preventing release of nor epinephrine at the neurovascular junction of the sympathetic system. Because of the complexity of surgical digital artery sympathectomy along with its associated high risk of persistent symptoms, our finding of the therapeutic use of Botulinum toxin A injections represents an attractive alternative therapy.
Botox Therapy for Ischemic Digits
Institution where the work was prepared: Southern Illinois University School of Medicine, Sprpingfield, IL, USA
Jessica Gillespie, MD; Christopher Chambers; Michael Neumeister
SIU School of Medicine
Raynaud's phenomenon (RP) is an episodic digital asphyxia caused by arterial insufficiency whose etiology remains poorly understood (Sycha et al., 2004). Clinically, treatment for RP is difficult and often requires invasive surgical procedures that are not fully successful in resolving the morbidity associated with the condition. Botulinum toxin A (Botox®; Allergan) is an established neuromuscular blocking agent that is successfully used for cosmetic, neurological, and hyperhidrosis conditions. Its primary mechanism of action is inhibition of cholinergic transmission at the neuromuscular endplate. Recently, its use as a therapy for patients with RP has been explored (Sycha et al., 2004). The data on five patients with RP who had Botox® injections will be presented. We have also employed Botox® for treatment of RP in the clinical setting, monitoring reestablishment of peripheral blood flow using laser Doppler (LD) imaging; we are also exploring additional mechanisms of action in in vitro tissue bath experiments. Two patients were seen in our clinic presenting with symptoms of RP. One patient displayed bilateral RP involvement had been treated approximately 10 months prior with Botox and described immediate and long-lasting relief from pain and ulceration. When seen again in the clinic, we obtained before and 5 min after perfusion LD images and quantitated the results. This patient responded well to the therapy, showing 70 ± 300% increases in perfusion (post-Botox® injection/pre-Botox® injection). The second patient presented with unilateral (right hand) RP symptoms and received the Botox® therapy for the first time. Again, we obtained LD images before, 5 min, and 30 min post-Botox® injection. At 5 min postinjection, this patient's perfusion increased 11–29% when compared to the preinjection perfusion, and at 30 min postinjection his perfusion ranged from 16% to 26% greater than preinjection level. Additionally, both patients reported improvements in range of motion and pain following the injections. We are continuing to follow these patients for relief from pain and ulceration. We are currently exploring the mechanisms by which Botox® affects the peripheral vasculature through in vitro tissue bath experiments. While our and other group's experience with Botox® for the treatment of RP has shown some early success, it is clear that continued investigation of its clinical usefulness is warranted, as are studies designed to elucidate the proper dosing for patients with RP.
Inhibition of Vibration-Induced Microvessel Damage by D-4F
Institution where the work was prepared: Medical College of Wisconsin, Milwaukee, WI, USA
David J. Rowe, MD; Ji Geng Yan; Lin Ling Zhang; Danny A. Riley; Kirkwood A. Pritchard; Hani S. Matloub
Medical College of Wisconsin
Introduction Hand-arm vibration syndrome (HAVS), a debilitating sequelae of neurological and vascular dysfunction, is caused by prolonged exposure to hand-transmitted vibration. We have recently demonstrated that rat tail arteries exposed to short-term vibration injury show damage at the cellular level. The present study was performed to investigate the efficacy of D-4F, an apolipoprotein A-1 mimetic with known antioxidant and vasodilatory properties, in preventing vibration-induced endothelial cell damage.
Methods Forty Sprague–Dawley rats were randomly assigned to five groups: sham and D-4F groups with vibration for either 1 or 3 days, as well as a nontreatment, nonvibration control group. The animals were given intraperitoneal injections of either saline (sham) or 3 mg/ kg D-4F (experimental) 1 h prior to the experiment and continued for the allotted experimental period. Tails were then subjected to 4 h/day of vibration at 60 Hz, 5 g (49 m/s) acceleration for a total of 1 or 3 days. Injury was determined by light microscopy, electron microscopy, and NFATc3 immunostaining. The degree of vasoconstriction was evaluated by using morphometric analysis of luminal volume versus internal elastic membrane volume.
Results Electron microscopy revealed vacuolar changes at 1 day and damage and loss of endothelial cells at 3 days of vibration, while there was minimal damage seen with the D-4F group. Vasoconstriction in the sham control groups was statically significant when compared to D-4F groups at 1 and 3 days. Increased immuno staining by NFATc3 was seen after 1 day of vibration in the sham control group, but not in the D4-F group.
Conclusion This study has shown that D-4F, an apolipoprotein A-1 mimetic, reduces early endothelial cell damage in rat tails exposed to vibration injury. These findings indicate that vasoprotective agents may be beneficial in the prevention of HAVS. D-4F is currently in phase II clinical trials as an antiatherosclerosis agent and may be available for human consumption in the near future.
Tendon and Tumor
Biomechanical Comparison of Three Tendon Transfers for Supination of the Forearm
Institution where the work was prepared: University of New Mexico, Albuquerque, NM, USA
Tahseen A. Cheema, MD; Keikhosrow Firoozbakhsh; Alex F De Carvalho; Deana Mercer
University of New Mexico
Flexion–pronation of the hand and the forearm is a common deformity when upper extremity is affected by cerebral palsy. Many solutions have been used to treat pronation deformity including release of pronator muscles, tendon transfers to assist in supination or combination of release, and tendon transfer operations. Flexor carpi ulnaris is commonly transferred to wrist extensors to improve wrist extension. Improvement in supination is cited as its secondary benefit. Pronator teres rerouting has been advocated on the premise that it converts a deforming force into a corrective force. Brachioradialis rerouting has also been used to improve supination. The purpose of this study was to compare the efficacy of these three tendon transfers in restoring supination in cadaver forearms. Ten fresh-frozen adult cadaveric, above-elbow, upper extremities were uses for this study. In each specimen, three tendon transfers, i.e., FCU to ECRB, PT rerouting, and BR rerouting, were performed sequentially and each muscle was loaded incrementally with 1–10 lb in line of muscle fibers. The specimen was mounted in a specially designed jig, and the effect of loading the transfer on supination from 90° of pronation and from neutral position was measured with a protractor. The FCU proved to be the most effective transfer for creation of supination. This transfer enabled the forearm to reach its neutral position with 2.1 lb loading and forearm continued to rotate up to 82° of supination at 8 lb loading (a total rotation of 172°). The BR was the second best transfer. For this transfer, the forearm reached its neutral position with 3 lb of loading and continued to rotate up to 35° of supination at 8 lb loading (total of 125°). The PT rerouting was the least effective and with this transfer the forearm was never able to reach its neutral position, and under full loading of 8 lb the forearm rotated only 55° from full pronation of 90°. The FCU transfer to ECRB, which is commonly performed for wrist extension, seems to be the most effective for creation of supination also. If combined with appropriate release procedures, addition of other procedures such as PT rerouting or BR transfer would give minimal extra advantage.
Analysis of Relative Motion Splint for Zone VI Extensor Tendon Injuries in the Hand
Institution where the work was prepared: Virginia Commonwealth University School of Medicine, Richmond, VA, USA
Joy V. Sharma, MD; Ni-Jui Liang; John R. Owen, PE; Jennifer S. Wayne; Jonathan Isaacs, MD
Virginia Commonwealth University
Purpose Early motion is desirable in zone VI extensor tendon injuries to improve tendon tensile strength and prevent loss of flexion, tendon adhesions, and joint contractures. Dynamic splinting allows protected early motion but can be cumbersome. The “relative motion” splint, previously described by Merrit, holds the affected digit in 15° of extension relative to the uninjured digits. This protects the tendon repair while allowing some motion of all digits. We hypothesize that the relative motion splint shields the repaired extensor tendon from large strain. To test this theory, we measure tendon elongation with and without splint protection.
Methods The EDC, FDS, and FDP tendons of 10 fresh frozen cadaveric upper extremities were exposed and mounted on a testing apparatus with the flexor and extensor tendons coupled to five pounds of weight. An external fixator locked the wrist in 25° of extension. Alternating application of loads to the tendons induced a full range of motion for 25 cycles. Differential variable reluctance transducers (DVRTs) measured micro elongation in the index, middle, and ring extensor tendons in zone VI. Measurements of intact tendon elongation were obtained with and without the relative motion splint. The middle digit extensor tendon was then transected (in zone VI) and immediately repaired. Measurements were repeated with and without splint protection. Elongation ratios were calculated and statistically analyzed.
Results For the intact middle digit tendon, splinting reduced elongation in extension by 0.7% (p < 0.03), in flexion by 2.4% (p < 0.04), and at rest by 2.6% (p < 0.02). After transaction and repair of this same tendon, splinting reduced elongation in extension by 5.2% (p < 0.0001), in flexion by 6.7% (p < 0.0002), and at rest by 6.3% (p < 0.0002). Cycling without splint protection caused permanent stretching at the repair site. Reapplication of the splint decreased elongation at the repair site in extension by 1.7% (p > 0.01), in flexion by 3.3% (p < 0.001), and at rest by 3.1% (p < 0.0002), but less than with immediate splint application.
Conclusions The relative motion splint reduces effective strain on intact and repaired zone VI middle digit extensor tendons. The splint's effects were most pronounced during flexion.
Outcome Evaluation for Surgical Intervention for Medial and Lateral Epicondylitis
Institution where the work was prepared: Orthopaedic Department, Medical College of Wisconsin, Milwaukee, WI, USA
Steve Grindel, MD1; Barbara Haines, OTR, CHT2; Roger A. Daley, MD, PhD3; Mei Wang2
1Medical College of Wisconsin
2Froedtert and Medical College of Wisconsin
3Medical Colloge of Wisconsin
Purpose Our aim was to identify the outcome results of all patients who where diagnosed with medial/or lateral epicondylitis.
We hypothesized that patients who failed conservative treatment would benefit from surgical intervention. We aimed to determine the time of recovery following surgery and establish a return to function. Pain level, grip strength, and elbow ROM were compared to pre- and postoperative levels. Our results also sought to identify various tasks and grip testing positions that may be predictors of outcome.
Methods Inclusion criteria were patients diagnosed with medial/or lateral epicondylitis. Data was gathered via patient questionnaire, physical examination, and record review. Pain was identified as the common presenting symptom. Its severity was quantified by a verbal pain scale from 0 to 10. Functional criteria were assessed pre- and postoperatively to test our hypothesis. This included grip testing in various positions and tracking return to work status. The following data was established: worker compensation status, acute injury vs. gradual onset of symptoms, number of cortisone injections given, and type of hand therapy provided. Surgery was offered after failed conservative treatment. Treatment included a standard epicondylar release as described by Nirschl. Data was gathered at 2, 3, 6, and 12 months postoperative.
Results A total of 128 patients are enrolled in our study, of which 42 underwent surgery. All patients experienced improvement in their pain levels following surgery:
Avg. Score
2 months
6 months
Task
Preop
Postop
Postop
Rest
3.00
1.4
0.4
Palpate over epicondyle
6.9
3.9
1.9
Repetitive arm movement
6.1
3.1
2.6
Carry bag
7.5
2.9
1.7
By 6 months postoperatively, the patients grip strength was significantly improved to within 13% compared to the nonsurgical side.
Conclusion A comprehensive conservative treatment approach for epicondylitis has been shown to be effective in up to 70–80% of patients. We have found that a significant number of patients will continue to have symptoms despite appropriate conservative treatment. Surgical intervention for recalcitrant epicondylitis can provide timely relief of symptoms. Our initial findings demonstrate that 100% of the patients treated surgically had decreased pain by 2 months and continued to demonstrate decrease pain at 1 -year follow-up. Grip strength at 2 months remained decreased but returned to a functional level by 6 months.
Eighty-six patients treated nonoperatively were followed during the same time frame and are being compared to the operative cohort. This information will allow us to provide the patient with objective information regarding our recommended intervention.
Surgeon-Performed Ultrasound Evaluation of Flexor Tendon Injuries: A Cadaveric Study
Institution where the work was prepared: New York University Medical Center, New York, NY, USA
Roberto Luis Flores, MD; Roberto Galiano; Venkata Bodavula; David W. Friedman
New York University
Background Flexor tendon lacerations are one of the most common problems faced by hand surgeons. If the cut proximal tendon end retracts, retrieval by either tendon grasping forceps and/or exploratory incisions increase trauma to the tendon sheath as well as to the tendon and surrounding structures. The resultant increased scarring caused by these maneuvers can compromise functional outcome in these patients. To minimize the trauma associated with localization and retrieval of the proximal tendon end, we explored the reliability of surgeon-performed ultrasound in evaluating lacerated flexor tendons. Our goal was to correctly diagnose the tendon injury and to localize the proximal tendon end within 1 cm.
Methods Fresh cadavers were used in the study. Forty-five individual digits, including the thumbs (81 tendons), were randomly assigned to either laceration of the flexor digitorum superficialis, laceration of the flexor digitorum profundus, laceration of both tendons, or to a sham group. The lacerated tendons were randomly assigned to injury subsets: no retraction, partial retraction, and retraction to the carpal tunnel. Next, a surgeon, blinded to the injury status of the digits, performed real-time ultrasound with a 5- to 10-MHz, 38-mm broadband linear array transducer (SonoSite, Bothell, WA).
Results The average time to image each digit was 2 min and 25 s. A total of 50 of 81 tendons were completely lacerated. Correct diagnosis of flexor tendon injury was made in 78 of the 81 tendons (96.2%). There were no intact tendons incorrectly identified as being lacerated. Three tendons were identified as intact when they were injured. The correct localization of the proximal tendon end was made in 39 of the 50 lacerated tendons (78%). Of the tendons incorrectly localized, 8 were superficialis tendons and 3 were profundus tendons. No errors were made in the thumb or index finger, whereas in the long finger 2 errors were made. The ring finger and small finger had 3 and 6 errors, respectively. If the small finger is excluded from our analysis, correct localization was made in 45 of the 50 lacerated tendons (90%).
Conclusions Surgeon-performed ultrasound evaluation of the hand is a quick and reliable means to diagnose flexor tendon injuries and to accurately locate the cut proximal tendon end, thereby preventing unnecessary surgical trauma. Currently, we do not recommend using this technique to image flexor tendon injuries of the small finger.
Predictive Value of MRI in Determining Presence of Residual Disease Following Unplanned Marginal Excision of Soft Tissue Sarcomas of the Hand
Institution where the work was prepared: Memorial Sloan Kettering Cancer Center and Hospital for Special, New York, NY, USA
Edward A. Athanasian, MD; Mark Manoso; Jeffry Pratt; Douglas Mintz
Hospital for Special Surgery & Memorial Sloan Kettering Cancer Center
Purpose A retrospective analysis was performed on patients with the diagnosis of soft tissue sarcoma of the hand (STSH) to assess the predictive value of postmarginal resection MRI at referral in determining the presence of subsequent reexcision specimen residual disease at the time of definitive surgical treatment.
Materials and Methods From 1995 through 2003, 35 patients were treated with reexcision of STSH after undergoing marginal excision at outside institutions for what was thought a benign lesion. Prior to reexcision, repeat MRI was obtained and evaluated for surgical planning. Complete records were available on 33 patients. Of these, 17 were men and 16 were women. The mean age was 39.7 years (range 1–86 years). The average time between MRI and reexcision was 19 days. The types of tumors included seven synovial sarcomas, six epithelioid sarcomas, four malignant fibrous histiocytomas, two liposarcomas, and 14 others.
The most common stage at presentation was 2(23) and average tumor size 3.4 cm (SE 0.4).
Results MRI was read as positive for residual tumor in 17 cases. Of these, pathology reports showed 14 to have STS present and 3 did not. The positive predictive value (PPV) in determining residual disease was 82%. MRI was read as negative for residual tumor in 16 cases. Of these, pathology reports demonstrated presence of disease in 4 cases and no evidence of remaining tumor in 12 cases. The negative predictive value (NPV) was 75%.
Specificity of MRI was 80% and sensitivity was 78%.
Conclusions MRI is a valuable tool in preoperative planning. However, sensitivity and specificity, the PPV, and NPV remain insufficient on MRI alone to reliably determine the presence or absence of residual tumor following unplanned marginal excision.
Treatment of Stage 3 Giant Cell Tumor of the Distal Radius
Institution where the work was prepared: Hospital for Special Surgery & MSKCC, New York, NY, USA
Edward A. Athanasian, MD1,2; Lana Kang1; Mark Manoso2
1Hospital for Special Surgery
2Memorial Sloak Kettering Cancer Center
Purpose To retrospectively evaluate the rate of local recurrence (LR) of a single surgeon's consecutive series of stage III giant cell tumor (GCT) of the distal radius (DR) treated with either curettage, cryosurgery, and cementation (CCC) or wide enbloc excision (WEE) and reconstruction, and to identify tumor presentation factors that predict or preclude successful intralesional treatment.
Methods From 1995 to 2002, nine patients were treated with CCC, and 6 were treated with WEE, fibula grafting, and segmental wrist arthrodesis. Preoperative patient and radiographic data, postoperative function, and rates of LR were compared. Tumor volumes were determined based on MRI. Joint involvement and soft tissue extension were assessed.
Results Ten males and 5 female patients between the ages of 25 and 87 (average age 41) were evaluated. Nine patients underwent CCC and 6 patients underwent WEE. Demographics were similar. All patients treated with CCC had either a single palmar perforation with soft tissue contamination bound by the pronator quadratus or an additional minimal second penetration. No patient treated with CCC had extension, perforation, or pathologic fracture into the RC joint. There was a significant difference in tumor volume at presentation (12 vs. 43 cm3). Follow-up averaged 49.4 months (range, 22–96 months). The CCC average postoperative extension and flexion were 60° and 66°. All patients had symmetric and full forearm rotation. Strength averaged 34 kg in the CCC and 24 kg in the WEE group. All arthrodeses united. VAS and DASH scores were 1.17 versus 3.03, and 6 versus 21, respectively. LR occurred in 1 of 9 CCC and 0 of 6 WEE patients.
Discussion LR is reported to be more frequent following intralesional procedures for DR GCT. Historically, WEE has been recommended for stage III tumors. For carefully selected stage III patients, CCC can be performed successfully with low risk. Factors predicting successful intralesional treatment have been identified. Tumor size, cortical perforation, RC involvement, and pathologic fracture are determinants of treatment choice. Decreased primary surgical site morbidity, lack of donor morbidity, and superior motion, strength, and functional outcome scores are the benefits of CCC.
Basic Research
The Effect of Minocycline on Hypertrophic Scarring: A Pilot Study
Institution where the work was prepared: University of Missouri-Columbia, Columbia, MO, USA
Steven L. Henry, MD; University of Missouri-Columbia; Matthew J. Concannon, MD
University of Missouri
Background Matrix metalloproteinases (MMPs) are enzymes that serve to degrade the extracellular matrix, giving them a central role in the inflammatory process. MMP activity has been shown to be up-regulated in various pathologic conditions, including hypertrophic scarring. The purpose of this study was to examine the effect of minocycline, a known MMP inhibitor, on hypertrophic scarring.
Methods Multiple standardized wounds, through the excision of skin and perichondrium, were created on the anterior ears of adult New Zealand white rabbits. A total of 64 identical wounds were created on eight rabbits. Four of the rabbits received daily injections of minocycline, while the other four rabbits received saline injections. After 4 weeks, the resulting scars were harvested and their thicknesses measured by using a micrometer.
Results All wounds healed with some degree of hypertrophic scarring. In the rabbits treated with minocycline, the scars averaged 0.43 + 0.04 mm in differential thickness (i.e., the elevation above the level of the surrounding, unwounded skin), compared to 0.57 + 0.04 mm in the rabbits treated with saline, a statistically significant difference (p = 0.008, by independent t-test). The relative hypertrophy (i.e., the thickness of the scar expressed as a percentage of the surrounding, “baseline” skin thickness) of the scars in the minocycline-treated rabbits averaged 131 + 11%, compared to 175 + 12% in the control rabbits, also a statistically significant difference (p = 0.003, by Mann-Whitney rank sum test).
Conclusion Systemically administered minocycline significantly reduces the severity of hypertrophic scarring in a rabbit model. Although not directly examined in this pilot study, MMP inhibition likely contributes to this effect. Determination of the effect of minocycline at different doses, as well as measurement of the expression and activity of MMPs and other components of the hypertrophic scar milieu, are the objectives of future investigations.
MMP14 Gene Polymorphism is Strongly Associated with Dupuytren's Disease
Institution where the work was prepared: CIGMR, Manchester, United Kingdom
Constantinos Kanaris, BSc; Sally John; Jenny Hankinson; John K. Stanley; William E.R. Oilier
Ardeshir Bayat University of Manchester
Dupuytren's disease (DD) is a progressive and recurrent fibroproliferative disease of unknown etiology affecting human hands. It is a familial disorder and genetic studies have yet to identify the genes involved in its formation.
Matrix metalloproteinases (MMPs) are proteolytic enzymes and, via their function in protein degradation, have an important role in fibrogenesis. MMP3 (Stromelysin-1) and MMP14 (membrane-type MMP1) are members of the MMP family, produced by connective tissue cells that can synergistically degrade the major components of the extracellular matrix.
Previous studies have suggested that MMPs may be involved in the pathogenesis of DD; a decrease in the systemic MMP ratio to their natural inhibitors causes increased synthesis and deposition of collagen. Therefore, the aim of this study was to assess the association between single nucleotide polymorphisms (SNPs), in the MMP3 and MMP14 genes, with the risk of the development of DD. DNA isolated from 256 cases of Caucasian origin and 288 Caucasian control subjects from northwest of England were used for this study. SNPs were genotyped in all subjects by using the 5′ nuclease assay for allelic discrimination (TaqMan).
The frequency of a missense mutation in the 5′ UTR region of the MMP14 gene was found to be more common in cases vs. controls. The odds ratio is 2.75 (95% CI;2–3.7) in the DD group when compared to the controls. These results indicate a strong genetic link for an MMP 14 gene polymorphism to the development of DD. This mutation may potentially affect mRNA stability with translational regulation.
Experimental Limb Transplantation: Induction of Immune Tolerance in a Mouse Limb Transplant Model Using Triple Therapy
Institution where the work was prepared: University of Western Ontario, London, ON, Canada
Toni Zhong, MD; C.L.F. Temple; J. Jiang; Y. Liu; F. Sun; B. Garcia; R. Zhong; D.C. Ross
University of Western Ontario
Introduction The application of clinical hand transplantation is limited by long-term use of toxic antirejection drugs. The purpose of this study was to determine whether a short course of monoclonal antibody against CD45RB (mAb), LF 15-0193 (LF) and rapamycin (Rap) would achieve long-term survival by inducing tolerance in a mouse limb transplant model.
Methods Twenty-one hind limb transplants were performed across MHC incompatible C57BL/6 and BALB/c mice. Four mice were treated with mAB (3 mg/kg) and LF (2 mg/ kg) alone, and 14 mice were treated with mAB, LF, and Rap (2 mg/kg) for 14 days posttransplantation. Three C57BL/6 to BALB/c transplants receiving no drug therapy and three isogeneic transplants served as controls. Rejection was determined by using clinical criteria, routine, and immunopathology. Immune tolerance was determined by using flow cytometry and mixed lymphocytic reaction.
Results Isografts had normal histology and function of the limb grafts on day 100. Untreated C57BL/6 to BALB/c allografts developed acute rejection within 7 days. The combination of mAb and LF prolonged the allograft survival to 39 ± 7 days. The group that received triple therapy successfully achieved long-term survival (100 + 7 days). Evidence of acute rejection was not found on the pathology of these long-term surviving limb grafts. In vitro testing of tolerance using flow cytometry found that 1% and 1.6% of lymphocytes isolated from the spleen and bone marrow in long-term surviving mice belong to the donor. This level of lymphocytic chimerism was twice as high as found in the naive mice. Serum levels of antidonor antibodies (IgG2a and IgM) were found to be lower in the long-term surviving allograft recipient compared to untreated allograft recipients, but higher than in the naïve group.
Conclusion A short-term course of anti-CD45RB mAB and LF 15-0195 prolonged limb allograft survival. The addition of rapamycin to this protocol significantly prolonged limb allograft survival to over 100 days. In vitro testingusing flow cytometry showed that microchimerism existed in the long-term surviving allograft recipients who received triple therapy. In addition, the long-term surviving group also demonstrated lower levels of antigraft antibodies than the untreated group as a result of triple therapy. Both microchimerism and inhibition of antigraft antibodies may be possible mechanisms underlying the development of tolerance.
Lymphoid Engraftment of Donor-Specific Cells Permits Central and Peripheral Tolerance in Hindlimb Allograft Transplants
Institution where the work was prepared: The Cleveland Clinic Foundation, Cleveland, OH, USA
Maria Siemionow; Dariusz Izycki; Aleksandra Klimczak; Galip Agaoglu; Emrah Arlsan; Sakir Unal
The Cleveland Clinic Foundation
Purpose The goal for composite tissue allograft transplant such as human hand is to induce donor-specific tolerance. Recently, we have demonstrated that vascularized composite tissue allograft transplants treated with alpha/beta-T cell receptor (alpha/beta-TCR) monoclonal antibody and Cyclosporine A (CsA) for 7 days developed tolerance across MHC barrier. In this study the role of host thymus in tolerance induction was evaluated in rat hindlimb allograft model across MHC barrier.
Methods Sixty rats were studied in 10 groups (six animals each). Euthymic (group A) and thymectomized (group B) Lewis (RT11) recipients received hindlimb allografts from LBN (RTll+n) donors. Group IA and IB served as euthymic and thymectomized isograft controls. Group IIA and IIB received no treatment and served as rejection control. Monotherapies groups IIIA and IIIB received alpha/beta-TCRmAb and IVA and IVB CsA for 7 days. In groups VA and VB, combined alpha/beta-TCR/CsA protocol was given for 7 days only. Flow cytometry monitored immunodepletion and donor-specific chimerism in peripheral blood. Mechanism of allograft tolerance was assessed by immunocytochemistry for the presence of donor-specific MHC class I (RTln) cells within lymphatic tissue. Mixed lymphocyte reaction (MLR) and skin grafting evaluated donor-specific tolerance.
Results Isograft controls survived indefinitely. Nontreated allografts rejected within 5–9 days (IIA and IIB). Monotherapy with alpha/beta-TCR extended survival up to 14 days (IIIA) and 17 days (IIIB) and with CsA up to 21 days (IVA) and 30 days (IVB) (p < 0.05). Treatment with alpha/beta-TCR/CsA resulted in 385 days survival in euthymic rats (VA) and up to 55 days in thymectomized rats (VB) (p < 0.001). At day 120, posttransplant chimerism in peripheral blood of euthymic rats showed 17.3% CD4+/RTln and 13.9% CD8+/RTln. The presence of donor passenger leukocytes in the thymus, lymph nodes, and spleens of euthymic rats confirmed chimerism. Donor-derived cells were present in the lymphatic tissues of thymectomized recipients at day 7 posttransplant, but not at the time of rejection. MLR and skin graft acceptance confirmed donor-specific tolerance in euthymic group (VA).
Conclusions The presence of thymus was imperative for induction of donor-specific tolerance in limb allograft transplants under 7 days protocol of alpha/beta-TCR/CsA. Our results indicated that both central and peripheral mechanisms play a role in tolerance induction in limb allograft recipients.
Detailed Characterization of Schwann Cell Migration into Murine Peripheral Nerve Allografts
Institution where the work was prepared: Washington University School of Medicine, St. Louis, MO, USA
Terence M. Myckatyn, MD; Ayato Hayashi; Alice Tong; Daniel Hunter; Susan Mackinnon
Washington University in St. Louis
Antigenic tissues in a peripheral nerve allograft are eventually replaced by regenerating host axons and Schwann cells to preclude the need for indefinite immunosuppression. Schwann cell migration into peripheral nerve allografts is poorly characterized in terms of the rate of migration, organization of migrating Schwann cells, Schwann cell phenotype at various stages after nerve grafting, and the associated intracellular signaling pathways. We have developed a double-transgenic murine model to study the rate of Schwann cell migration and axonal regeneration across peripheral nerve allografts. S100-GFP mice, whose Schwann cells constitutively express GFP, were bred to thyl-CFP(23) mice whose axons express CFP. The rate of nerve regeneration and Schwann cell migration of S100-GFP/thyl-CFP(23) mice was then characterized across C57BL/6J mouse allografts that were devoid of fluorescence. Using a fluorescent dissecting microscope and supersensitive CCD, the intensity of fluorescent emission was plotted on the y-axis and the distance of migration across the graft plotted along the x-axis to quantify Schwann cell migration and nerve regeneration at multiple time points in living animals. Confocal microscopy of harvested specimens provided more detailed characterization of Schwann cell migration, and colabeling studies using immunohistochemical markers to pAkt, and Erk enabled characterization of the activity of intracellular signaling components of the tyrosine kinase receptor relevant to Schwann cell differentiation. Histomorphometry and retrograde labeling further characterized nerve regeneration. Western blot analysis of other signaling proteins relevant to Schwann cell differentiation are pending. This study represents a novel model for simultaneously studying Schwann cell migration and nerve regeneration into peripheral nerve allografts at multiple time points and provides further insights at an intracellular level into the characteristics of migrating adult Schwann cells.
Expression of Major Histocompatibility Antigens on Isolated Human Chondrocytes for Tissue Engineering
Institution where the work was prepared: Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
Niamh-Anna O'Sullivan, MD; Shinichi Ibusuki; Mark Randolph; Michael Yaremchuk
Massachusetts General Hospital and Harvard Medical School
One option for obtaining large numbers of cells for engineering cartilage is to use allogeneic sources. A central issue involving allotransplantationof chondrocytes is their potential to elicit an immune response after the removal of their immunoprotective matrix (e.g., isolation for tissue engineering), which may expose major histocompatibility antigens on the cell surface. It is crucial to determine the antigenicity of chondrocytes in order to assess the utility of allogenic chondrocytes for tissue engineering. This study examined MHC expression in human articular chondrocytes from both osteoarthritic (OA) and healthy hip and knee joints. In addition, the antigenicity of isolated auricular, nasal, and costal chondrocytes was ascertained, as these cells are being increasingly used to tissue engineer cartilage.
Methods Chondrocytes were isolated by enzymatic digestion from fresh human osteoarthritic hip and knee joint articular cartilage, and healthy articular, auricular, nasal, and costal cartilage. Peripheral blood lymphocytes were isolated from human blood to serve as the positive control cell type. Human dermal fibroblasts served as the negative class II cell control. All cells were prepared by cytospin onto plus glass slides. Indirect immunoperoxidase assay was performed with mouse monoclonal antibodies against HLA class-1, HLA class 2-DR. Negative controls specimens were incubated without the primary antibody. After staining, the slides were subjected to double-blind evaluation by three independent observers.
Results All blood cells expressed both class I and class II MHC antigens as expected. All fresh hip and knee OA chondrocytes were found to express class I MHC antigens. The OA chondrocytes were also shown to express class II-DR antigens, but the presence of class II antigen expression was less prevalent. Isolated human articular (non-OA), auricular, nasal, and costal cells were found to consistently express class I and class II MHC antigens. Frozen sections taken from the same cartilage samples, however, failed to express either type I or type II MHC antigens.
Conclusion In conclusion, human OA articular chondrocytes were shown to express class I and class II MHC antigens, which is contrary to previously published findings. Additionally, all other tested sources of human cartilage were found to positively express both antigens. Although allogeneic cells may be a suitable alternative for tissue engineering approaches to cartilage repair and regeneration, these findings could present an obstacle for their use if the MHC antigens are exposed. The next step would be to assess and quantify the immunogenicity of tissue engineered cartilage, both in vitro and in vivo.
AAHS Concurrent Scientific Paper Session B-2
Distal Radius Fractures and Wrist
Radiographic Evaluation of Dorsal Screw Penetration Following Volar Fixed Angle Plating of the Distal Radius: A Cadaveric Study
Institution where the work was prepared: The Cleveland Clinic Foundation, Cleveland, OH, USA
Steven Maschke, MD; Jeffrey Lawton; Peter Evans; David Schub
Cleveland Clinic
Extensor tendon irritation and attritional tendon ruptures are serious complications following open reduction and internal fixation of distal radius fractures and are now being reported following errant screw placement during volar fixed angle plating. Intraoperative detection of improper screw placement is critical, as corrective action can be taken prior to completion of the operative procedure.
The purpose of this study was to define the extensor tendon compartments at risk secondary to dorsal screw penetration and compare 45° pronation and supination radiographs with standard lateral radiographs in demonstrating dorsal screw prominence during volar locked plating.
Eight cadaveric upper extremities underwent fixation with a volar, fixed angle distal radius locking plate. Three radiographic views (neutral lateral, 45° supinated view and 45° pronated view) and dorsal wrist dissections were compared to determine accuracy in detecting dorsal screw prominence and extensor tendon compartment violation. Afterwards, screws measuring 2, 4, 6, 8, and 10 mm longer than the measured depths were sequentially inserted into each distal locking screw position. The three radiographic views were repeated for each longer screw with each image deemed either “in” or “out”.
The radial most distal locking screw (position-1) violated either the first (25%) or second (75%) extensor tendon compartments. The average screw prominence required for radiographic detection was 2 mm for 45° supinated views and 6.5 mm for lateral views. Screws occupying plate position-2 consistently entered Lister's tubercle, with 5/ 8 exiting the apex and 3/8 exiting the radial base. The average screw prominences for radiographic detection were 3.0 mm for 45° supinated views and 2.75 mm for lateral views. Screws occupying plate position-3 violated the third extensor tendon compartment in 7/8 specimens with 1/8 exiting the ulnar base of Lister's tubercle. The average screw prominences for radiographic detection were 2.5 mm for 45° pronated views and 3.5 mm for lateral views. Screws occupying plate position-4 all violated the IV dorsal extensor compartment—2/8 screws were noted to tent the posterior interosseous nerve. The average screw prominences required for radiographic detection were 2.5 mm for 45° pronated views and 4.0 mm for lateral views.
We have seen in our practice, and as also reported in the literature, an increased number of extensor tendon complications arising from unrecognized dorsally prominent screws, pegs, or tines. Standard radiographs cannot adequately visualize screw position and length secondary to the angular geometry of the bone. We believe this study supports the routine application of intraoperative, pronosupination radiographs for enhanced confirmation of distal locking screw position and length.
Distal Radius Fractures and Concomitant Ulnar Styloid Fractures
Institution where the work was prepared: Miami Hand Center, Miami, FL, USA
Jorge Orbay, MD; Alejandro Badia, MD; Roger Khouri, MD; Eduardo Gonzalez-Hernandez, MD; Igor Indriago, MD
Miami Hand Center
Purpose Despite progress in the treatment of the distal radius fracture, understanding about the concomitant ulnar styloid fracture remains unchanged. This retrospective study examines the clinical results of a cohort of distal radius fractures treated with volar fixed angle fixation and early rehabilitation but no specific treatment for the ulnar styloid fracture.
Methods We reviewed 200 distal radius fractures treated with volar fixed angle fixation and followed for a minimum of 6 months. No specific treatment, besides accurate reduction, stable radial fixation, and early forearm rotation, was provided for concomitant ulnar styloid fractures. Cases with fractures of the ulna proper were removed from the study. If present, ulnar styloid fractures were classified radiographically according to size, displacement, degree of comminution, and foveal involvement. Information was obtained from the clinical, rehabilitation, and radiographic records. Functional results were measured in terms of final finger and wrist motion, forearm rotation, and grip strength.
Results Out of 200 distal radius fractures in 194 patients, 18 (9%) presented with concomitant fractures of the ulna proper. Therefore, 182 distal radius fractures remained in the ulnar styloid study group. Of these, 59% presented with radiographic evidence a concomitant ulnar styloid fracture and 41% did not. Of those presenting with an ulnar styloid fracture, 21% had involvement of the ulnar fovea, 39% had a large fragment, 15% a small fragment, and 25% had other classifications. Only 19% of the ulnar styloid fractures united. Of those distal radius fractures presenting without evidence of a concomitant ulnar styloid fracture, 15% subsequently developed a local calcification or other radiographic evidence of a soft tissue injury. There was no statistically significant correlation between final functional results and the presenting or final radiographic appearance of the ulnar styloid. There were no cases of DRUJ instability in this series.
Conclusions and Significance With this method of treatment, the incidence of ulnar styloid nonunion is high but functionally insignificant. The precise restoration of radial length provided by volar fixed angle fixation combined with early forearm rotation may decrease the need for internal fixation of large styloid fragments. The decision to fix ulnar styloid fractures should not be based on their size, but on the presence of gross instability.
A Meta-Analysis of Outcomes of External Fixation versus Plate Osteosynthesis for Unstable Distal Radius Fractures
Institution where the work was prepared: University of Michigan, Ann Arbor, MI, USA
Zvi Margaliot, MD, MS, FRCSC; Steven C. Haase, MD; Sandra V. Kotsis, MPH; Hyungjin M. Kim, ScD; Kevin C. Chung, MD, MS
University of Michigan
Purpose External fixation and open reduction and internal fixation have been the traditional techniques for surgical fixation of unstable distal radius fractures. The existing literature has not identified which is superior, primarily due to the lack of comparative trials. We performed a comprehensive systematic review and meta-analysis of the current literature on external fixation and internal fixation of distal radius fractures to determine the dominant strategy based on available scientific evidence.
Methods We searched MEDLINE and EMBASE for English-language papers published between 1980 and 2004 that satisfied predetermined inclusion and exclusion criteria. The outcomes of internal and external fixation were compared by using continuous measures of grip strength, wrist range of motion and radiographic alignment, and categorical measures of pain, physician-rated outcome scales, and complication rates. Outcomes were pooled by random effects meta-analysis and metaregression analysis was used to control for patient age, presence of intraarticular fracture, duration of follow-up, and date of publication. Sensitivity analyses were used to test the stability of the meta-analysis results under different assumptions.
Results Forty-six papers were included in the review, with 28 (917 patients) external fixation studies and 18 (603 patients) internal fixation studies. Meta-analysis did not detect clinically or statistically significant differences in pooled grip strength, wrist range of motion, radiographic alignment, pain, and physician-rated outcomes between the two treatment arms. There were higher rates of infection, hardware failure, and neuritis in the external fixation arm, and higher rates of tendon complications and early hardware removal in the internal fixation arm. Significant heterogeneity was present in all studies and adversely affected the precision of the meta-analysis.
Conclusions The current literature offers no evidence to support the use of internal fixation over external fixation for unstable distal radius fractures. Comparative trials using appropriately sensitive and validated outcome measurements are needed to guide treatment decisions.
Arthroscopic Debridement and Closed Pinning for Late Presenting Dynamic Scapholunate Instability
Institution where the work was prepared: Allegheny General Hospital, Pittsburgh, PA, USA
Nickolaos Darlis, MD, PhD1
Robert A. Kaufmann, MD2; RW Weiser1; D.G. Sotereanos1
1Allegheny General Hospital
2University of Pittsburgh Medical Center
In dynamic scapholunate (SL) instability presenting more than 3 months postinjury, open procedures (capsulodesis, tenondesis, SL ligament reconstruction, intercarpal fusions) are preferred, but the optimal approach is yet to be determined. The efficacy of arthroscopic debridement and pinning of the SL interval in such patients is unclear.
A restrospective review of the senior author's records produced 13 patients with late presenting dynamic SL instability who were unwilling to undergo an open procedure and were initially treated with aggressive arthroscopic debridement and pinning. Eleven of the initial 13 patients were available for follow-up. Their mean age was 36 years (range 23–50 years) and the mean time elapsed from injury was 7 months (range 4.5–10 months). The diagnosis of dynamic SL instability was based on a positive Watson's test, SL gapping on grip view radiographs, and arthroscopic findings of a Geissler type III (in 5 patients) or type IV (in 6 patients) SL tear. The SL angle was under 55° in all patients. The procedure included aggressive arthroscopic debridement of the torn portion of the SL ligament to bleeding bone in order to induce scar formation in the SL interval. The SL interval was subsequently reduced and pinned (with two pins through the SL and one pin across the scaphocapitate joint) under fluoroscopy. The pins were removed at a mean of 9.6 weeks (range 8–14 weeks).
The mean follow-up was 36 months (range 12–76 months). Three patients were reoperated at 9, 10, and II months after the initial procedure. Reoperations included a dorsal capsulodesis, a four-corner fusion, and a wrist arthrodesis. The eight remaining patients achieved two excellent, four good, one fair, and one poor result with the Mayo wrist score. Patients diagnosed with Geissler III tears achieved better final wrist score (mean 86 points versus 76 points in patients with Geissler IV tears).
Late (more than 3 months postinjury) arthroscopic debridement and pinning was found to be only moderately successful for dynamic SL instability (6 out of 11 patients achieved a good or excellent result without reoperation). This approach, however, does not preclude subsequent open surgery. It may be best suited for patients with Geissler type III tears (not a gross drive through sign) who are unwilling to undergo an extensive open procedure provided they under stand the risks and benefits of this approach.
Conversion Rate of Intercarpal Fusion to Wrist Pan-Arthrodesis
Institution where the work was prepared: Chicago Center for Surgery of the Hand, Chicago, IL, USA
Samuel S. Koo, MD, MPH1; Daniel J. Nagle, MD2; Alicia Martinez, BSN2; Thomas A. Wiedrich, MD3; John Stogin, MD2
1Northwestern University
2none
3Northwestern University Medical School
Purpose To study the rate of conversion of intercarpal fusion to wrist pan-arthrodesis.
Methods A retrospective chart review was conducted of 90 consecutive patients who underwent intercarpal fusion from 1990 to 2002. All procedures were conducted by three surgeons. Complete data including demographics, insurance status, and conversion to total wrist arthrodesis was available for 72 patients. The data were analyzed using SPSS software.
Results Twelve of 72 (17%) intercarpal fusions went on to require total wrist arthrodesis. This included 9 of 34 (26%) midcarpal fusions, 2 of 24 (8%) triscaphe fusions, and 1 of 10 (10%) lunotriquetral fusions. None of the six radiocarpal fusions went on to require total wrist arthrodesis. The average time from the index surgery to total wrist fusion was 13 months. The average follow-up time was 37 months. The age of the patients ranged from 17 to 59, with the average being 35 years. Worker's compensation patients comprised 75% of the cohort. Age, gender, and worker's compensation status did not influence conversion rates.
Conclusions Seventeen percent of all intercarpal fusions failed and required total wrist arthrodesis at an average follow-up period of 37 months. The midcarpal arthrodesis was more likely to fail, whereas the triscaphe, lunotriquetral, and radiocarpal fusions had relatively low conversion rates. Worker's compensation status did not influence the need for total wrist fusion.
The RASL (Reduction and Association of the Scaphoid and Lunate Using the Herbert Screw) Procedure: An Evaluation of Intercarpal Kinematics in Cadaveric Wrists
Institution where the work was prepared: Columbia University Medical Center, New York, NY, USA
Faiq Amin, MD1; Byung-Hoon Ko, MS2; Michael W. Grafe, MD1; Noah Matthew Raizman, BA1; Thomas Robert Gardner, MCE; Melvin Paul Rosenwasser
1Columbia University
2Korea Advanced Institute of Science and Technology
Introduction Scapholunate dissociation is the most common type of carpal instability. The resultant abnormal loading pattern results in altered kinematics of the wrist leading to degenerative change and eventually scapholunate advanced collapse (SLAC). Although many options exist for treating this problem, the results of various ligamentous reconstruction procedures are variable and often disappointing. Clinical outcomes data seem to favor the RASL (reduction and association of the scaphoid and lunate using the Herbert screw) procedure. However, the question of whether normal wrist kinematics are restored has not been clearly answered in a biomechanical study.
Purpose To determine if trans-scapholunate placement of the Herbert screw restores the normal obligatory rotation of the scaphoid and lunate in the axis of flexion and extension while correcting diastases.
Methods Ten fresh-frozen human hand-wrist-forearm specimens were dissected free of all soft tissue except for the superficial and deep finger flexors, the wrist flexor and extensor tendons, the interosseous membrane, and the extensor and flexor retinacula. The hands were mounted in a joint testing rig with measurement triads rigidly fixed into the pipe, the scaphoid, and the lunate bones. A coordinate measuring machine (CMM) was used to precisely measure the three translations and three rotations of the scaphoid and lunate for normal, injured, and repaired specimens with the wrist in neutral, extension, flexion, radial deviation, ulnar deviation, and a clenched fist. The injury was created by transecting the scapholunate ligament complex and a RASL performed by reassociating the scaphoid and lunate using a Herbert screw. Fluoroscopic images of the hand in each tested position were obtained during several experiments.
Results The simulated scapholunate injury model resulted in increased scapholunate motion for all positions tested which was then reduced by the application of the Herbert screw. On average, the reduction achieved was within 5° of the neutral position in the preinjury state for flexion/ extension and radial/ulnar deviation and within 10° for pronation/supination. The resulting pattern of scapholunate postrepair motion, when adjusted for offset at reduction, was within 5° of the preinjury state for all positions tested in the directions of flexion/extension, ulnar/radial deviation, and pronation/supination.
Conclusions The RASL procedure for scapholunate dissociation restores the preinjury pattern of scapholunate motion. These data may explain the favorable clinical results in the RASL procedure for the treatment of chronic SL instability.
Fragment Specific Fixation of Distal Radial Fractures
Institution where the work was prepared: University of Calgary, Calgary, AB, Canada
Jeffrey F. Haasbeek, MD, FRCSC; C. Vaughan A. Bowen; Jeremy G.R. Reed
University of Calgary
Treatment of complex distal radius fractures remains a challenge. Basic orthopedic principles for any complex intraarticular fracture remain near anatomic reduction, maintenance of the reduction, and rehabilitation as soon as possible (i.e., early range of motion). Fragment-specific fixation allows potentially for early rehabilitation while maintaining the fracture reduction. We present a retrospective consecutive series of 90 patients treated in this manner. Potential cases were identified from the database of a single surgeon. All fractures were classified as AO type C2 or C3. Other types of fractures were excluded. All patients were between the ages of 18 and 60 years. Mean age of the patients were 40 years. Interim comprehensive assessment was carried out in 23 patients at 6 months postfracture treatment. Later radiographic assessment was evaluated in 90 patients. The patients (average scores in brackets) were analyzed in terms of the following: type of fixation (radial or ulnar pin plates, volar peg plates, buttress pin types, ulnar styloid fixation), bone graft (used in 65% of cases), radial inclination angle (22°), palmar tilt angle (3°), ulnar variance (0 mm), intraarticular gap deformity (0.3 mm), intra-articular step deformity (0.5 mm), grip strength (29 kg), key pinch strength (9 kg), range of motion (pronation 73°, supination 69°, extension 59°, flexion 48°, radial deviation 17°, ulnar deviation 22°), return to work (21 weeks). Patient Rated Wrist Evaluation (PRWE) score and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire were also analyzed. The average PRWE score was 20 out of 100, whereas the average DASH score was 15 out of 100. Higher scores indicate poorer outcomes. Complications included hardware removal, tendon ruptures, and infection with rates similar to other reported series. Our length of follow-up is not sufficient to comment on the hypothesized reduced rate of posttraumatic arthritis with fragment-specific fixation. We feel that fragment-specific fixation is a safe method of maintaining reduction of complex intra-articular distal radius fractures. Its ability to provide fixation for small articular fragments combined with early range of motion to promote cartilage remodeling may offer a reduction in the rate of posttraumatic arthritis of both the radiocarpal and radioulnar joints. Longer-term follow-up is required to make any such definitive statements.
Volar Plating of Distal Radius Fractures Effect of the Pronator Quadratus
Institution where the work was prepared: University of Mississippi Medical Center, Jackson, MS, USA
William Geissler, MD; Sheila Lindley; Robert Dews; Matthew Thomas
University of Mississippi Medical Center
Volar plating of distal radius fractures has recently become quite popular. This in part is attributable to the stronger volar plates that have been developed, and less irritation of the surrounding soft tissues. There is some controversy whether the pronator quadratus, which is released during the exposure of the fracture, should be closed after fracture stabilization. The purpose of the study was to determine if closure of the pronator quadratus affected the final results. Forty patients with a displaced extraarticular fracture of the distal radius underwent stabilization with a volar distal radius plate. In 20 patients (group I), the pronator quadratus was not closed and left open following stabilization. In another 20 patients, group II, the pronator quadratus was then meticulously closed over the plate. There were 26 women and 14 males in the study. The average age was 38 years (range 18–70 years). Patients were evaluated by a pinch grip range-of-motion study 3 months postoperatively. In group I, average extension was 58°, and palmar flexion averaged 62°. Average supination was 75° (range 50–90°), and average pronation was 85° (range 80–90°). In group II, average extension was 52°, average flexion 47°, supination 58° (range 45–70°), and average pronation 80° (range 75–85°). There was no difference in grip strength at 3 months postoperatively between the two groups. The decision to close or leave the pronator open did not affect grip strength at 3 months postoperatively. Closure of the pronator resulted in less supination as compared with those patients where the pronator was left open. This may potentially be secondary to scarring of the pronator quadratus, which results in decreased supination. Based on this preliminary study, closure of the pronator is not recommended.
Is There a Role for Dorsal Distal Radial Plating for Extraarticular Dorsal Comminution?
Institution where the work was prepared: Loma Linda University, Loma Linda, CA, USA
Dan Kemper, MD; Montri D. Wongworawat, MD
Loma Linda University
Purpose Dorsal plating, while often used when there is dorsal comminution, frequently results in soft tissue complications. With the advent of fixed angle volarly placed devices, we reexamine the necessity of dorsal plating from a biomechanical standpoint.
Methods and Materials Twelve pairs of embalmed soft-tissue free cadaveric radii were divided into two groups for comparison: V and D (see table). Three left and three right radii from each group underwent metaphyseal osteotomy with 30° dorsal wedge removal to simulate dorsal comminution. For group V, the six osteotomized specimens were fixated with the volar fixed angle device (SCS/Volar, Avanta Orthopaedics, San Diego, CA). Load to failure along the longitudinal axis of the radii were performed, and paired comparisons (Wilcoxon) were made between the osteotomized-fixated specimens and intact radii. Group D underwent similar treatment, but with dorsal fixation using the dorsal fixed angle device (SCS/Dorsal). Further comparisons between the intact radii and the two osteotomized-fixated sets were performed by using Kruskal–Wallis ANOVA.
Results In terms of rigidity, groups V and D paired comparisons demonstrated that intact radii were significantly more rigid than osteotomized-fixated specimens (p = 0.0277 and 0.0464, respectively). ANOVA comparisons between intact specimens, group V osteotomized and group D osteotomized, showed intact radii to be significantly more rigid (p = 0.0052) than the other two groups, which were similar to each other. For ultimate strength, groups V and D paired comparisons demonstrated that intact radii had higher ultimate strength (p = 0.0277 and 0.0464, respectively). When expressed as a percentage of intact specimens, both groups showed similar normalized ultimate strength. ANOVA comparisons showed intact radii to have significantly higher ultimate strength (p = 0.0028), but no difference between dorsal or volar fixation.
Conclusions Volar plating is similar to dorsal plating in terms of strength and rigidity. Although dorsal plating continues to be fraught with soft tissue problems, the volar fixed angle device is an acceptable solution for extraarticular distal radius fractures with dorsal comminution.
Table
Group V (Volar plating) Osteotomized
Intact Control
Rigidity (N/mm)
120 ± 23
206 ± 72
Ultimate load (N)
892 ± 173
1,523 ±542
Normalized load
59%
Group D (Dorsal plating) Osteotomized
Intact Control
Rigidity (N/mm)
185 ± 98
335 ± 168
Ultimate load (N)
1,357 ± 668
2,267 ± 992
Normalized load
60%
Comparison between the Volar Approach and the Minimally Invasive Dorsal Approach in the Management of Extraarticular Distal Radius Fractures
Institution where the work was prepared: Miami Hand Center, Miami, FL, USA
Jorge L. Orbay, MD; Amel Touhami; Igor Indriago; Miami Hand Center
Purpose To compare the radiographic and functional outcomes including the complications of two common fixation techniques for the management of extra-articular distal radius fractures.
Methods This retrospective study compares a total of 70 extraarticular distal radius fractures treated either with ORIF using the volar plate or the dorsal nail plate, respectively. The clinical, radiological, and rehabilitation records of 54 women (median age, 66 years) and 16 men (median age, 54 years) were reviewed. The mean duration of follow-up was 18 months. All fractures were scored according to the AO classification. None of the injured wrists presented static intercarpal instability or unstable lesions of the distal radioulnar joint. Outcomes were evaluated at the time of the latest follow-up. Patients were assessed with both traditional objective measurements (range of finger and wrist motion, forearm rotation, and grip strength), and with the subjective self-administered Disabilities of the Arm, Shoulder, and Hand questionnaire. The radiographic assessment included the measurements of the final volar tilt, ulnar variance length, loss of radial length, and the final radial inclination. All outcome factors were subjected to statistical analysis with special emphasis on whether volar or dorsal plating showed any differences in the final outcome.
Results Between April 2002 and November 2004, 9 (37.5%) AO type A2 and 15 (62.5%) AO type A3 fractures were treated with ORIF using the fixed angle volar plate. Thirty-four (74%) AO type A2, and 12 (26%) AO type A3 fractures were treated with ORIF using the fixed angle dorsal nail plate, respectively. Patients who underwent volar fixation had significantly improved flexion compared with those who underwent dorsal fixation (77° vs. 71°; P = 0.02); this is probably a result of the dorsal placement of the incision. Wrist extension and forearm rotation were close to prefracture levels by 6 weeks in both groups. Grip strength averaged 82% of the contralateral side after the dorsal approach, compared with 77% after the volar approach. DASH scores were similar for both groups. No significant correlation was found between the type of fracture and the final score (P < 0.418). No significant complications were recorded in both groups. Conclusions This study demonstrates that the results of these two techniques are comparable. However, elderly patients may benefit more from an early minimally invasive dorsal approach, which is technically easier and reduces the overall period of disability.
Nonbridging External Fixation for Unstable Fractures of the Distal Radius
Institution where the work was prepared: Yokosuka Hokubu Kyosai Hospital, Yokosuka, Japan
Hiroaki Sakano, MD, PhD
Yokosuka Hokubu Kyosai Hospital
Introduction External fixation for fractures of the distal radius was mainly performed by bridging external fixation. In this study, nonbridging external fixation was performed for unstable fractures of the distal radius and the radiographic alignment and clinical results were followed up.
Methods Eighty patients (55 women, 25 men) with fractures of the distal radius were treated by nonbridging external fixation with Hoffmann 2 compact external fixator. But fractures that have communition of articular surface and volar cortex were excluded. Their average age at the time of surgery was 61 years (range, 22–92 years). The average periods of external fixation was 6.6 weeks. The average follow-up period was 1.3 years (range, 1–3 years). At follow-up examinations, radial inclination (RI), palmar tilt (PT), and ulnar variance (UV) were measured as the radiographic alignment at the point of injured and at reduction, at removal of external fixation, and at follow-up to evaluate acquirement and maintenance of reduction. Clinical assessment was achieved through the use of Mayo wrist scoring chart (Mayo score).
Results At average, final flexion was 60′, extension 61′, supination 85′, and pronation 86′. Grip strength was 81.4% of the contralateral side. According to Mayo score, there were 32 excellent, 34 good, and 14 fair results. Radiographic alignment, RI, was 15.9′ at injured and 24.4′ at the point of reduction (p < 0.001), 25.0′ at removal of fixator, 24.4′ at follow-up. PT was −15′ and 10.6′ (p < 0.001), 10.8′ (p < 0.05), 10.3′. UV was 4.0 and 1.2 mm (p < 0.001), 1.8 mm (p < 0.05), 2.0 mm. Only four cases had a loosening of half pin at metaphyseal site and three cases had pin site infection. Two patients had temporally sensory disturbance of superficial blanch of the radial nerve. No patients had extensor tendon injury.
Discussion and Conclusion Nonbridging external fixation can acquire good stability to resist dorsal tilt and axial shortening by using subchondral support, and satisfactory clinical results were gained with a few complications, even for unstable fractures of the distal radius. Nonbridging external fixation was considered to be one of the useful surgical procedures for unstable fracture of the distal radius.
A Prospective Study of Corrective Osteotomy of Distal Radius Malunion Using the Internal Distraction Device
Institution where the work was prepared: University of Michigan, Ann Arbor, MI, USA
Kevin C. Chung, MD, MS; Andrew J. Watt; Sandra V. Kotsis
University of Michigan
Purpose Radial collapse with >1 cm of radial shortening poses a difficult technical challenge in the treatment of distal radius malunion. We conducted a prospective outcomes study by using an internal distraction device (Rayhack® Osteotomy Systems, Tampa, FL) for severe distal radius malunion with radial collapse.
Methods We prospectively enrolled consecutive patients presenting with >1 cm of radial collapse that occurred for more than 1 year after inadequate reduction of distal radius fracture. Patients were distracted by using the Rayhack device, and internal fixation was accomplished with a dorsal T-plate. The following outcomes parameters were measured preoperatively, and at 3 months, 6 months, and 1 year postoperatively: (1) radiographic measurements, (2) grip and pinch strength, (3) wrist range of motion, (4) Jebsen–Taylor test, and (5) the Michigan Hand Outcomes Questionnaire (MHQ). Complications were also recorded.
Results Five patients were enrolled over a 1-year period. The radiographic data showed correction that matched the opposite uninjured control wrist. Anatomical reduction was achieved and maintained during the follow-up period. Wrist range of motion, hand strength, and Jebsen–Taylor test were markedly improved from preoperative values. The outcomes data are presented in Table 1. Patients reported much better functional and aesthetic outcomes at the 1-year follow-up period. There were no complications in this series.
Michigan Hand Outcomes Questionnaire Data
Test
Preoperative, mean ± SD
3 months postoperative, mean ± SD
MHQ Overall
43.5 ± 16.5
68.7 ± 5.0
Function
34.0 ± 24.3
56.7 ± 12.6
Activities of daily living
51.6 ±25.6
66.3 ± 15.6
Work
42.0 ± 23.3
63.3 ± 17.6
Pain
46.0 ± 30.7
16.7 ± 2.9
Aesthetics
52.5 ± 14.4
81.3 ± 27.2
Satisfaction
26.7 ± 22.0
61.1 ±8.7
6 months postoperative, mean ± SD
1 year postoperative, mean ± SD
MHQ Overall
66.8 ± 17.8
80.1 ± 11.2
Function
59.0 ± 9.6
75.0 ±7.1
Activities of daily living
62.2 ± 21.1
87.0 ± 7.3
Work
70.0 ± 32.4
90.0 ± 0.0
Pain
22.0 ± 16.8
27.5 ± 17.7
Aesthetics
76.3 ± 21.8
81.3 ± 17.7
Satisfaction
64.2 ± 17.6
75.0 ± 17.7
Conclusions Correction of severe distal radius malunion is technically difficult, but the excellent radiographic and functional outcomes justify the use of this system for treating severe distal radius malunion.
All of the MHQ scales are based on a scale of 0 to 100. For all of the scales except pain, the higher the scores, the better the subject's hand performance. For the pain scale, the lower the score, the less pain the subject experiences.
Fractures and Congenital
Kapandji Pinning of Proximal Phalanx Fractures; Addressing the Difficult and Disabling Hyperextension Fracture Pattern
Institution where the work was prepared: Miami Hand Center, Miami, FL, USA
Eduardo Gonzalez-Hernandez, MD
Miami Hand Center
Introduction Hyperextension fractures of the proximal phalanx are common following falls FSH in elderly patients. Failure to maintain or even to achieve reduction is not uncommon. Malunion of proximal phalanx fractures can have significant functional consequences. Kapandji pinning, as performed in the distal radius, is in principle an ideal approach to correct this sagittal plane deformity.
Methods This is a prospective study of 18 patients (52-77 years of age) who underwent minor surgery to reduce and stabilize 27 fractures about the proximal phalanx. Initial closed reduction was not satisfactory and soft tissue edema precluded forceful splinting with MP joints flexed. The fifth digit was most commonly injured. The procedure is performed under local anesthesia and fluoroscopy. A 2-to 3-mm incision is made at the fracture site. The incision is just lateral to the central tendon, creating a small longitudinal tenotomy over the extensor hood to avoid tethering over the pin. A 4.5 pin is introduced freehand into the fracture site. The free end of the pin is levered proximally while the finger is flexed to reduce the extension deformity. The pin is advanced to engage the opposite cortex. Range of motion is checked and the pin is cut underneath the skin. An MP blocking cast is applied, leaving PIP joints free. All pins are removed at 4 weeks.
Results All but one fracture healed in good alignment; one patient fell and lost reduction. Average residual dorsal angulation was 5°. Significant swelling in 35% of patients, secondary to initial trauma, was managed aggressively with therapy, anti-inflammatories, strict elevation, and in two with Medrol dose packs. One patient underwent stellate ganglion blocks for CRPS. ROM of the involved digit was sufficiently restored in all patients such that the tip-to-palm distance was nil. Most developed a mild contracture of the PIP joint measuring 5° on average. Grip strength at 6 months was equivalent to the opposite side when adjusted for dominance. All were highly satisfied and were able to return to preinjury activities.
Conclusion These injuries are not inconsequential. Once a malunion develops, the patient cannot effectively make a fist. This fracture pattern may be difficult to correct and maintain by closed methods. In addition, swelling and stiffness can develop rapidly in the elderly. Minimally invasive Kapanji intrafocal pinning of these fractures, together with early PIP range of motion and edema control, can lead to excellent results in most patients.
Experimental Study of the Role of Locked Plates in Metacarpal Fracture Fixation
Institution where the work was prepared: University of Arkansas for Medical Sciences, Little Rock, AR, USA
Randy R. Bindra, MD, FRCS; Pramod K. Nelluri; Torrance A. Walker; William R. Hogue, BS
University of Arkansas for Medical Sciences
Purpose The ability to lock screws into a plate has been a significant advance in internal fixation and has found wide application in lower extremity fracture management. The reduced tendency for screw loosening makes them advantageous in osteoporotic bone. While the benefits of locked plates have been examined with axial loading in long bones, the effect of tension loading of locked plates in small bones such as the metacarpal have not been examined. The purpose of this study was to evaluate the stability provided with locked plating and compare it with conventional plating in a metacarpal fracture model for both normal and osteoporotic bone.
Methods We used a 2.0-mm, 6-hole Smartlock™ plate (CMF system, Stryker-Leibinger Inc.) that can be applied with conventional or locking 2.0-mm screws. The locking screws have modified threads near the head to lock into the plate hole as the screw is fully seated. Fixation was evaluated in two standardized test materials of differing strengths. Laminated blocks (failure load = 1,025 N) simulated normal bone and 15 pcf density polyurethane blocks (failure load = 115 N) represented osteoporotic bone (Sawbones®, WA). Each block was divided to create a transverse fracture, and then reduced and plated with three screws in each fragment. A total of 40 specimens were studied, with 10 specimens for each of the two materials and the two plating systems. Mechanical testing was performed by using a 3-point loading protocol with an MTS Bionix testing machine (MTS System Corp., MN). Specimens were loaded in tension by force application opposite the plated side at a rate of 0.1 mm/s until failure. The failure mode and ultimate failure load (Newtons) were recorded for each specimen. Stiffness (N/mm) was calculated from the linear slope of the load–displacement curve.
Results All specimens failed by material fracture through the distalmost screw hole. In normal models, locked plates had a significantly higher failure load (1,263 versus 1,129 N) and were significantly stiffer (615 versus 415 N/ mm) than conventional plates. In the osteoporotic model, material weakness led to similar failure loads (191 and 192 N) but locked plates were significantly stiffer than conventional plates (74 versus 62 N/mm).
Conclusions A stiffer plate-bone construct implies increased fracture stability with reduced tendency for displacement with mobilization. Our results suggest that the use of locked plates for dorsal plating of metacarpal fractures may provide increased fracture stability in both normal and osteopenic bone.
Mechanical Properties of Unicortical Versus Bicortical Plating in a Metacarpal Fracture Model
Institution where the work was prepared: University of Arkansas for Medical Sciences, Little Rock, AR, USA
Randy R. Bindra, MD, FRCS; Torrance A. Walker; Pramod K. Nelluri; William R. Hogue, BS
University of Arkansas for Medical Sciences
Introduction Dorsal plating provides the most stable method of metacarpal shaft fracture fixation. A recent study has suggested that unicortical plating does not adversely affect fracture stability. However, the role of unicortical fixation has not been examined for different bone strengths and may be inadequate in osteoporotic bone.
Aim We hypothesized that there is no difference in stability of unicortical versus bicortical plate fixation in metacarpal fracture models of normal or osteoporotic bone.
Methods Laminated blocks (failure load = 1,025 N) were used to simulate normal metacarpals and 15 pcf density polyurethane foam blocks (failure load = 115 N) were used as osteopenic metacarpals. Specimens were divided in the middle to simulate a transverse shaft fracture that was fixed with a 2-mm, six-hole plate (CMF system, Stryker-Leibinger Inc.) with three screws in each fragment. A total of 40 specimens were studied, with 10 unicortical and 10 bicortical screw fixations for each of the two materials. Mechanical testing was performed with an MTS 858.20 Bionix servohydraulic machine with TestWorks 4 software (MTS System Corp., MN, USA). The specimens were loaded in tension using a 3-point bending load applied opposite the plated surface at a loading rate of 0.1 mm/s until failure. Load to failure was recorded in Newtons and stiffness (N/mm) was calculated from the linear slope of the load–displacement curve. The mode of failure was also recorded.
Results Failure occurred by fracture of the material through the most distal screw hole in all groups except unicortically plated osteoporotic models where failure occurred by screw pullout. In the normal bone model, the mean load to failure was significantly higher for bicortical (1,129 N) versus unicortical fixation (884 N). Bicortical plating was also significantly stiffer (445 N/mm) than unicortical (360 N/ mm). Similarly in the osteoporotic models there was a significant difference in the load to failure for bicortical (192 N) versus unicortical plating (126 N). Bicortical fixation (62 N/mm) was also significantly stiffer compared to unicortical plating (30 N/mm).
Conclusions Our findings suggest that unicortical fixation of a plate may result in significant decrease in the strength and stability of fixation when loaded in tension. The reduced stability of unicortical plating may be even more obvious in osteopenic bone when failure may occur by screw pullout. The role of unicortical fixation for plating of metacarpal fractures needs to be evaluated further before it can be routinely recommended for clinical application.
Intramedullary Rod Fixation of Multiple Metacarpal Fractures
Institution where the work was prepared: Valley Orthopaedic Surgery Associates, Van Nuys, CA, USA
George Walter Balfour, MD
Valley Orthpaedic Surgery Associates
Purpose Multiple metacarpal shaft fractures tend to shorten and angulate. Multiple methods for treatment have been described. The purpose of this study is to present the results of treatment in patients with multiple metacarpal fractures treated with an intramedullary rod device (Hand Innovations).
Methods Over a period of 4 years, 66 patients were treated with minimally invasive intramedullary rod fixation (Small Bone Fixation by Hand Innovations) of the metacarpals and phalanges. Ten of these patients had multiple metacarpal shaft fractures. I retrospectively reviewed my results in these 10 patients This device is a soft, flexible rod. Its tip is prebent and can be additionally shaped to fit each metacarpal. The device is inserted by hand. No power instruments are used. A small 0.5- to 1-cm incision is used and the device is inserted by hand under fluoroscopic control. Rotation is controlled either by stacking a second rod in a metacarpal shaft, or by buddy taping to adjacent digits, or by both.
Results The average follow-up time was 129 days. The average time to rod removal was 93 days. Five patients had some stiffness, which persisted in three patients for more than 1 month (averaging 76 days). No patients had residual deformity or rotational error. All but one patient was thought to have a good or excellent result.
Conclusions Intramedullary rod fixation of multiple metacarpal fractures by a minimally invasive technique has proved to be an acceptable treatment method with good results and few complications. Careful attention to rotation is required. The need to remove the rods at a second procedure is the principal disadvantage.
A Biomechanical Study of the Radial Head and Radial Head Replacements During Pronation-Supination
Institution where the work was prepared: Allegheny General Hospital, Pittsburgh, PA, USA
Adrian L. Butler, MD; Mark Baratz; Mark Miller; Karol Galik
Allegheny General Hospital
Background Several treatment options are available for radial head fractures: radial head excision, open reduction with internal fixation, and arthroplasty. Arthroplasty is most commonly indicated for radial head fractures that are not reconstructable with associated elbow valgus instability, distal radioulnar joint, or interosseous membrane injury. However, the choice of implant has been largely undetermined.
Methods Eight cadaveric elbows were used to study the travel of the native radial head with and without annular ligament, with a monoblock (Evolve, Wright Medical) and a bipolar (Katalyst, Kinetos Medical Inc) prosthesis. Marker arrays were attached to the distal radius, distal ulna, radial head, and humerus. Specimens were mounted on a custom frame with the elbow fixed at 90°. A constant force of 22 N was applied to the triceps and brachialis. Forearm rotation was initiated via traction on the pronator teres and biceps tendons. Analysis of excursion was performed with a passive marker motion analysis system (Peak5). After each experiment, the specimen was disarticulated and digitized by using a coordinate measuring machine. This permitted calculation of radial head travel, location of the pronation–supination axis, and the distance of this axis from the ulnar styloid and center of the capitellum. Statistical analysis was performed with the paired t-test.
Results Travel of the native radial head with respect to the capitellum varied considerably from 3 mm laterally to 7.4 mm medially and from 0.7 mm anteriorly to 4.2 mm posteriorly. Mean translations of the radial head are 2.0 ± 1.2 mm medial–lateral and 2.5 ± 0.9 mm anterior–posterior. After transaction of the annular ligament, the pattern of radial head travel was not altered; however, the magnitude increased by 35% (p < 0.05) in both directions. After insertion of the prostheses, the radial head traveled laterally and anteriorly from the neutral position with both pronation and supination. With the monopolar implant, an average increase of 1.0 cm (p < 0.05) in medial–lateral translation was observed when compared to the native radial head. No statistically significant difference in medial–lateral translation was appreciated between the bipolar and native radial head. When the monopolar and bipolar implants were compared, the bipolar medial-lateral translation was 0.7 mm less (p < 0.05). The mean pronation–supination axis was 2.3 ± 3.2 mm medial and 0.3 ± 2.4 mm posterior from the center of the capitellum and 0.3 ± 1.1 mm medial and 5.8 ± 2.1 mm anterior to the ulnar styloid. This axis did not change.
Distraction Lengthening for Radial Longitudinal Deficiency
Institution where the work was prepared: Children's Hospital and Beth Israel Deaconess Medical Center, Boston, MA, USA
Amir H. Taghinia, MD1; Ayman Al-Sheikh, MD2; Joseph Upton, MD2
1Brigham and Women's Hospital
2Children's Hospital and Beth Israel Deaconess Hospital
Introduction Distraction lengthening for radial longitudinal deficiency is well described in the literature. It is used to reposition the severely deviated wrist in infants and toddlers, and to lengthen the inevitably short forearm in adolescents. This report describes one surgeon's 16-year experience with distraction lengthening in children with radial longitudinal deficiency.
Materials and Methods Clinical records were reviewed of 13 consecutive patients who underwent 15 upper extremity distractions using uniplanar devices. Six distractions were performed (prior to centralization or radialization) to reposition the severely deviated wrists in five patients with type IV radial longitudinal deficiency. Nine distractions were performed to lengthen the short forearms in seven patients with radial longitudinal deficiency and two patients with Volkmann-type contractures due to neonatal forearm ischemia. After adequate lengthening, the distractor was removed and a bone flap (vascularized fibula) or graft was secured in the gap with plates and screws. The age at the time of distraction ranged from 14 days to 23 years and the duration of the distraction from 6 weeks to 15 months.
Results Distractions performed to reposition the wrist improved the average hand-forearm angle by 91.8° and the average hand-forearm position by 30 mm. Mild deformity recurred in the long term, commensurate with preoperative deformity. Distractions performed to lengthen the short forearm were successful (average length 116 mm, range 30–225 mm) except in two patients with Volkmann-type contractures, due to dense scar. Apparatus malfunction and pin-tract infections occurred in proportion to the time the distractor was left on the limb. Other complications included skin irritation, impending hardware exposure, and development of flexion contractures.
Conclusions Distraction lengthening is a powerful technique for the pediatric hand surgeon. It can be used prior to centralization or radialization to reposition the severely deformed wrist in patients with radial deficiency. Using this technique, the surgeon avoids skeletal shortening and undue strain on the nerves and vessels. When lengthening the forearm, distraction can achieve single-stage stable length improvements that far exceed those reported in the lower limb. Osteosynthesis with bone flap or graft provides stable fixation, promotes rapid healing, and avoids prolonged external fixation, thus minimizing device-related morbidity. A well-motivated patient and family are essential for this type of reconstruction. Distraction in those with Volkmann-type contractures due to neonatal ischemia is not recommended.
AAHS Poster Presentations
Abdominoplasty Use in Reconstruction of the Mangled Upper Extremity
Institution where the work was prepared: Lutheran General Hospital, Park Ridge, IL, USA
Taizoon Baxamusa, MD1; Loren S. Schechter, MD2;
1The Illinois Bone & Joint Institute
2Lutheran General Hospital
Mangled hand and upper extremity injuries present challenges to the surgeons faced with their reconstruction. Options for soft tissue coverage have traditionally involved the use of skin grafts and flaps, each with their own donor site scarring and morbidity. In attempting to minimize donor site morbidity and maximize pliable soft tissue coverage for these devastating injuries, our combined orthopedic hand and plastic surgery service has developed a regimen for the use of full-thickness skin grafts obtained from the abdomen in conjunction with negative pressure (wound vac) dressings. In utilizing this approach, we have been able to provide a large quantity of full-thickness skin for soft tissue coverage, with the additional benefit of turning donor site morbidity into a secondary advantage. We present three cases involving women age 31 to 40 with combined hand and upper extremity degloving and musculo sketal trauma. In each case, the mechanism of injury involved high-energy industrial equipment. All patients underwent emergent operative debridement and orthopedic stabilization of the musculoskeletal system followed by a second debridement at 48–72 h. The wounds were dressed with negative pressure dressings (wound vac) during the interval between debridements. Adequacy of the wound bed was assessed by the attending orthopedic and plastic surgeons. All patients were counseled as to the risks and benefits of split-thickness graft harvest from a thigh donor site, versus full-thickness graft harvest from an abdominal donor site. All three patients chose to proceed with full-thickness skin grafts from an abdominal donor site. All patients had complete graft take with no abdominal donor site complications. All patients were pleased with the appearance of their abdominal donor site and underwent uneventful postoperative recovery and therapy. The use of full-thickness skin grafts from the abdomen should be considered when the area of skin required exceeds that which is readily available from traditional donor sites such as the groin or upper arm. Full-thickness skin grafts provide more durable skin with an improved aesthetic appearance as compared to split-thickness grafts. Furthermore, in determining choice of donor site, consideration must be given to donor site scarring and morbidity. In utilizing the abdominal donor site, there is actually an improvement in donor site appearance. In our series, all patients were extremely satisfied with their abdominal donor site, and despite the severity of the injury to their limbs, these patients had favorable results with upper extremity rehabilitation and returned to work.
Aberrant Course of a Communicating Branch of the Ulnar Nerve to the Median Nerve Contributing to Hypothenar Hammer Syndrome
Institution where the work was prepared: Division of Plastic Surgery, Baylor College of Medicine, Houston, TX, USA
Jamal Bullocks, MD; Winston Richards, MD; Morgan Edward Norris, MD, DDS
Baylor College of Medicine
A 55-year-old male pipe fitter presented with digital ischemia of his right ring finger 3 days after repetitive traumatic use of his hand at work. Clinical and radiographic evidence revealed ulnar artery thrombosis, consistent with hypothenar hammer syndrome. Treatment included surgical exploration with excision and microsurgical reconstruction of the thrombosed ulnar artery segment. At surgery, a communicating branch of the ulnar nerve to the median common digital nerve of the ring finger was identified crossing volar to the superficial palmar arch. The superficial palmar arch proximal to this crossing nerve branch was dilated and thrombosed. The incidence of a communicating branch between the ulnar and median nerves ranges between 60% and 90% in the general population. The course of this nerve as it relates to the superficial palmar arch is not well described in the literature. The etiology of hypothenar hammer syndrome is related to repetitive palmar trauma impacting the ulnar artery in Guyon's canal. Intrinsic arterial fibrodysplasia has been proposed as a predisposing factor for the development of HHS. This paper is one of the first to describe an anatomical variant acting as an extrinsic contributing factor to the development of HHS. The clinical findings in this case suggests that either the communicating branch played a role in compression and stenosis of the vessel leading to thrombosis or defined the stopping point of distally progressing thrombus. There is the possibility that this variant of anatomy, if not recognized, could represent a source of failure of surgical or nonsurgical management of HHS. Further investigation of the relationship between the communicating branch and the superficial palmar arch is needed to determine a possible link to hypothenar hammer syndrome.
Assessment of Four Midcarpal Radiologic Determinations
Institution where the work was prepared: Texas Tech University HSC & Walter Reed AMC, El Paso, TX, and Washington, DC, USA
Miguel Pirela-Cruz, MD1; Mickey Cho, MD2; Vincent Batista1
1Texas Tech University HSC, El Paso
2William Beaumont Army Medical Center/Texas Tech University HSC
Purpose Several radiologic measurement methods have been described in determining static midcarpal alignment of the wrist. These include the scapholunate, radiolunate, and capitolunate angles. The triangulation method is an alternative radiologic measurement that, we believe, is easier to use and more reproducible and reliable than the above-mentioned methods. The purpose of this study is to assess the intraobserver reproducibility and interobserver reliability of the triangulation method, scapholunate, radiolunate, and capitolunate angles.
Methods Twenty orthopedic residents and staff at varying levels of training made four radiologic measurements (triangulation method, scapholunate, radiolunate, capitolunate, and) on five different lateral, digitized radiographs of the hand and forearm in neutral radioulnar deviation. Thirty days after the initial measurements, the participants repeated the four radiologic measurements using the same radiographs.
Results The triangulation method had the best intra- and interobserver agreement of the four methods tested. This agreement was significantly better than the capitolunate and radiolunate angles. The scapholunate angle had the next best intraobserver reproducibility and interobserver reliability.
Conclusions The triangulation method has the best overall observer agreement when compared to the scapholunate, radiolunate, and capitolunate angles in determining static midcarpal alignment. No comment can be made on the validity of the measurements because there is no radiographic gold standard in determining static midcarpal alignment.
Can Contralateral C7 be Used to Neurotize Two Recipient Nerves at the Same Time?
Institution where the work was prepared: Hua Shan Hospital, Fudan University, Shanghai, China
Introduction Contralateral C7 is a good source of nerve outflow for nerve transfer especially in pan brachial plexus avulsion injuries when donor nerves are lacking. To make better use of its abundant nerve fibers, contralateral C7 was used to neurotize more than one recipient nerves. The efficacy of nerve transfer was evaluated.
Materials and Methods Total root avulsion of the left brachial plexus was created in 105 adult Sprague-Dawley rats. Various fashions of contralateral C7 transfer were performed according to group assignment. Those included C7 to median nerve alone (A), C7 to musculocutaneous nerve alone (B), C7 to radial nerve alone (C), C7 to median and musculocutaneous nerve simultaneously via pedicled ulnar nerve graft only (D), C7 to median and musculocutaneous nerve simultaneously via both ulnar nerve and sural nerve grafts (E), C7 to median and radial nerve simultaneously via pedicled ulnar nerve graft only (F), and C7 to median and radial nerve simultaneously via both ulnar nerve and sural nerve grafts (G). Recovery of median, musculocutaneous, and radial nerve function was evaluated by grasping test, grooming test, and pawprinting test, respectively on a weekly base during the first postoperative month and then at 2, 3, and 6 months.
Results Postoperatively, total palsy of the left forelimb was noted followed by atrophy. As the postoperative interval prolonged, function of the affected limb gradually recovered. Grasp was observed at postoperative days 49.2 ± 6.6, 54.4 ± 8.2, 51.0 ± 3.9, and 57.0 ± 8.9 in groups A, D, E, and F, respectively. Grasp force of group A was stronger than that of groups D, E, and F at 2 months. The difference, however, disappeared at 3 and 6 months. On average, grooming was observed 51.2 ± 6.6, 56.5 ± 9.4, and 54.0 ± 9.1 days after surgery in groups B, D, and E, respectively. Eighty percent of group B, 40% of group D, and 80% of group E achieved grade 3 and higher recovery in grooming test. As for pawprinting test, there was no significant difference in groups C, F, and G.
Conclusion Functional recovery of C7 transfer to two recipient nerves was comparable to the results when C7 was transferred to one single nerve. Nerve regeneration in the double neurotization procedure was as good as that in single neurotization. Contralateral C7 can be used to neurotize two recipient nerves at the same time.
Carpal Kinematic Changes from Trapezium Excision
Institution where the work was prepared: University of Southern California, Los Angeles, CA, USA
Christopher L. Olch, MD1; Stephen Schnall, MD2; Thomas Hedman
1Naval Hospital Bremerton
2University of Southern California
Objective To determine if excisional arthroplasty of the trapezium, commonly performed for basal arthritis of the thumb, results in carpal instability.
Methods Eight cadaver specimens of the wrist were potted in polyurethrane. A tension of 4.5 N was applied to the sutured groups of the finger flexors, wrist flexors, and finger extensors. A cable sutured to the extensor carpi radialis brevis and longus was connected to an MTS testing device. Light emitting diode (LED) arrays were attached to threaded pins fixed in the base of the middle metacarpal and the dorsal scaphoid. Three-dimensional optical tracking of wrist and scaphoid rotational motion was measured as the MTS tension on the wrist extensors was varied to allow wrist flexion and extension. The specimens were tested with the trapezium intact and with the trapezium excised to determine if there was any change in the kinematics of the wrist or scaphoid.
Results There was no statistically significant difference in wrist rotational motion after excision of the trapezium by paired t test. There was a significant increase in scaphoid flexion extension motion (FEM) and in radial ulnar deviation (RUD), with trapezium excision, each p = 0.012 by paired t test. There was no significant change in scaphoid pronation supination rotation (PSR). Scaphoid FEM relative to wrist FEM increased, approaching statistical significance with a p = 0.06.
Conclusion Excisonal arthroplasty of the trapezium results in more flexion and ulnar deviation of the scaphoid in vitro. Carpal instability rendering the scaphoid and proximal carpal row to a dorsiflexed posture did not occur. Clinical significance of the scaphoid kinematic changes could be determined by in vivo prospective study of patients before and after trapezium excision with axial helical computed tomography employing three-dimensional registration techniques.
Closure of Complex and High-Risk Hand Wounds with Integra Artificial Skin
Institution where the work was prepared: St. Joseph's Hospital, Phoenix, AZ, USA
Marc E. Gottlieb, MD
St. Joseph's Hospital
Complex, high-risk hand wounds can be safely and dependably closed when customary models of wound closure—repairs, grafts, flaps—are not eligible. Integra Dermal Regeneration Matrix (Integra Life Sciences), is a collagen-chondroitin sponge, originally developed for burns. It has unique biological properties, such as suppression of inflammation and normal repair. Regenerating instead via embryonic mechanisms, its use constitutes in situ tissue engineering, a new paradigm of wound surgery that is independent of physiological wound healing.
Specific properties include the following: high-grade artificial skin, protects essential structures; not initially alive, it is tolerant of disease, injury, and conditions which fail autogenous closure; suppresses inflammation, controlling progressive injury in ischemic and pathological wounds; suppresses wound healing, preventing scars and contractures; thin compliant final tissue, suitable for mechanical areas such as the hand; conducts histogenesis, permitting tissue formation over voids, such as joints and hardware.
Integra survives and regenerates where ordinary repairs and grafts fail. For complex wounds, it has the same nominal indications as flaps, but Integra works where flaps, too, might fail. The governing principle is to use Integra whenever conventional concepts mandate a flap, but a flap cannot be used because of circumstances of disease or injury, altered anatomy, and patient health and risk. Illustrative cases:
A 42-year-old diabetic woman with hand atherosclerosis. Fingertip injury progressed to complete long and partial ring finger necrosis. The ring finger was salvageable, but flaps and grafts were not available, would have failed, and would have put the hand at additional risk. Integra was used to close ring finger flexor tendons and IP joints. Healed without complication.
A 43-year-old man with scleroderma, upper extremity angiopathy, and ulcerated dorsum of index finger, with open bone, tendons, and intraarticular MP joint. Sclerotic, angiopathic skin precluded local flaps, and risk was high for any autogenous repair. Integra over the exposed structures (with angiolysis and digital sympathectomy) resulted in a healed hand with compliant MP joint.
A 58-year-old man with intraarterial injection injury causing hand necrosis. Salvageable parts included metacarpals below the heads, but insufficient skin for closure. Integra was used for skin restoration, instead of further bone and hand shortening. Healed, stable, and functional.
Integra should be used for complex wounds where flaps are conventionally indicated but cannot be performed because of disease, altered anatomy, or patient risk. Similar histories and successful results are presented for seven hand patients, plus illustrative examples from other areas.
Community-Acquired MRSA in Hand Infections at Urban Medical Center
Institution where the work was prepared: Temple University, Philadelphia, PA, USA
Ravi Kiran, MD; Adam P. Angeles; Melinda Lacerna; Beth Mccampbell; Richard Montilla; Carlos Medina; Julie Spears; Amit Mitra; Earl Fleegler; Rhoda Powell, MD
Temple University
Introduction In the past few years, there has been an increased incidence of community-acquired MRSA (CA-MRSA) reported in the literature. Community acquired MRSA infection outbreaks have been found in select groups of patients including prison inmates, IV drug users, and nursing home patients. The purpose of this paper is to report the increased incidence of CA-MRSA in hand infections at an urban medical center.
Materials and Methods We performed a retrospective review of all patients with hand infections over a 21-month period (September 2003-May 2005) and all patients with culture-positive MRSA were identified. Demographic data was collected along with risk factors for nosocomial MRSA. Based on further chart review, these patients were determined to be community-acquired MRSA and separated from those of nosocomial MRSA patients. The study period was divided into three 7-month periods to evaluate the incidence of CA-MRSA.
Results A total of 343 hand infections were treated over a 21-month period. Eighty-nine (89) patients with culture-positive MRSA were identified. Fourteen patients were determined to be hospital-acquired MRSA patients based on chart review. The remaining 75 patients were determined as community-acquired MRSA patients. During the last 7-month period, a significant increase in MRSA in hand infections was identified. MRSA incidence increased to 47% during the last 7 months compared to 16% and 17% in the first two 7-month periods, respectively. The mean length of stay for CA-MRSA patients was 3.15 days.
Conclusions There is a significant increase in community-acquired MRSA in hand infections. Health care providers including emergency room physicians, plastic surgeons, hand surgeons, and orthopedic surgeons should be aware of the increased incidence of CA-MRSA in hand infections. Health care institutions need to make a coordinated effort to control the epidemic of community-acquired MRSA. This needs to involve education of the patients regarding resistant bacteria and prophylactic efforts to control spread of MRSA in the community as well as preventive efforts by the health care providers in the inpatient setting. Cultures should be carefully followed for treatment with appropriate antibiotics.
Endoscopically Assisted Excision of Digital Enchondroma
Institution where the work was prepared: Northwestern University, Chicago, IL, USA
Jeffrey F. Dietz, MD1; Sergey M. Kachar, DO2; Daniel J. Nagle, MD1
1Northwestern University, Feinberg School of Medicine
2Midwestern University
We present two cases of endoscopically assisted curettage of enchondromas of the hand. After initial open curettage of the lesion, a 1,9-mm arthroscope was introduced through the cortical window. Under arthroscopic guidance, residual pathologic material was freed from the cavity wall and evacuated with the aid of repeated saline lavage combined with suction. The endoscope was then used to observe the filling of the cavity with demineralized bone matrix (DBX, Synthes). We believe that endoscopically assisted curettage presents several advantages over open curettage alone. First, direct visualization of the medullary canal permits accurate assessment of the extent of the enchondroma. Second, the endoscope permits accurate assessment of the adequacy of the curettage avoiding the need to perform multiple, blind, and aggressive passes with a curette. Multiple passes can increase the risk of violation of the cortical shell and prolong the procedure. Third, the ability to completely clear the medullary canal of all tumor should logically reduce the rate of recurrence.
Hand Trauma Associated with High Energy Winch and Cable Pulley Accidents
Institution where the work was prepared: New York University School of Medicine, New York, NY, USA
Keith Michael Blechman, BA; Roberto Luis Flores, MD; David W. Friedman
New York University
Introduction Winches and pulleys composed of a cable wound around a cylinder are common devices used to lift loads in both recreational and industrial settings. Because of the intense shear and compressive forces applied, significant trauma to both the soft tissues and bone results from accidents in which hands are caught in these devices. Management is typically complex involving multiple surgical procedures. The purpose of this study was to analyze the injury patterns, types of reconstruction, and complications seen in these patients.
Methods This IRB-approved retrospective study examined five consecutive cases at a single New York City institution. Charts and radiographic images were reviewed for causes of injury as well as injury patterns. Management, numbers of operations, and subsequent follow-up evaluations were reviewed as well.
Results The average patient age was 39 years. Two injuries occurred on a boat, two while repairing an elevator and one while repairing an escalator. The dominant hand was injured in three patients. All patients sustained trauma to digits III, IV, or V manifesting as either fracture, degloving, and/or amputation. The most common amputation pattern was avulsion of the digit from the base of the proximal phalanx with tendon avulsion from the forearm muscle belly. Trauma to digit II was present in three patients and also consisted of amputation at or just distal to the MCP joint. Thumb injury occurred in only one patient and consisted of a Rolando's fracture. No replantations or revascularizations were deemed possible because of the significant soft tissue injury. All cases required debridement. Three patients underwent reconstruction for major soft tissue loss by pedicled groin and forearm flaps. Each patient required, on average, 2.4 operations. There was one case of late infection resulting in a single digit amputation and one case of volar forearm compartment syndrome requiring fasciotomies.
Conclusion High-energy winch and cable pulley accidents cause severe trauma to the hands when caught in these devices. The common pattern of injury is characterized by multidigit bone and soft tissue avulsion amputations at or just distal to the MCP joint, more likely on the ulnar aspect of the hand, with tendon avulsions from the forearm muscle bellies. Multiple operative procedures are typically required. These patients should be carefully monitored for the development of a compartment syndrome or infection. Long-term functional outcome in these patients is currently being studied.
In Vivo Contact Pressures from MRI-Based Computer Models
Institution where the work was prepared: University of Kansas, Lawrence, KS, USA
Kenneth J. Fischer, PhD1; Ravi R. Pillai1; Bhaskar Thoomukuntla1; Terence E. Mclff2; Gerard A. Ateshian3; EB Toby, MD2
1University of Kansas
2University of Kansas Medical Center
3Columbia University
This study evaluated the feasibility of MRI-based joint contact models for determining in vivo joint contact pressure distributions during functional loading. Four subjects underwent MRI scans of the wrist during constant light grasp and with the hand relaxed. The MRI data from the two image sets was used to construct surface models of the bones. The contact area, pressure distribution, and forces were determined for the light grasp loading condition. Contact areas directly measured from the MRI images were used to verify the results.
The overall average contact areas from the MRI-based contact models and the direct MRI measurements were within 10% for radioscaphoid and scapholunate contact, indicating reasonable model accuracy. The contact pressure data indicated dorsal scaphoid contact on the radius for all subjects and dorsal lunate contact for all but one subject (Fig. 1). The ratio of radioscaphoid contact area to radiolunate contact area from this study is consistent with experimental studies for neutral flexion to 20° wrist extension. Our mean ratio of radioscaphoid peak pressure to radioscaphoid force is nearly identical with published values. Novel scapholunate contact data indicate that the contact was generally well centered on the lateral aspect of the lunate. Scapholunate contact parameters appear to be very similar to radiolunate contact pressure, area, and force.
Presures on the distal radius (medial-volar view) and lunate from scaphoid contact (lateral view).
MRI-based contact models can provide contact pressures between the small bones of the wrist, and can produce data to help evaluate surgical procedures. Contact pressure maps for patients will help clinicians understand the level and distribution of arthritic degeneration. For patients with postinjury deformity, the MRI-based models could be used to determine if contact pressures in the radiocarpal joints require corrective surgery.
Initial Validation of MRI-Based Models for in Vivo Contact Data
Institution where the work was prepared: University of Kansas, Lawrence, KS, USA
Kenneth J. Fischer, PhD1; Bhaskar Thoomukuntla1; Gerard A. Ateshian2; Mehmet Bilgen, PhD3; Terence E. Mclff3; E.B. Toby, MD3
1University of Kansas
2Columbia University
3University of Kansas Medical Center
MRI-based contact models can provide in vivo contact pressures between the small bones of the wrist, and could yield in vivo data to help evaluate surgical procedures. Contact pressure maps for patients will help clinicians understand the level and distribution of arthritic degeneration and determine the most appropriate course of treatment. The objective of this study was to begin validation of MRI-based contact models.
One cadaver specimen was subjected to simulated grasp by loading the FDP, FDS, and FPL tendons. The Tekscan system was used to measure the radiocarpal pressures during simulated grasp. The specimen also underwent two MRI scans—one without load and one with simulated grasp. MRI data from the two image sets were used to construct surface models of the bones. The contact area, pressure distribution, and forces were determined for the simulated grasp loading condition. Contact areas directly measured from the MRI images and the Tekscan data were used to verify the model results.
The contact pressure distribution from the MRI-based model qualitatively corresponds well to the pressure sensitive film data and the Tekscan sensor data (Fig 1). Both measures indicate that the contact regions are located dorsally on the radius. The Tekscan data indicate somewhat of a horizontal and vertical axis of increased pressure for the radioscaphoid contact. This corresponds well to pressure distribution from the MRI-based model, with the vertical axis corresponding to pressure along the lateral ridge of the scaphoid fossa. Lunate contact is smaller and more circular in both the Tekscan plot and the pressure map from the model. Quantitatively, the radioscaphoid peak pressure from the MRI-based model (1.4 MPa) is within 10% of the value from the Tekscan sensor (1.5 MPa). The difference between the model (1.1 MPa) and the Tekscan (0.7 MPa) data for radiolunate peak pressure was only 0.4 MPa. Contact area and contact force data were also in reasonable agreement.
Telescan sensor presures on the distal radius and presures from the MRI-based model of radiocarpal contact.
Isolated Volar Dislocation of the Ulna at the Distal Radioulnar Joint: A Case Report with an Evidence-Based Assessment of the Literature
Institution where the work was prepared: Jeffrey F. Haasbeek; C. Vaughan; A. Bowen, Calgary; AB, Canada; C. Vaughan; A. Bowen
University of Calgary
We present a 20-year-old female with a late presentation of an isolated volar dislocation of her left ulna at the distal radioulnar joint (DRUJ). In this case, a closed reduction was successful although our plans were an open reduction with a DRUJ reconstruction. As there is no clear consensus for treatment, an evidence-based investigation of the literature was undertaken. The hypothesis was that closed treatment failed when there was a delay in diagnosis and treatment. The current knowledge on this problem was investigated. The basic science as well as clinical examination, imaging techniques, and treatments were reviewed. A volar dislocation of the distal ulna is thought to occur from a hypersupination injury. The forearm is locked in supination. It can also occur from a direct volar force on the distal ulna when the wrist is supinated. Medline and Science Citation Index computer searches were performed of the literature by using the terms “volar dislocation ulna distal radioulnar joint.” The references were analyzed in regards to the following: age of the patient; injury mechanism; time to treatment; treatment type (closed treatment, length and position of immobilization) (open treatment, type of procedure); follow-up time; range of motion; strength; return to work; complications; further treatment required. The 80 Medline (1950–present) and Scientific Citation Index Expanded (1975–present) searches yielded 25 articles used in this paper. Using the references from these papers yielded an additional 16 papers. A total of 28 patients were reported with isolated volar dislocation of the distal ulna in this study. All investigations were noncontrolled case reports. With a small number of case reports in the literature on isolated volar dislocations of the distal ulna, no consensus exists for the best management of the condition. The data would suggest closed treatment for injuries within a week and open treatment for those injuries 6 weeks or greater. With limited data, we can only discuss trends that seemed to have occurred in the world's literature on this subject. It is impossible to be more certain. Our understanding of the anatomy, injury mechanism, and diagnosis of volar distal ulna dislocation far exceeds our ability to select the best treatment method, especially when treatment is delayed. Therefore, the treatment still is influenced by the experience, expertise, and bias of the individual clinician.
Morphometry and Architecture of the Human Scaphoid: A Cadaveric Study
Institution where the work was prepared: University of Arkansas for Medical Sciences, Little Rock, AR, USA
Randy R. Bindra, MD, FRCS; Andrew D. Heinzelmann; Graeme C. Archer; Daniel S. Perrien; Larry J. Suva
University of Arkansas for Medical Sciences
Purpose Several implants varying widely in size and design are now available for scaphoid fracture fixation. Information on scaphoid morphometry and architecture of the bone is lacking and may affect choice of implant. The purpose of this study was to correlate morphometric and demographic data to establish normative measurements of the human scaphoid. The internal architecture of the scaphoid was evaluated by using microcomputerized tomography (microCT).
Methods We studied 34 paired cadaveric scaphoids by using a digital caliper to obtain the following measurements: scaphoid length (anatomical and surgical) and width (proximal pole, waist, and distal pole). The scaphoid size was correlated with commercially available screw sizes. Five specimens were scanned in a microCT40 (SCANCO Medical AG, CH) at 70 kV, 114 mA, with a slice thickness of 36 μm. 3D reconstructions were created and longitudinal sections of the scaphoid were examined to establish trabecular pattern.
Results The male scaphoid was significantly longer (28.8/ 25.9 mm) and wider (proximal: 4.5/3.7 mm, waist: 12.3/ 10.5 and distal: 7.4/6.3 mm) than the female scaphoid. The smaller size of the proximal scaphoid pole implied that some screw types were too large for insertion by antegrade techniques. The minisized options available with some manufacturers were more appropriate for female scaphoids. Architectural assessment of the specimens revealed that the scaphoid consists of a narrow rim of cortex enclosing trabecular bone distributed in a consistent pattern that follows the vascular distribution. Trabeculae were most dense in the proximal pole and thinnest at the waist.
Conclusions The female scaphoid is smaller in length and diameter, and this must be taken into consideration when planning internal fixation. With the narrowest diameter at the proximal pole and most dense trabeculae, placement of a central guide wire in the scaphoid and screw fixation may best be achieved from a proximal to distal direction. Because of the thin cortical structure and largely trabecular structure, a fully threaded screw may provide more stable fixation. We are undertaking further micro structural studies to examine the effect of screw fixation on the scaphoid bone.
Nerve Grafting in the Upper Extremity (Review of 130 Cases)
Institution where the work was prepared: Boston University School of Medicine, Boston, MA, USA
Harilaot T. Sakellarides, MD
Boston University School of Medicine
Purpose To demonstrate that autogenous nerve grafting can give rewarding results provided certain techniques can be provided.
Methods The study covered a total of 130 cases: 70 involved the median nerve, 40 the ulnar nerve, and 20 the radial nerve. Study population consisted of 85 males and 45 females, whose ages ranged from 20 to 60 years. The time of injury to grafting was from 6 months to 5 years. Follow-up ranged from 2 to 15 years. The procedure consisted of exploring the injured peripheral nerve with excision of neuromas and insertion of autogenous nerve grafts that were taken from the lower extremities of the patient. The nerve grafts were approximated to the proximal and distal ends of the injured nerve under the microscope by using fine instruments and microsurgical techniques.
Results Motor recovery for median nerve low lesion were as follows: recovery of thenar muscles from M3-M4 level was excellent in 40%; M2-M3, good in 40%; M1-M2, fair in 20%. Ulnar nerve motor recovery for intrinsics to level M3-M4 was excellent in 38%; for level M2-M3, it was good in 40%; for M1-M2, fair 22%. Motor recovery for radial nerve: extensors of wrist, fingers, and thumb, to level M3-M4 excellent in 42%, good in 38%, and fair in 20%.
Conclusions In a large number of patients, this method has improved the function of the extremity considerably. It has given us much superior results than before the use of microscope and microsurgical instruments. By doing nerve grafting, one avoids excessive mobilization of nerve ends, stretching, suture under tensin, and immobilizing of joints.
Schwannomas of the Upper Extremity—An Operative Series
Institution where the work was prepared: University of Massachusetts, Worcester, MA, USA
David Kahng, MD; Rodrigo Santamarina, MD; Mustafa Akyurek, MD; John Sufflebarger, MD; Thomas Breen, MD; Douglas Rothkopf, MD
University of Massachusetts
Schwannomas are the most common benign nerve tumors occurring in the peripheral nerves of the upper extremity. Between 2001 and 2005, a total of 10 patients (6 male and 4 female, average age 50.6 years) underwent surgical excision of 14 schwannomas of the peripheral nerves of the upper extremity. The incidence of involved nerve, follow-up results, and complications were evaluated. The brachial plexus was the site in one patient, the ulnar nerve was involved in five patients, the median nerve in three patients, and a digital nerve in one patient. Most patients had complaints of a palpable mass and/or intermittent pain. One patient had, in addition, weakness of the hand. A single patient had two recurrences: one in the same location and the other located remotely. Another patient had multiple tumors occurring in the same anatomic area. The duration of the symptoms/signs prior to presentation ranged from 10 months to 16 years (average 43 months). MRI was used as a diagnostic imaging technique in 7 out of 10 patients. EMG studies (2/10 patients) were used in complex cases or in patients with complaints of weakness. Complete excisions were performed in all cases. The tumors were displacing normal nerve fascicles without penetrating the fascicles themselves. This allowed resection without interrupting nerve continuity. The average size of the tumor excised was 2.1 × 1.4 × 1.2 cm. Postoperatively, all patients had resolution of their preoperative complaints of a mass, pain, and weakness. All the patients had normal 2-point discrimination and normal motor exam. Six out of the 10 patients had postoperative paresthesias that were either resolved or resolving. Follow-up averaged 10 months. Pathology revealed schwannomas with no malignant transformation seen. In conclusion, this large series of schwannomas of the upper extremity demonstrates a common mode of presentation and complication-free surgical resection after appropriate diagnostic study. Anatomic location is varied, but our treatment protocol leads to uniformly safe outcomes.
The Role of Scientific Program Committees in Ensuring Research Subject Protection
Institution where the work was prepared: Regions Hospital, St. Paul, MN, USA
Loree K. Kalliainen, MD
Regions Hospital
Purpose Adherence to Institutional Review Board (IRB) guidelines is a legal requirement for human subject research but is not universally followed. In the author's experience as an IRB Chair at a large university and in discussions with investigators at national conferences, noncompliance is not unusual. The purpose of this study was to determine how frequently IRB approval is required for inclusion of papers in scientific programs and to record the frequency with which authors disclose IRB approval in abstracts or in presentations.
Methods Instructions to authors of 11 conferences related to the practices of plastic, maxillofacial, and orthopedic surgery were reviewed. The abstracts from 5 years of hand surgery conferences were reviewed, and the author recorded mention of IRB approval at the talks attended at the most recent national hand surgery meeting. Instructions to authors of 30 peer-reviewed journals were also read.
Results The Instructions to Authors for 11 conferences currently accepting abstracts were reviewed. None required IRB approval for studies involving human subjects research. In the past 5 years of abstracts presented at a national hand surgery meeting, 5/265 (2%) mention obtaining IRB approval. At the most recent meeting, 6% of talks mentioned IRB approval. Of note, only 67% of peer-reviewed journals required documentation of IRB approval for acceptance, yet 80% require financial disclosure, and 73% require patient permission for identifiable photographs.
Conclusions IRB approval is a legal requirement for human subjects research, but it is not clear that all investigators understand or comply with the process. IRB review helps ensure that research subjects are protected while participating in studies and ensures a basic level of ethics and validity in study design. If it is reasonable to mandate documentation of financial bias, it is reasonable to expect documentation of IRB approval or waiver. Requiring documentation at the level of national presentations increases the likelihood that investigators will comply, optimizing human subjects protection.
Upper Extremity Replantation: National and Local Trends
Institution where the work was prepared: Yale University, New Haven, CT, USA
Michael W. Chen, MD; Deepak Narayan
Yale University
Objective To determine national and local trends in upper extremity replantation, and to demonstrate that large, teaching hospitals are bearing the proportionally largest economic burden of managed care's declining reimbursements for upper extremity replantation.
Methods We used the largest all-payer inpatient care database that is publicly available in the United States, the Nationwide Inpatient Sample, which is part of the Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality. The database is organized according to ICD-9 codes and we studied 10 years of data from 1993 to 2002. Locally, we utilized the Yale Billing Office database from 2000 to 2005. All analyses were performed by using SAS 9.1 statistical software. This project was approved by the Yale IRB.
Results We identified 3,219 upper extremity replants in the database, representing more than 15,000 replants performed in the United States from 1993 to 2002. We noted a near twofold increase in the percentage of replants performed at teaching (versus nonteaching) hospitals. In addition, locally at Yale, we noted a dramatic decrease in the reimbursements for replants from 100% in 2000 to 32% in 2005.
Conclusions This trend toward more and more replants being performed at teaching hospitals and less reimbursements for these replants will force teaching hospitals to find new, sustainable economic and clinical models of replantation.
Use of a Self Drilling Schanz Screw to Aid in the Excision of Carpal Bones
Institution where the work was prepared: Hospital of the University of Pennsylvania, Philadelphia, PA, USA
Kathy Huang, MD; Benjamin Chang
University of Pennsylvania
Several reconstructive wrist procedures involve resection of one or more carpal bones. Typically, this is accomplished by sectioning the bone with a saw or osteotome, followed by piecemeal removal of the fragments with a fine-tipped rongeur. This process can be tedious and imprecise, placing adjacent ligaments, tendons, and nerves at risk for inadvertent injury. We present a novel technique to simplify excision of the carpal bones, improving both safety and efficiency in these cases.
In our case series of nine patients, a 4.0/3.0 mm self-drilling Schanz screw from the Synthes® distal radius external fixator set was drilled into the carpal bone to be excised. After attaching a T-handle, the Schanz screw was then used as a “joytick” to maneuver the carpal bone in all directions. Additionally, the treaded nature of the screw allowed traction to be applied during the resection. The ligaments surrounding the carpal bones could then be dissected in a controlled fashion under direct visualization with minimal damage to the surrounding wrist capsule and adjacent structures. The same Schanz screw was reused if more than one bone was to be excised. This technique has been used successfully in three cases of scaphoid excision with four-corner fusion, two cases of trapezium excision for CMC arthroplasty, and four cases of proximal row carpectomy.
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