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Journal of Hand Surgery Global Online
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ISSN (Online) 2589-5141
Published by Elsevier Homepage  [3206 journals]
  • Outcomes and Return to Work Following Complex Nerve Lacerations in the
           Volar Forearm in an Underserved Spanish-Speaking Population

    • Abstract: Publication date: Available online 20 February 2020Source: Journal of Hand Surgery Global OnlineAuthor(s): Ryan B. Bucknam, John C. Dunn, Isaac Fernandez, Leon J. Nesti, Gilberto A. GonzalezPurposeLacerations to the ulnar and median nerve in the volar forearm have demonstrated considerable long-term clinical and socioeconomic impacts on patients. The purpose of this study was to evaluate the outcomes of complex volar forearm lacerations involving one or more major peripheral nerves in an economically disadvantaged patient population.MethodsIn this study, a retrospective analysis of 61 patients who sustained lacerations to the median nerve, ulnar nerve, or both with volar wrist lacerations was performed. Each patient’s preinjury and postinjury occupation, dominant extremity, and demographic variables were evaluated. Sensation recovery, motor recovery, Disabilities of the Arm, Shoulder, and Hand scores, visual analog scale scores, cold intolerance, and return to work were evaluated at 3, 6, and 12 months after the injury.ResultsPatients with isolated median nerve injuries demonstrated improved motor recovery compared with patients with isolated ulnar nerve injuries. Patients with combined nerve injuries had worse sensation recovery and motor recovery, and lower rates of return to work than either group of patients with isolated nerve injuries. Manual laborers had worse motor recovery and lower rates of return to work than did patients who were office workers.ConclusionsPatients with combined median and ulnar nerve injuries have worse functional recovery and lower rates of return to work than do patients with isolated median or isolated ulnar nerve injuries at 1 year. Manual laborers demonstrated worse functional recovery and lower rates of return to work compared with office workers at 1 year.Type of study/level of evidenceTherapeutic III.
       
  • Dynavisc as an Adhesion Barrier in Finger Phalangeal Plate Fixation—a
           Prospective Case Series of 8 Patients

    • Abstract: Publication date: Available online 8 February 2020Source: Journal of Hand Surgery Global OnlineAuthor(s): Johanna von Kieseritzky, Jenny Rosengren, Marianne ArnerPurposeAdhesion problems are common after plate fixation of finger phalanges and often lead to stiffness and reoperations with plate removal and tenolysis. The aim of this prospective case series was to study the effect of the adhesion barrier gel Dynavisc on total active motion (TAM), postoperative pain, and grip strength after plate fixation of phalangeal fractures. Total active motion at 3 months after surgery was the primary outcome.MethodsEight patients with a fracture of the proximal phalanx underwent surgery with open reduction and plate fixation. The adhesion barrier Dynavisc was applied between plate and extensor tendon and between tendon and skin. Results in terms of pain, grip strength, and TAM at 2 weeks, 3 months, and 1 year after surgery were collected. Results on TAM were classified according to Page and Stern.ResultsAfter 3 months, only 2 patients had a result classified as excellent. After 1 year, 3 patients fulfilled the criteria for an excellent result. There were no adverse events. Patients with long-standing postoperative pain had a worse outcome on TAM.ConclusionsThe antiadhesive effect of Dynavisc in this prospective case series was unconvincing. Only 2 patients had an excellent result on TAM at 3 months. Because the gel is resorbed within 30 days after application, it is questionable whether the gel had a role in improvement that occurred later in the postoperative course. Larger, randomized studies would be required to show any anti-adherent effect of Dynavisc definitively in finger fracture surgery.Type of study/level of evidenceTherapeutic IV.
       
  • Direct Cost of Surgically Treated Adult Traumatic Brachial Plexus Injuries

    • Abstract: Publication date: Available online 6 February 2020Source: Journal of Hand Surgery Global OnlineAuthor(s): Christopher J. Dy, Nithya Lingampalli, Kate Peacock, Margaret A. Olsen, Wilson Z. Ray, David M. BroganPurposeThe economic implications of brachial plexus injuries (BPI) in the United States are not well understood. The purpose of our study was to quantify the direct costs associated with surgical treatment of BPI after traumatic injury in adults, which would enable future study of the societal value of surgical reconstruction.MethodsUsing an administrative database of patients with commercial insurance, a cohort of patients aged 18 to 64 years with BPI treated surgically from 2007 to 2015 was assembled and assessed for index admission associated with BPI surgery and all payments toward claims (including medical, surgical, therapy, and pharmacy claims) for 1 year after surgery.ResultsAmong 189 patients undergoing surgery for BPI, median direct payments were $38,816 (interquartile range: $18,209 to $72,411; minimum: $3,512; maximum: $732,641).ConclusionsRelative to recently published data for the indirect cost of traumatic BPI (median: $801,723), direct payments for 1 year after surgical treatment represent 4.6% of the total long-term cost of BPI. In the context of existing literature demonstrating cost-effectiveness in models of BPI surgical care, our data suggest that surgery and other interventions to maximize return to work after traumatic BPI in adults may be beneficial to society.Type of study/level of evidenceEconomic and Decision Analyses IV.
       
  • Long-Term Outcomes of Donor Site Morbidity After Sural Nerve Graft
           Harvesting

    • Abstract: Publication date: Available online 6 February 2020Source: Journal of Hand Surgery Global OnlineAuthor(s): Kaoru Tada, Mika Nakada, Masashi Matsuta, Daisuke Yamauchi, Kazuo Ikeda, Hiroyuki TsuchiyaPurposeAlthough nerve autografts have been considered the standard treatment for peripheral nerve defects, limited studies have reported long-term outcomes of nerve harvesting over 15 years after surgery. This study aimed to evaluate the long-term outcomes of donor site morbidity after sural nerve graft harvesting.MethodsThirteen patients for whom more than 15 years had passed after harvesting of the sural nerve for peripheral nerve defects were included. Mean follow-up was 29.5 years. Sensory disturbances and difficulty in performing foot movements immediately after surgery and currently were evaluated on a 10-point scale. Influences on daily living and work and current satisfaction with the autologous sural nerve graft were evaluated.ResultsSensory disturbances and difficulty in movement tended to improve; however, the differences between time points were not significant. Influences on activities of daily living and work were mild, and the satisfaction level for autologous sural nerve graft was high.ConclusionsAlthough donor site morbidity after sural nerve graft harvesting persisted for a long time after surgery, foot symptoms and functional impairment were mild.Type of study/level of evidenceTherapeutic V.
       
  • Suture Button Suspensionplasty in the Treatment of Carpometacarpal
           Arthritis: A Retrospective Analysis of One Surgeon’s Experience Over 9
           Years

    • Abstract: Publication date: Available online 8 January 2020Source: Journal of Hand Surgery Global OnlineAuthor(s): Nathan Walter, Emily Duncan, Mellisa Roskosky, Tyler B. Smith, Michael S. ShulerPurposeTrapeziectomy with suture button suspensionplasty (SBS) to treat thumb carpometacarpal (CMC) arthritis has been proposed as an alternative to ligament reconstruction tendon interposition. There have been limited large-scale or long-term reports regarding SBS outcomes. Single-surgeon intermediate follow-up is reported.MethodsWe conducted a retrospective review of patients undergoing SBS procedures by a single surgeon. Implant manufacturer and postoperative immobilization protocol were recorded. Surgical outcomes, complications, and revision procedures were identified. Postoperative Disabilities of the Arm, Shoulder, and Hand scores were collected.ResultsA total of 242 SBS surgeries were included, involving 215 patients, average age 64.82 years (range, 42–86 years). Average follow-up was 35 ± 25 months. In all, 183 Arthrex and 59 Stryker systems were used, 42 of which were immobilized for 6 weeks after surgery and 200 of which were mobilized at 2 weeks afterward. Postoperative Disabilities of the Arm, Shoulder, and Hand surveys were completed by 122 patients (57%), with an average score of 12. No scaphometacarpal abutment was reported. Thirteen complications were reported (5%), 7 of which were implant-associated (3%) and 6 of which were not (2%). Implant-associated complications consisted of 3 suture button pull-outs, 2 thumb–index metacarpal abutments, one suture tail irritation, and one index metacarpal fracture. Operative revision was required in 4 of 7 implant-associated cases and 5 of 6 non–implant associated cases. No suture button pull-outs required revision surgery.ConclusionsResults for a large series of SBS for CMC arthroplasty with intermediate follow-up revealed excellent clinical outcomes and low complication rates.Clinical relevanceSuture button suspensionplasty as an alternative to ligament reconstruction tendon interposition may be a viable option for treating thumb CMC arthritis. In addition, a technique to manage thumb–index metacarpal abutment is described.
       
  • A Novel Approach to Ray Resection of the Hand

    • Abstract: Publication date: Available online 24 December 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Brendan MacKay, Hillary Wall, Amanda Weaver, Tyler Sexson, Jon Wall, Matthew Blue, Marcus DoughtyRay resections have been a viable treatment option for patients with tumors, trauma, infection, vascular insufficiency, or other abnormalities of the hand since the procedure was described in the 1920s. The creation of a functional hand after central ray resection presents unique technical challenges: insufficient closure of the gap between the metacarpals bordering the resected ray can produce an enlarged space between remaining digits and potentially cause digital malrotation, both of which negatively affect hand function. The goal is to make the space between resulting fingers as close to normal as possible. A number of procedures were described to address this issue, but unfortunately, they can be technically onerous and may require prolonged immobilization, the use of internal hardware, or the use of temporary hardware requiring removal.We describe a technique for amputation of the affected ray at the proximal metacarpal metadiaphyseal flare and a concomitant closing wedge osteotomy to allow superior gap closure between the residual fingers while maintaining the structure of the carpus and alignment of the hand. This improves functional and aesthetic outcomes after central ray resection of the hand.
       
  • Endoscopic Carpal Tunnel Release Using Wide-Awake Anesthesia

    • Abstract: Publication date: Available online 16 December 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Thuan V. Ly, Vera Urban, Claudia Meuli-Simmen, Itai PasternakPurposeWe report on patient and surgeon experience after single-port endoscopic carpal tunnel release (CTR) using wide-awake local anesthesia no tourniquet (WALANT) technique.MethodsFrom July to November 2018, patients undergoing endoscopic CTR with WALANT were prospectively included. Follow-up was 3 months. Patient ratings before, during, and after the operation were collected. We recorded the surgeon’s experience during surgery compared with the endoscopic CTR under local anesthesia with exsanguination and tourniquet. Complications were defined as nerve injury, infection, or the need for revision surgery.ResultsThe cohort consisted of 20 patients (24 wrists). All patients except one reported a complete or substantial decrease of symptoms. The 2 surgeons involved judged the procedure to be technically more demanding owing to impaired visualization (33%) caused by increased bleeding and edema in the operative field. There was one conversion from endoscopic to open surgery.ConclusionsWe recommend starting single-port endoscopic CTR using WALANT with a noninflated tourniquet in place for use when necessary.Type of study/level of evidenceTherapeutic IV.
       
  • Nonsurgical Treatment for Acute Posttraumatic Distal Radioulnar Joint
           Instability: A Case Series

    • Abstract: Publication date: Available online 4 December 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Andrew J. Bachinskas, Elizabeth A. Helsper, Harry A. Morris, Bernard F. HearonPurposeWe investigated the clinical outcomes of patients with acute posttraumatic distal radioulnar joint (DRUJ) instability who were treated with our nonsurgical protocol.MethodsThe electronic database of our community-based orthopedic practice was queried to identify patients with posttraumatic wrist pain and DRUJ instability who presented for treatment less than 6 weeks after injury. Medical records review defined a cohort of 16 patients treated between November, 2000 and December, 2016 with immobilization of the wrist and elbow for 6 weeks and gradual return to full activity at 6 months after injury. Data from the medical records were compiled and analyzed to assess short-term outcomes. Eight patients with a minimum 2-year follow-up completed questionnaires and underwent a wrist-focused examination to assess long-term outcomes. We used Wilcoxon signed-ranks exact test and McNemar chi-square exact test to confirm the statistical significance of observed trends in key outcome measures.ResultsAt a mean long-term follow-up of 6.7 years, there was statistically significant improvement in ulnar-sided wrist pain and all eight subjects examined demonstrated a negative dorsopalmar stress test indicating improved DRUJ stability. Analysis of the entire cohort showed that 11 of 16 patients (69%) were overall improved with respect to wrist pain and DRUJ stability at final follow-up evaluation. Ulnar-positive variance was a relative contraindication to nonsurgical treatment.ConclusionsPrompt above-elbow immobilization of patients with acute posttraumatic DRUJ instability may result in a good clinical outcome without operative treatment.Type of study/level of evidenceTherapeutic IV.
       
  • Radiographic Outcomes of Dorsal Spanning Plate for Treatment of Comminuted
           Distal Radius Fractures in Non-Elderly Patients

    • Abstract: Publication date: Available online 28 November 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Behnam Sharareh, Scott MitchellPurposeMultifragmentary fractures of the distal radius with articular and metaphyseal comminution (AO 23-C3) represent challenging injuries to manage. Distal fracture lines, articular comminution, and limited distal bone stock may preclude stable fixation with a volar locking plate. The use of a dorsal spanning plate (DSP) offers an alternative treatment option in this setting. We examined the radiographic outcomes of a consecutive series of patients with comminuted intra-articular distal radius fractures not amenable to volar locked plating, who were treated with a DSP.MethodsWe reviewed all distal radius fractures treated with a dorsal spanning plate at our institution between October, 2014 and March, 2018. Patients with AO 23-C3 fractures treated with dorsal spanning plate fixation were included in this study. Demographic data, time from plate placement to removal, and postoperative radiographic outcomes were examined.ResultsWe identified 24 patients, mean age 41 years (range, 19–62 years). Mean follow-up was 19.5 weeks (range, 12–35 weeks) from the time of plate placement. Plates were removed at a mean of 87 days (range, 40–215 days) after surgery. All patients achieved radiographic union. Mean radial height at the time of union was 11.1 mm (SD, ±3.7 mm; range, 6–18 mm), radial inclination was 19.7° (SD, ±5.4°; range, 9° to 30°), ulnar variance was 1.0 mm (SD, ±2.4 mm; range, –3 to 6 mm), and volar tilt was 1.4° (SD, ±5.2°; range, –10° to 14°). Mean articular displacement was 1.7 mm (SD, ±1.7 mm; range, 0–6 mm). Malalignment of at least one of these radiographic parameters was identified in 16 of 24 patients at the time of union.ConclusionsDorsal spanning plate fixation offers an alternative treatment option for comminuted intra-articular distal radius fractures (AO 23-C3). Although this technique presents a straightforward means for fixation of complex distal radius fractures, radiographic outcomes may be inferior relative to less complex fractures treated with standard volar plating techniques.Type of study/level of evidenceTherapeutic IV.
       
  • Vascularized Bone Graft to the Lunate Combined with Shortening of the
           Capitate and Radius for Treatment of Advanced Kienböck Disease After a
           Follow-Up for More Than 10 Years

    • Abstract: Publication date: Available online 27 November 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Ryosuke Kakinoki, Haruhiko Nishichi, Ryosuke Ikeguchi, Souichi Ohta, Kazuhiro Otani, Masao AkagiPurposeThis study aimed to report the outcomes of patients with stage III Kienböck disease after treatment with a vascularized bone graft (VBG) to the lunate combined with capitate shortening osteotomy (CS) after a more than 10-year follow-up.MethodsA VBG to the lunate was combined with CS in 10 patients with stage III Kienböck disease (6 patients with stage IIIA and 4 with stage IIIB). We performed VBG, CS, and radial shortening osteotomy (RS) on 7 patients. Among them, 4 had undergone RS previously. The passive wrist extension angle and wrist flexion angle, grip strength (GS), carpal height ratio, Stahl index, visual analog scale of wrist pain, and Mayo modified wrist score were assessed before surgery and at the final follow-up.ResultsThe flexion angle decreased markedly after surgery, when GS increased in all 10 patients. Radiographic examinations revealed that the carpal height ratio decreased in 9 of 10 patients, whereas the Stahl index increased in 8 patients and remained unchanged in 2. The oldest 3 of 7 patients who underwent VBG, CS, and RS exhibited fusion of the proximal carpals except the pisiform. The mean visual analog scale decreased from 27.6 before surgery to 5.7 afterward. The Mayo modified wrist score improved in 9 patients after surgery and remained unchanged in one.ConclusionsIn stage III Kienböck disease, VBG to the lunate combined with CS relieved wrist pain and increased GS and lunate height but was followed by severely restricted wrist motion. Fusion of the proximal carpals developed in 3 of 7 patients who received VBG with CS and RS.Type of study/level of evidenceTherapeutic Ⅳ.
       
  • Unplanned Early Reoperation Rate Following Thumb Basal Joint Arthroplasty

    • Abstract: Publication date: Available online 27 November 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Jack G. Graham, Michael Rivlin, Asif M. IlyasPurposeThumb basal joint arthritis is a common degenerative condition of the hand that is often managed with thumb basal joint arthroplasty (BJA). This procedure generally results in a high level of patient satisfaction; however, the rate and cause of early unplanned reoperation after thumb BJA are not well-understood. Therefore, we performed a review to better understand the rate and cause of early reoperation.MethodsA retrospective review of all thumb BJA cases performed at a single private academic center between 2014 and 2016 yielded 637 patients and 686 primary thumb BJAs with a minimum 1-year follow-up (mean, 2.4 years). Data collection included patient demographics, surgical technique and type of thumb BJA performed, time to reoperation, reason for early reoperation (within 2 years), and type of reoperation.ResultsOf 686 patients undergoing thumb BJAs, 10 had unplanned early reoperation (1.5%). Mean duration between the index procedure and reoperation was 5.2 months (range, 0.5–14.3 months). Of the 10 unplanned early reoperations, 4 thumbs in 4 patients required revision arthroplasties owing to persistent pain. Time to reoperation for revision arthroplasty was 9.6 months (range, 3.9–14.3 months). Three of 10 reoperations resulted from early infection, 2 from unplanned early removal of symptomatic K-wires, and one from radial sensory neuritis.ConclusionsIn this series of nearly 700 consecutive cases, we identified an unexpected early reoperation rate of 1.5%, with only a 0.6% reoperation rate specifically for painful subsidence requiring a revision arthroplasty. Mean time to revision was 9.6 months. These rates are lower than those published previously and should be considered by patients and surgeons when planning thumb BJA.Type of study/level of evidencePrognostic IV.
       
  • Acute Pain Intensity After Collagenase Clostridium histolyticum Injection
           in Patients With Dupuytren Contracture

    • Abstract: Publication date: Available online 27 November 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Kimitoshi Noto, Michiro Yamamoto, Katsuyuki Iwatsuki, Shigeru Kurimoto, Masahiro Tatebe, Hitoshi HirataPurposeTo investigate multidimensional pain intensity and quality after collagenase Clostridium histolyticum (CCH) injection in patients with Dupuytren contracture using a pain visual analog scale (VAS) and the revised version of the Short-Form McGill Pain Questionnaire (SF-MPQ-2).MethodsThis prospective observational study was carried out from 2015 to 2017. As a primary end point, patients completed the pain VAS (range, 0 [no pain] to 100) and SF-MPQ-2 before and after CCH injection; 3, 9, and 24 hours after CCH injection; after the extension procedure; and 3 and 7 days after CCH injection. In addition, they reported the dose and duration of supplementary analgesic use during this period.ResultsA total of 41 patients were enrolled in this study (51 joints). Mean pain VAS score (mean ± SD, 34 ± 21) was maximal 9 hours after CCH injection and decreased within the following 7 days. The total score of the SF-MPQ-2 significantly increased after CCH treatment and decreased in the 7 days after the injection. Among the SF-MPQ-2 subscales, the highest and lowest scores after CCH injection were recorded for continuous pain and affected descriptors, respectively. Nonsteroidal anti-inflammatory drugs were most frequently self-administered during 7 days after the extension procedure compared with any other study period.ConclusionsThe pain VAS and SF-MPQ-2 revealed acute pain after CCH injection. However, all examined pain aspects dramatically improved within 7 days after injection. Pain after CCH injection is characterized by low scores in the Affective Descriptors subscale of the SF-MPQ-2.Type of study/level of evidencePrognostic Ⅳ.
       
  • Lidocaine With Epinephrine Versus Bupivacaine With Epinephrine as Local
           Anesthetic Agents in Wide-Awake Hand Surgery: A Pilot Outcome Study of
           Patient’s Pain Perception

    • Abstract: Publication date: Available online 31 October 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Julian Diaz-Abele, Mario Luc, Alina Dyachenko, Salah Aldekhayel, Antonio Ciampi, Jane McCuskerPurposeWide-awake local anesthesia hand surgery has many advantages over other forms of anesthesia, including faster recovery, lower cost, and improved patient safety; however, few studies compare postoperative pain and analgesic consumption after long- and short-acting anesthetics. This is important because surgeons seek to minimize opioid consumption during the opioid epidemic.MethodsThis was a double-blinded, prospective, randomized, parallel design pilot study. We randomized 61 patients to receive carpal tunnel surgery with a short-lasting regional anesthetic (lidocaine, 29 patients) or a long-lasting one (bupivacaine, 32 patients). Primary outcomes were pain levels over the first and second 24 hours. Secondary outcomes were postoperative consumption of acetaminophen and opioids over the first and second 12 hours after surgery.ResultsPain intensity and acetaminophen consumption were significantly less in the bupivacaine group over the first 24 and 12 hours after surgery, respectively. The bupivacaine group consumed less opioids in the first 12 hours and delayed consumption of the first medication after surgery, but these results were not statistically significant. There was no difference in pain intensity or analgesic consumption between 24 and 48 hours after surgery.ConclusionsThe use of a long-term anesthetic (bupivacaine) over a short-term one (lidocaine) in awake carpal tunnel release surgery decreases postoperative pain over the initial 12 hours after surgery and delays the initiation of analgesic consumption; however, this difference is small. The amount of opioid consumption was not significantly different between groups, but both groups consumed less than 10% of the prescribed opioids. It is important to reevaluate the need for opioids in minor hand surgery and favor the use of alternatives such as nonsteroidal anti-inflammatory drugs and acetaminophen.Type of study/level of evidenceTherapeutic I.
       
  • A Comparison of Changes in Median Nerve Cross-sectional Area Between
           Endoscopic and Mini-Open Carpal Tunnel Release

    • Abstract: Publication date: Available online 31 October 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): William R. Smith, David C. Hirsch, David O. Osei-Hwedieh, Robert J. Goitz, John FowlerPurposeThe purpose of this study was to determine whether there is a difference in the change in cross-sectional area (CSA) of the median nerve in patients undergoing carpal tunnel release (CTR) based on surgical technique and whether this change is associated with changes in patient-reported outcomes evaluated using the Carpal Tunnel Syndrome Assessment Questionnaire.MethodsIndividuals with carpal tunnel syndrome were evaluated with ultrasound and the CTSAQ before and 6 weeks after surgery. Patients were eligible for inclusion if they underwent either a mini-open CTR (MOCTR) or endoscopic CTR (ECTR). A single surgeon performed all surgeries. Changes in median nerve CSA, Carpal Tunnel Syndrome Assessment Questionnaire scores, and their associated surgical technique (MOCTR vs ECTR) were analyzed.ResultsA total of 77 patients were enrolled, 13 of whom were lost to follow-up, which left 64 for analysis. Of those, 42 patients underwent ECTR and 22 MOCTR. Mean age was 55 years; there were 52 women and 12 men. Mean changes in CSA for endoscopic and mini-open techniques from before to 6 weeks after surgery were –1.9 mm2 (95% confidence interval [CI], –1.1 to –2.7) and +0.6 mm2 (95% CI, –1.6 to 0.4), respectively. Mean Symptom Severity Scores improved after endoscopic and mini-open release by 1.7 (95% CI, 1.4–2.1) and 1.5 (95% CI, 1.2–1.9), respectively. Mean Functional Status Scores improved after endoscopic and mini-open release by 1.2 (95% CI, 0.9–1.9) and 0.7 (95% CI, 0.03–1.3), respectively.ConclusionsPatients undergoing ECTR demonstrated decreased median nerve CSA, whereas those undergoing MOCTR demonstrated increased median nerve CSA at 6 weeks. All patients undergoing surgical intervention demonstrated improvement in both Symptom Severity Scores and Functional Status Scores after surgery. Whereas both techniques successfully improve patient outcome scores, an increase in CSA after MOCTR may be seen in the initial postoperative period, potentially contributing to a slower short-term improvement in outcome in functional scores compared with ECTR.Type of study/level of evidenceTherapeutic IV.
       
  • Wide-Awake Local Anesthesia for Minor Hand Surgery Associated With Lower
           Opioid Prescriptions, Morbidity, and Costs: A Nationwide Database Study

    • Abstract: Publication date: Available online 29 October 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Gopal R. Lalchandani, Ryan T. Halvorson, Paymon Rahgozar, Igor ImmermanPurposeWe sought to investigate the perioperative opioid prescription patterns, complication rates, and costs associated with wide-awake local anesthesia (WALA) techniques using a nationwide insurance claims-based database.MethodsWe used the PearlDiver Humana administrative claims database to identify opioid-naive adult patients who underwent a carpal tunnel release, trigger finger release, or de Quervain release between 2007 and 2015. Patients were divided into WALA and standard anesthesia groups by the presence or absence of anesthesia Current Procedural Terminology codes. We evaluated for differences in perioperative opioid prescribing patterns, rates of opioid refills, and insurance reimbursement. The incidence of surgical complications and medical complications within 30 days of surgery were determined by International Classification of Diseases, Ninth Revision codes. Adjusted odds ratios were calculated with multivariable logistic regression models to identify factors associated with filling or refilling opioid prescriptions and complication rates.ResultsThere were 6,285 patients in the WALA group and 28,657 in the standard anesthesia group. The WALA patients were prescribed significantly lower quantities of opioids than were standard anesthesia patients across all 3 procedures. After controlling for type of surgery, gender, and comorbidities in a multivariate model, WALA patients were less likely to fill an initial opioid prescription during the perioperative period but were equally likely to obtain a refill. The WALA patients had lower odds of developing both surgical and medical complications compared with standard anesthesia patients. Moreover, WALA was associated with significantly lower costs for all procedures.ConclusionsWide-awake local anesthesia technique is an increasingly common and viable option for minor hand surgery. It is a cost-effective and safe technique for simple hand surgical procedures and can be a strategy to minimize postoperative opioid use.Type of study/level of evidencePrognostic II.
       
  • A New Approach for the Correction of Type I Thumb Deformity Owing to
           Rheumatoid Arthritis

    • Abstract: Publication date: Available online 25 October 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Ryo Oda, Shogo Toyama, Hiroyoshi FujiwaraA major transition in the surgical treatment of rheumatoid arthritis has been facilitated by a recent paradigm shift in its diagnosis and treatment. Improved outcomes in the treatment of the rheumatoid thumb are desirable; however, the results of conventional surgery are less than ideal. Even if the rheumatoid arthritis is well-controlled, the progression of thumb deformity may persist owing to an ineffective deformity correction and an insufficient understanding of the mechanism by which the deformity occurs. The mechanism of rheumatoid thumb deformity should be considered, using it to base the appropriate correction. We applied a new deformity correction procedure that accounts for the mechanism of type I rheumatoid thumb deformity and obtained positive results without recurrence. Although the primary cause of type I thumb deformity is believed to be an extensor mechanism failure resulting from synovitis of the metacarpophalangeal (MCP) joint, surgical outcomes are negatively affected as a result of flexion contracture caused by the adductor pollicis (ADP). Because the ADP attaches to the ulnar sesamoid on the palmar side of MCP joint, we release the ADP tendon to improve flexion contracture of the MCP joint. We consider release of ADP to be effective in preventing the recurrence of flexion contracture of the MCP joint and re-tensioning of the extensor pollicis brevis. Rheumatoid thumb deformity can be restored by applying this procedure, improving a patient’s outcome.
       
  • Salvage Operation for a Failed Total Wrist Prosthesis and Darrach
           Procedure by Total Wrist Revision and Distal Radioulnar Joint Arthroplasty
           

    • Abstract: Publication date: Available online 25 October 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Hanne Vandevivere, Jeroen Vanhaecke, Marleen Dezillie, Filip StockmansAn unstable distal ulnar stump after Darrach resection, alongside pathology of the radiocarpal joint, is difficult to manage without fusion of at least one joint. Currently, no standard 2-in-1 arthroplasty is available. We report the case of a 72-year-old woman with loosening of the radial stem of a Universal 2 total wrist prosthesis combined with radioulnar impingement after a Darrach procedure. Because of poor radial bone stock, the standard fixation technique of a semi-constrained distal radioulnar joint prosthesis (Aptis) was not possible. We present a technique to fix the semi-constrained distal radioulnar joint prosthesis as well as a total wrist prosthesis by a custom 3-dimensional printed flange prosthesis to the ulnar border of the radius. Three years after surgery, the patient remained pain-free, with 60° flexion, 75° extension, 80° pronation, and 80° supination.
       
  • Triquetral Motion Is Limited In Vivo After Lunocapitate
           Arthrodesis

    • Abstract: Publication date: Available online 25 October 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Thorsten Schriever, Henrik Olivecrona, Maria WilckePurposeLunocapitate arthrodesis is a motion-preserving salvage procedure for painful wrist osteoarthritis. Because the arthrodesis is limited to the capitate and the lunate, the adaptive motion of the triquetrum is theoretically maintained. We aimed to examine whether triquetral motion is sustained in vivo after lunocapitate arthrodesis.MethodsWe examined 7 patients after lunocapitate arthrodesis at least 1 year earlier, with computed tomography at 2 wrist positions: maximal radial extension and maximal ulnar flexion. Triquetral motion in vivo was analyzed using volume registration technique of the paired computed tomography scans and compared with the contralateral side.ResultsThe triquetrum moved in all patients, but the degree of motion was small compared with the nonsurgical wrist. A minor degree of motion of the hamate relative to the fused lunocapitate could also be demonstrated.ConclusionsTriquetral motion is limited after lunocapitate arthrodesis.Type of study/level of evidenceTherapeutic IV.
       
  • Pediatric Fingertip Injuries: Association With Child Abuse

    • Abstract: Publication date: Available online 25 October 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Christopher S. Klifto, Jessica A. Lavery, Heather T. Gold, Michael T. Milone, Raj Karia, Vincent Palusci, Alice ChuPurposePediatric fingertip injuries are most commonly reported in the setting of an accidental occurrence. The purpose of this study was to determine whether there is an association of child abuse and neglect with pediatric fingertip injuries.MethodsThe New York Statewide Planning and Research Cooperative System (2004 to 2013) administrative database was used to identify children aged 0 to 12 years who presented in the inpatient or outpatient (emergency department or ambulatory surgery) setting. International Classification of Diseases, Ninth Revision diagnosis codes were used to identify fingertip injuries (amputation, avulsion, or crushed finger) and abuse. Cohort demographics of children presenting with fingertip injuries were described. We analyzed the association between fingertip injuries and child abuse using multivariable logistic regression, with variables for insurance status, race, ethnicity, sex, and behavioral risks including depression, attention-deficit hyperactivity disorder, aggressive behavior, and autism.ResultsOf the 4,870,299 children aged 0 to 12 years in the cohort, 79,108 patients (1.62%) during the study period (2004 to 2013) presented with fingertip injuries. Of those with a fingertip injury, 0.27% (n = 216) presented either at that visit or in other visits with a code for child abuse, compared with 0.22% of pediatric patients without a fingertip injury (n = 10,483). In an adjusted analysis, the odds of a fingertip injury were 23% higher (odds ratio [OR] = 1.23; 95% confidence interval [CI], 1.07–1.41) for children who had been abused, compared with those who had not. Patients were more likely to present with fingertip injuries if they had ever had Medicaid insurance (OR = 1.40; 95% CI, 1.37–1.42) or had a behavioral risk factor (OR = 1.35; 95% CI, 1.30–1.40).ConclusionsPatients presenting with abuse are significantly more likely to have fingertip injuries during childhood compared with those without recorded abuse, which suggests that these injuries may be ones of abuse or neglect. Medicaid insurance, white race, and behavioral diagnoses of depression, attention-deficit hyperactivity disorder, aggressive behavior, and autism were also associated with increased odds of presenting with fingertip injuries.Type of study/level of evidencePrognostic III.
       
  • Effect of Bupivacaine Liposome Injectable Suspension on Sensory Blockade
           and Analgesia for Dupuytren Contracture Release

    • Abstract: Publication date: October 2019Source: Journal of Hand Surgery Global Online, Volume 1, Issue 4Author(s): Catherine F. Vandepitte, Sam Van Boxstael, Joris F. Duerinckx, Ine Leunen, Maxine M. Kuroda, Dieter Mesotten, Marc Van De Velde, Admir HadzicPurposeTo study the efficacy of bupivacaine liposome injectable suspension in prolonging sensory blocks of the median and ulnar nerves for subjects with Dupuytren contracture release by collagenase injection. We hypothesized that combining liposome bupivacaine and bupivacaine hydrochloride would extend the duration of blocks without added complications.MethodsWe randomized 32 subjects scheduled for Dupuytren contracture release with collagenase Clostridium histolyticum injections to receive forearm blocks of the median and ulnar nerves with a mixture of 5 mL liposome bupivacaine 1.33% plus 2.5 mL bupivacaine hydrochloride 0.5% per nerve (n = 16) or 7.5 mL bupivacaine hydrochloride 0.5% alone per nerve (n = 16). Sensory block and analgesia were assessed through the first posttreatment week.ResultsSensory block was nearly 4 times longer in subjects who received the liposome bupivacaine mixture compared with subjects who received bupivacaine hydrochloride alone. Most subjects (13 of 16) who received the liposome bupivacaine mixture had adequate analgesia for finger manipulation to rupture the cords, whereas most subjects (15 of 16) who received bupivacaine hydrochloride alone required additional anesthesia. Subjects in the liposome mixture group reported lower pain scores through the first 3 days after treatment. There were no serious side effects.ConclusionsAddition of liposome bupivacaine to forearm blocks for Dupuytren contracture release prolonged sensory block and improved pain scores without increasing side effects or impairing hand function. Supplemental lidocaine injections for the painful phases of Dupuytren contracture release with collagenase C histolyticum injections were not required by most subjects who received liposome bupivacaine.Type of study/level of evidenceTherapeutic I.
       
  • Intermediate-Term Outcomes of Trapeziectomy With a Modified Abductor
           Pollicis Longus Suspension Arthroplasty

    • Abstract: Publication date: Available online 3 October 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Brandon E. Earp, Ariana N. Mora, Jacob A. Silver, Kyra A. Benavent, Philip E. BlazarPurposeThere is limited literature characterizing intermediate-term surgical and clinical outcomes of basal thumb arthritis after trapeziectomy and modified abductor pollicis longus suspension arthroplasty (APLSA). We hypothesized that patients who underwent APLSA would have favorable intermediate-term outcomes.MethodsPatients were contacted after APLSA at a median follow-up of 4.8 years (interquartile range, 3.0–6.0 years). Follow-up clinical evaluation included grip, key pinch, and tip pinch strength. We obtained patient-reported outcomes surveys: visual analog pain score and Disabilities of the Arm, Shoulder, and Hand score. Information on demographics, surgical information, and complications was obtained from the electronic medical record and patient interviews.ResultsThis study evaluated 66 hands in 60 patients (51 women and 9 men, average age 60.4 years at surgery). At the time of index surgery, 8% of hands had prior ipsilateral surgery (not involving the carpometacarpal joint), 56% had concurrent ipsilateral surgery (35% carpal tunnel release, 32% hemitrapezoid resection, 22% other soft tissue procedures (mucous cyst excision, ganglion cyst excision, or trigger finger release), 5% metacarpal capsulodesis, and 5% metacarpal arthrodesis. Median time between operation and most recent evaluation was 4.8 years (interquartile range, 3.0–6.0 years). Operative hand grip (18.7 ± 11.1 kg), key pinch (4.7 ± 2.1 kg), and tip pinch (3.2 ± 1.7 kg) strength was 94%, 84%, and 86%, respectively, of nonsurgical grip, key pinch, and tip pinch strength. Median (interquartile range) outcomes were a visual analog pain score of 0.0 (0.0–2.0) and Disabilities of the Arm, Shoulder, and Hand score of 9.1 (2.3–26.1).ConclusionsResults at 4.8 years for APLSA demonstrated 84% to 94% grip, key pinch, and tip pinch compared with the contralateral side. Patients experienced little to no pain in the operated joint and minimal disability of the upper extremity at intermediate-term follow-up. Abductor pollicis longus suspension arthroplasty is a favorable procedure for achieving pain relief and functional use associated with basal thumb arthritis.Type of study/level of evidencePrognostic IV.
       
  • Patient Preferences of Physician Introductions In Hand and Upper-Extremity
           Surgery

    • Abstract: Publication date: Available online 3 October 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Kempland C. Walley, Aron Lechtig, Amber M. Parker, Arriyan Samandar Dowlatshahi, Carl M. Harper, Tamara D. RozentalPurposeCommunication between patients and physicians is critical in reaching a diagnosis, improving compliance, and optimizing outcomes and patient satisfaction. The doctor–patient relationship begins when a physician introduces himself or herself to a patient; however, no optimal method has been reported on how best to perform an introduction in hand surgery.MethodsWe enrolled 254 consecutive patients presenting for initial outpatient consultation with a board-certified hand and upper-extremity surgeon at a level 1 urban academic medical center. A brief questionnaire was administered assessing patients’ preference toward how the hand surgeon should introduce himself or herself in the initial patient encounter. Preferences were quantified in the context of demographic characteristics such as age, sex, race, ethnicity, education level, and type of presenting injury (eg, urgent or nonurgent).ResultsAmong all respondents, patients meeting the hand surgeon for the first time in an outpatient clinic setting most preferred the construct “Hello, my name is Dr Appleseed,” in which “Appleseed” is the physician’s last name (n = 156, 61%), followed by first–last (n = 54; 21%), no preference (n = 28; 11%), and first only (n = 16; 6%). These preferences persisted across groups irrespective of race, ethnicity, type of injury, education level, and sex, and when assessing shared demographic variables with the treating physician. Among generational cohorts stratified by age, only patients born before 1943 differed in the preferred greeting construct; they selected first and last name as the desired option (33%).ConclusionsResults revealed that patients preferred hand surgeons to introduce themselves as “Hello, my name is Dr Appleseed,” in which “Appleseed” corresponds to the treating physician’s last name. Age, sex, race, ethnicity, and education level did not influence the choice of preferred greeting. Physicians should consider introducing themselves in this fashion to optimize the initial stages of the doctor–patient relationship.Type of study/level of evidenceEconomic/Decision Analysis IV.
       
  • Immediate Non-thumb Digit Transposition After Hand Trauma: Historical
           Perspective and Case Report

    • Abstract: Publication date: Available online 3 October 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Christopher S. Crowe, Jenny L. Yu, Sean M. Fisher, Jeffrey B. FriedrichMutilating hand trauma remains a challenge for reconstructive hand surgeons, owing to the involvement of multiple tissue types and segmental nature of these injuries. Principles of “spare parts” surgery may be useful in assessing how to make use of otherwise unsalvageable or functionless tissue. Pedicled heterotopic digit transposition is such a procedure; it may be safely performed in the acute posttraumatic setting. The historical basis for digit transposition and related techniques are reviewed. Two illustrative cases in which a single functional finger was created from 2 severely traumatized digits are presented. This reconstructive technique should be considered when a patent vascular pedicle, appropriate length, and intact articular surfaces are present in the donor digit. Digit transposition is a useful addition to the hand surgeon’s techniques for restoring posttraumatic hand function after mutilating injury.
       
  • A Novel Supraretinacular Endoscopic Carpal Tunnel Release: Instrumentation
           and Technique (Cadaveric Study)

    • Abstract: Publication date: Available online 26 September 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Kok Kheng Teh, Ch’ng Hwei Choo, Rukmanikathan Shanmugam, Joanne Hui-ling Ngim, Tunku Sara AhmadPurposeEndoscopic carpal tunnel release has been shown to be associated with a shorter return to work compared with open carpal tunnel release in the treatment of carpal tunnel syndrome. Unfortunately, it may be associated with a higher risk for median nerve injury when the carpal tunnel is used as a portal for instrumentation. The purpose of this study was to assess safety in using a newly designed retractor through a supraretinacular approach.MethodsWe used 8 wrists (4 left and 4 right wrists) from 4 fresh-frozen cadavers for this study. Supraretinacular endoscopic carpal tunnel release using the supraretinacular retractor was performed by a single investigator, followed by exploration of the carpal tunnel and the structures surrounding it. Surgeries were performed using a new surgical instrument consisting of an arch-shaped blade and handle. It includes a retainer adapted to receive a 2.4- or 2.7-mm endoscope and to retain it at the apex of the arch, which can be moved in and out to visualize the entire transverse carpal ligament. The space below the blade is also used as a portal to insert scissors and instrumentation to cut the transverse carpal ligament.ResultsAll 8 carpal tunnels were completely released with no injury to the median nerve, superficial palmar arch, flexor tendon, or violation into Guyon canal. Mean distance of the flexor retinaculum division to the recurrent motor branch, palmar cutaneous branch, and superficial palmar arch was 6.87 ± 2.80, 7.13 ± 5.33, and 9.13 ± 4.42 mm, respectively. All specimens had an extraligamentous recurrent motor branch.ConclusionsThe retractor and described technique were safe and effective in this cadaveric study. Further clinical trials are necessary before it can be adopted as a safe and reliable technique.Type of study/level of evidenceTherapeutic IV.
       
  • Double Fascial Flap Stabilization for Ulnar Nerve Instability After In
           Situ
    Decompression

    • Abstract: Publication date: Available online 23 September 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Shiro Yoshida, Brent Trull, Tsu-Min TsaiPurposeTo assess the outcomes of double fascial flap stabilization in managing ulnar nerve subluxation after a simple decompression procedure for cubital tunnel syndrome.MethodsWe conducted a retrospective review of 20 patients who experienced ulnar nerve subluxation after simple decompression and were treated with double fascial flap stabilization between 2016 and 2018. Fascial flaps were harvested from the flexor carpi ulnaris and the septum between the triceps and biceps. Patients were classified using McGowan criteria and outcomes were measured using the visual analog scale, grip strength, and the criteria of Messina and Messina for recovery. In addition, we assessed ulnar nerve instability after in situ decompression in 10 fresh cadavers. Tang’s grading and measuring system was used to measure ulnar instability.ResultsThere were 13 excellent and 7 good outcomes (65% and 35%, respectively). Mean follow-up duration was 9.1 months (range, 3–23 months). Mean visual analog scale scores improved significantly from 5.8 before to 1.3 after surgery. Mean Quick–Disabilities of the Arm, Shoulder, and Hand scores improved significantly from 37.9 before to 10.9 after surgery. Mean grip strength compared with the contralateral side improved significantly from 73.9% before to 89.6% after surgery. Anatomic cadaveric dissection revealed that 6 of 10 cadavers (60%) met the criterion of moderate to severe ulnar nerve instability.ConclusionsDouble fascial flap stabilization with simple decompression resulted in excellent short-term clinical results. This technique provides an alternative strategy to prevent ulnar nerve instability with the advantage of preserving nerve vascularity. Long-term follow-up is required to evaluate the potential impact on recurrence or failure of simple decompression.Type of study/level of evidenceTherapeutic IV.
       
  • Preserved Sensation of the Palmar Radial Hand by the Superficial Branch of
           the Radial Nerve Following Median Nerve Laceration

    • Abstract: Publication date: Available online 23 September 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Sean M. Wade, DesRaj M. Clark, Matthew E. Miller, Jason M. Souza, Leon J. Nesti, Scott M. TintleMultiple variations of sensory innervation patterns in the hand exist and are well-recognized in the literature. These aberrant patterns can lead to diagnostic challenges and complicate the treatment of nerve-injured patients. Therefore, it is important to understand these variations to avoid potential clinical errors in caring for these patients. To date, most descriptions of aberrant innervation patterns in the upper extremity involve interneural connections between branches of the median and ulnar nerves with a paucity of descriptions involving the radial nerve. This report discusses a case of the superficial branch of the radial nerve innervating the hand’s classically described median nerve sensory distribution after transection of the proximal median nerve.
       
  • Accidental Pig Vaccine Injection Injury

    • Abstract: Publication date: Available online 18 September 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Robert E. Van Demark, Kevin L. Hofer, B. Joel Tjarks, Meredith Hayes, Hillary A. Becker, Matthew C. AndersonAnimal vaccine injection injuries of the hand are of special concern in veterinary medicine and agricultural fields. Although most of these injuries resolve with no or minimal treatment, major complications can occur. We report a case of a farmworker who experienced an accidental needlestick injury while vaccinating pigs. The operative findings, postoperative course, and treatment options for vaccine needlestick injuries are discussed.
       
  • Antegrade Intramedullary Screw Fixation: A Novel Approach to Metacarpal
           Fractures

    • Abstract: Publication date: Available online 18 September 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Don Hoang, Jerry HuangMetacarpal fractures are common upper-extremity fractures. Surgical fixation is recommended for open injuries, segmental bone loss, multiple metacarpal fractures, irreducible fractures, and unstable fracture patterns. For transverse and short oblique metacarpal shaft fracture patterns, intramedullary headless compression screws have been added most recently as a surgical option. Intramedullary headless compression screw fixation has been performed in a retrograde manner in which a guidewire and then a cannulated headless screw are placed through a skin excision, a split in the sagittal band or extensor tendon, and the dorsal central articular cartilage surface of the metacarpal head. Here, we describe a step-by-step novel approach to fixation of transverse and short oblique proximal and midshaft metacarpal fractures through an antegrade approach using intramedullary headless compression screws with a detailed 4K high-definition video demonstration and 2 clinical cases involving the middle and ring metacarpals. This surgical alternative addresses many concerns with the retrograde technique and avoids creating defects in the extensor tendon, the sagittal hood, the articular surface of the metacarpal head at the metacarpophalangeal joint, and the articulating surface of the trapezium, capitate, and hamate at the carpometacarpal articulation.
       
  • A Basic Spanish Language Template for the Upper Extremity Patient
           Encounter

    • Abstract: Publication date: Available online 13 September 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Adil S. Ahmed, Ryan L. Kim, Benjamin Ogden, Michael J. Garcia, Jason A. NydickEffective communication is fundamental to the quality and safety of healthcare. In the U.S., language and cultural differences combined with low health literacy are challenges that physicians must overcome. The Spanish-speaking patient population continues to grow and is disproportionately affected by this, with 25% speaking little to no English. In our hand and upper extremity surgery practice, a common problem arises both with verbal Spanish communication and with the physical exam. The hand and upper extremity examination requires a high level of patient involvement to elucidate subtle derangements in individual tendon or nerve function. Our purpose is to summarize a model upper extremity clinical encounter in Spanish and provide a guide for patient-physician interaction, particularly during the physical exam where visual aids can be more useful than simple verbal commands. This guide is a simple step towards enhanced communication and understanding between providers and patients, with the goal of providing higher quality care with greater efficiency and satisfaction. The purpose is not to replace the professional interpreter, but to augment the physician-patient interaction during the upper extremity clinical encounter. Incorporating a cross-language template may yield improved patient understanding, enhanced participation in the examination leading to better diagnosis, and improved satisfaction for both patient and provider.
       
  • Chimeric Thoracodorsal Artery Perforator (TAP) Flap–Scapula Flap for
           Repair of Congenital Floating Thumb

    • Abstract: Publication date: Available online 11 September 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Isao Koshima, Hirofumi Imai, Shuhei Yoshida, Shogo Nagamatsu, Kazunori Yokota, Shuji Yamashita, Haruki Mizuta, Jason H. Ko, Susie Zhi-Jie YaoWhen reconstructing a congenital floating thumb, we describe two children in whom preservation of all five digits is achieved through successful transfer of a thoracodorsal artery perforator (TAP) flap and vascularized scapula.
       
  • K-Wire Fixation of Metacarpal and Phalangeal Fractures: Association
           Between Superficial Landmarks and Penetration of Structures Surrounding
           the Metacarpophalangeal Joint

    • Abstract: Publication date: Available online 16 August 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Joshua Gordon, Nicholas Andring, Nicholas P. IannuzziPurposeThere is little information regarding the starting points for intramedullary K-wires and their effect on the soft tissues surrounding the metacarpophalangeal (MCP) joint. This study attempted to identify starting points for intramedullary K-wire fixation and determine the effect of these K-wires on soft tissues surrounding the MCP joint.MethodsWe placed intramedullary K-wires in the index, middle, and little finger metacarpals and proximal phalanges in 6 cadaveric specimens. We measured the starting points of the K-wires and performed dissection to evaluate which structures were penetrated. A Fisher exact test determined statistical significance between K-wire penetration of soft tissue structures and the starting point for K-wires.ResultsMetacarpal K-wires started 8.5 ± 1.5 mm volar to the dorsal aspect of the metacarpal head, 19.1 ± 4.6 mm proximal to the digital palmar crease, and 8.6 ± 1.2 mm from the metacarpal head midline. All MCP K-wires crossed at least one soft tissue structure about the MCP joint; the most commonly the sagittal band. Proximal phalanx K-wires started 8.9 ± 2.9 mm proximal to the distal aspect of the metacarpal head, 25.5 ± 5.9 mm proximal to the digital palmar crease, and 9.9 ± 1.5 mm from metacarpal head midline. All proximal phalanx K-wires crossed at least one soft tissue structure about the MCP, most commonly the joint capsule. No relation was established between K-wire start point and penetration of soft tissue structures.ConclusionsUse of these measurements may aid the physician in placing intramedullary K-wires into the proximal phalanges and metacarpals. Starting points that decrease the rate of penetration of soft tissue structures around the MCP joint have not been described, and all pins crossed at least one soft tissue structure adjacent to the MCP joint.Type of study/level of evidenceTherapeutic IV
       
  • Retrograde Intramedullary Absorbable Pin Fixation for Intraarticular
           Fracture of the Metacarpal Head

    • Abstract: Publication date: Available online 16 August 2019Source: Journal of Hand Surgery Global OnlineAuthor(s): Atsushi Okazaki, Hiroaki Sakano, Yutaka InabaPurposeTo review retrospectively the outcome of retrograde intramedullary absorbable pin fixation for intra-articular fractures of the metacarpal head.MethodsNine patients with intra-articular fractures of the metacarpal head were treated surgically with 1.5-mm-diameter unsintered hydroxyapatite particles and a poly-l-lactide pin. There were 2 women and 7 men, mean age 28.9 years. Patients were observed for a mean of 13.1 months after surgery. The metacarpophalangeal joint was exposed through a dorsal skin incision. After reduction of the fracture, 2 unsintered hydroxyapatite particles and poly-l-lactide pins were inserted from the articular surface of the distal bone fragment into the medullary canal of the metacarpal. A volar aluminum orthosis was applied in the intrinsic plus position for a mean of 1.8 weeks (range, 0–4 weeks), and range of motion exercises were started after the orthosis was removed.ResultsAnatomical reduction and bony union were achieved in all patients. Mean period required to achieve bone union was 4.6 weeks. No patients experienced pain after healing; all resumed normal activities at the time of follow-up, when mean flexion and extension of the metacarpophalangeal joint were 82.8° and –2.2°, respectively. There were no malunions or osteoarthritic changes, no breakage of the pin, aseptic inflammation, or avascular necrosis of the metacarpal head, and no foreign body reactions.ConclusionsWe performed a retrograde intramedullary absorbable pin fixation for intra-articular fracture of the metacarpal head. Using this method, damage to the articular cartilage and surrounding soft tissue was minimized, range of motion exercise could be started early after surgery, and hardware removal surgery was not necessary.Type of study/level of evidenceTherapeutic IV.
       
 
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