Surgical and technical aspects of hand transplantation: is it just another replant?

The ultimate goal of hand allotransplantation is to achieve graft survival and useful long-term function. To achieve these goals, selection of the appropriate patient, detailed preoperative planning, and precise surgical technique are of paramount importance. Transplantation should be reserved for motivated consenting adults in good general heath, who are psychologically stable and have failed a trial of prosthetic use. While the key surgical steps of transplantation are similar to those of replantation, there are major differences. This article describes the steps in hand allotransplantation, and the importance of patient selection as well as preoperative and postoperative care.

Technical aspects of the recipient operation in hand transplantation

The goal of hand allotransplantation is to achieve graft survival and useful long-term function. To achieve these goals, precise surgical technique is of critical importance. The key surgical steps and sequence of events in hand allotransplantation are similar to major upper extremity replantations, but are modified to accommodate major conceptual differences that exist between the two procedures.

Vascular anomalies of the upper extremity

The topic of vascular anomalies is uncommon in the hand surgery literature, but hand surgeons do diagnose and treat patients with hemangiomas and vascular malformations. These are separate entities and require different treatment strategies. Proper diagnosis will lead to timely and appropriate treatment.

Surgical treatment of partial distal biceps tendon ruptures

PURPOSE

To demonstrate that surgical repair of partial distal biceps tendon ruptures allows return of supination and flexion strength nearly equal to the contralateral side without compromising range of motion.

METHODS

We performed a retrospective study of 17 patients with unilateral partial biceps tendon ruptures who underwent surgical repair between 2003 and 2009, and who returned for further evaluation and strength testing. The follow-up examination included questionnaires, x-rays, strength testing, and range of motion with comparison to the opposite side. We used the Baltimore Therapeutic Equipment work simulator to objectively test isometric and dynamic elbow flexion and forearm supination strength of both extremities.

RESULTS

A total of 17 patients returned for additional testing, 14 of whom had failed nonsurgical treatment. One patient had asymptomatic heterotopic ossification. Two patients reported mild lateral antebrachial cutaneous nerve dysesthesias. There was one partial re-rupture 4 years after the original surgery. The second repair consisted of suture anchor fixation; 15 months after re-repair, the patient remains asymptomatic. Average postoperative Disabilities of the Arm, Shoulder, and Hand score was 9 (range, 0-33). One patient had limited pronation (50 degrees degrees). The average isometric and dynamic elbow flexion was 3% and 11% stronger, respectively, compared with the opposite side. Average isometric supination was 6% and average dynamic supination was 10% weaker.

CONCLUSIONS

After surgical treatment of partial distal biceps tendon tears, most patients achieved good return of strength with full motion. Surgical treatment of partial distal biceps tendon tears is a viable option after failed nonsurgical treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Comparison of the "contact biomechanics" of the intact and proximal row carpectomy wrist

PURPOSE

The proximal row carpectomy (PRC) is a clinically useful motion-preserving procedure for various arthritides of the wrist. However, there are few studies on the "contact biomechanics" after PRC. The purpose of this study is to evaluate the contact biomechanics in terms of pressure, area, and contact location of the intact and PRC wrist.

METHODS

Six fresh-frozen cadaver forearms were tested in neutral, 45 degrees of flexion, and 45 degrees of extension. In the intact wrist, Fuji UltraSuperLow pressure contact film was placed in the radioulnocarpal joint. The specimen was loaded to a total force of 200 N. We then performed a PRC, and the experiment was repeated using Fuji Low film. The film was scanned and analyzed with a customized MATLAB program. Multivariable analysis of variance with multiple contrast testing and Student's t-test were performed for statistics.

RESULTS

In the intact wrist, scaphoid contact pressure averaged 1.4 megapascals (MPa), and lunate contact pressure averaged 1.3 MPa. In terms of contact location, scaphoid contact in the intact wrist significantly moved dorsal and ulnar in flexion and significantly moved volar and radial in extension. Lunate contact significantly moved dorsal in flexion. PRC wrist contact pressure was 3.8 times that of the intact wrist, and the contact area was approximately 26% that of the intact wrist. Lastly, in terms of the amount of contact translation after PRC, the capitate contact translated (7.5 mm) more than did the scaphoid contact (5.6 mm) and had about equal translation to that of the lunate (7.3 mm).

CONCLUSIONS

Contact pressure increased significantly and contact area decreased significantly after PRC. There is significant contact translation after PRC (more than scaphoid translation but equal to lunate translation), which provides quantitative support of the theory that translational motion of the PRC may explain its good clinical outcomes.

Osteochondral resurfacing (OCRPRC) for capitate chondrosis in proximal row carpectomy

PURPOSE

Proximal row carpectomy (PRC) can be an effective treatment option for arthritis of the wrist, but the operation is contraindicated when there is substantial arthritis of the capitate head. We describe a new technique that involves resurfacing of the capitate when there is chondrosis by using osteochondral grafts harvested from the resected carpal bones. The purpose of this study was to assess the outcomes of patients who had osteochondral resurfacing in the setting of PRC (OCRPRC) for capitate chondrosis and to determine how they compare with published results of conventional PRC.

METHODS

Patients having PRC who had grade II to IV (Modified Outerbridge Scale) capitate chondrosis underwent osteochondral resurfacing of the capitate. Preoperative and postoperative pain level, employment status, range of motion (ROM), grip strength, and Mayo wrist scores were assessed, and Student's t-test was used. Postoperative Disability of the Arm, Shoulder and Hand (DASH) scores were also calculated.

RESULTS

Eight patients with an average age of 53 years were followed up for 18 months. Preoperatively, 7 patients described their pain as moderate to severe; postoperatively, 7 patients described their pain as mild to no pain. Preoperative arc of motion was 84 degrees (74% of the contralateral side); postoperative arc of motion was 75 degrees (66% of the contralateral side). Preoperative grip strength was 29 kg, or 62% of the contralateral side; postoperative grip strength was 34 kg, or 71% of the contralateral side. Preoperative Mayo wrist score was 51 ("poor"); postoperative Mayo wrist score was 68 ("fair"). Average postoperative DASH score was 19.5. Follow-up radiographs showed that 75% of patients had mild to no degeneration. Magnetic resonance imaging at 21 months postoperatively showed graft incorporation. No complications were encountered.

CONCLUSIONS

Our results with osteochondral resurfacing compare favorably with the published results of conventional PRC in terms of pain relief, employment status, ROM, and grip strength.

Outcome of surgery for lateral epicondylitis (tennis elbow): effect of worker's compensation

We retrospectively compared the results of extensor origin release for lateral epicondylitis (tennis elbow) against worker's compensation (WC) status. All patients (N = 57) underwent extensor origin release between October 1989 and June 1998. For the 33 patients (37 elbows) who received WC, mean follow-up was 55 months; for the 25 patients (26 elbows) who did not receive WC, mean follow-up was 45 months. Pain relief, symptom recurrence, satisfaction with procedure outcome, and ability to return to work (same or similar job) were evaluated. Pain relief was reliably achieved in the WC and non-WC groups (36/37 and 24/26 elbows, respectively). Symptom recurrence was intermittent in both groups, and few patients sought medical intervention for recurrent symptoms. Patient satisfaction was high in the WC and non-WC groups (35/37 and 26/26 elbows, respectively). A majority of patients in both groups returned to work, but a significantly higher percentage of patients in the WC group changed jobs because of persistent symptoms.

Comparison of arthroplasty and arthrodesis for the rheumatoid wrist

PURPOSE

To compare the outcomes of wrist arthrodesis and arthroplasty in the treatment of rheumatoid arthritis using validated outcome patient surveys and a review of surgical complications in 2 matched cohorts.

METHODS

Forty-six patients with 51 operated wrists (24 arthrodeses and 27 arthroplasties) were reviewed retrospectively at a follow-up range of 1 to 5 years. Patients completed the Disabilities of the Arm, Shoulder and Hand (DASH) inventory, the Patient-Rated Wrist Evaluation (PRWE), and a questionnaire designed specifically for this study. Surgical complications were obtained by chart review.

RESULTS

Treatment groups were well matched by patient characteristics and radiographic staging. There were no statistical differences in the survey scores between the 2 groups. Patients in the arthroplasty group, however, reported a trend toward greater ease with personal hygiene and fastening buttons. Complication rates were similar with a 56% complication rate in the arthrodesis group (22% major, 35% minor) and a 52% complication rate in the arthroplasty group (11% major, 41% minor).

CONCLUSIONS

The DASH and PRWE may not be designed properly to measure impairment caused by wrist disease in patients with generalized arthritis. The results show that patients with rheumatoid arthritis can and do accommodate to a wrist arthrodesis. It should not be construed, however, that patients with rheumatoid arthritis would not prefer or obtain greater benefit from a wrist arthroplasty [corrected].

Combining mandatory health insurance and medical savings accounts

The American tradition of freedom of choice is mirrored exceptionally well in the health care industry. The consequences of this system are the highest health care costs in the world and 38.7 million uninsured. Implementation of mandatory, high-deductible health insurance in conjunction with a medical savings account for every resident could have several benefits, and it may engender bipartisan support.

Arthroscopic reduction and internal fixation (ARIF) of lateral tibial plateau fractures

Arthroscopic reduction and internal fixation of tibial plateau fractures has been well documented over the last 15 years. Better visualization, less traumatic surgery, reconstruction of accompanying injuries and early mobilization have encouraged arthroscopic surgeons to use this technique more widely. With experience, surgeons became more comfortable in using arthroscopy-assisted surgery not only in split fractures of the lateral tibial plateau (41-B1) but also in more complex tibial and femoral fractures. In this study, 31 patients with intra-articular fractures of the lateral tibial plateau were operated on between 1991 and 1996. The fractures were classified as follows: x12 AO-type B1, x7 B2, x10 B3, x2 C3. Diagnostic arthroscopy and repair of soft tissue injuries was followed by arthroscopic reduction in all patients and supplemented with internal fixation in 29 patients. Postoperatively, an aggressive physical therapy regimen was performed with immediate mobilization and early partial weight bearing. All patients were examined for follow-up after 15-32 months (mean 25.1). In all cases the fractures were stable and allowed full weight-bearing. At follow-up, 25 patients had anatomic reduction. Anatomical reduction cannot be restored in all cases of open reconstruction because of cartilage defects. Fracture reduction using arthroscopic techniques is a suitable alternative for joint fracture repair because additional soft tissue damage can be minimized.

Operative treatment with radial shortening in Kienböck's disease

Eighty-eight patients underwent radial shortening for Kienböck's disease. Prerequisites for surgery were radiographic studies positive for Kienböck's disease without evidence of radiocarpal arthritis and wrist pain unrelieved by conservative management. Thirty-nine patients were evaluated by subjective questionnaire at a mean postoperative follow-up of 86 months (range: 24-188 months). Following surgery, a significant decrease was noted in pain severity, frequency, and duration. Functional status improved postoperatively, with the most significant gains noted in the following activities: opening jars, opening car doors, carrying bags, and shoveling. Only 3 of 34 patients employed outside the home were unable to return to their original occupations due to their wrist problems. Seventy-six patients were evaluated by physical examination at a mean postoperative follow-up of 31 months (range: 3-87 months). Objective evaluation by physical examination revealed a significant improvement in wrist motion and grip strength. Seventy-seven patients underwent radiographic evaluation at a mean postoperative follow-up of 31 months (range: 3-180 months). A significant progression in Lichtman stage of Kienböck's disease was noted despite the favorable subjective findings and high satisfaction ratings. Thirty-six of 39 patients stated they would undergo the surgery again. The long-term data demonstrate radial shortening in patients with stage II-IIIA Kienböck's disease provides substantial improvement over preoperative status.

A comparison of plate and pin fixation for arthrodesis of the rheumatoid wrist

This retrospective study compared plate fixation versus pin fixation in 57 patients with rheumatoid arthritis who underwent wrist arthrodesis. Fixation was achieved by using plates in 32 patients and longitudinal pins in 25 patients. Clinical follow-up averaged 29 months (range: 12-57 months) and radiographic follow-up averaged 16 months (range 12-39 months). Union occurred in 97% of the wrists fixed with plates and in 96% of the wrists fixed with pins. There were 6 (19%) complications in the plate group and 7 (28%) complications in the pin group. Three (12%) wrists fixed with pins moved from the immediate postoperative position to a position of relative volar flexion, while radiographs showed no changes in wrist position in the plate group. With both methods, successful arthrodesis stabilized the wrist in a high percentage of patients. Plate fixation offers an excellent alternative method for arthrodesis of the rheumatoid wrist.

Contact stress distributions in malreduced intraarticular distal radius fractures

Residual articular incongruity of the distal radius following intraarticular fracture has been correlated with early osteoarthritis (OA) and a poor clinical outcome. We developed a simple in vitro fracture model of the distal radius to investigate the relationship between degree of articular incongruity and the resulting distribution of radiocarpal contact stress. Twelve fresh-frozen cadaver arms were dissected, packets of Fuji Pressensor film were inserted into the wrist, and the wrist was loaded through its flexor and extensor tendons. We created a simple intraarticular fracture that allowed controlled distal radius articular incongruity. Loading trials were performed for the intact distal radius, for a fully reduced case, and for step-offs of 0.4, 1, 2, and 3 mm. Mean contact stress was significantly greater than the anatomically reduced case at only 3 mm of step-off. Contact area was greater than the anatomically reduced case at 0.4, 1, and 2 mm of step-off. The elevations in contact stress that we observed were only modest, suggesting that other factors may be involved in the pathogenesis of radiocarpal OA in the presence of residual articular incongruity.

Displaced intra-articular fractures of the distal radius: the effect of fracture displacement on contact stresses in a cadaver model

Contact stresses in the wrist were measured after simulating displaced fractures of the lunate fossa in the distal radius of eight human cadaver arms. Osteotomies created displaced lunate fossa fractures of 0, 1, 2, and 3 mm. Contact stresses were measured with Fuji pressure-sensitive film after loads of 100 N were applied to the wrist through wrist flexor and extensor tendons. Mean contact stresses were significantly increased with step-offs of 1 mm or more. Maximum stresses and overloaded areas were significantly increased with step-offs of 2 mm or more. As the magnitude of the fracture displacement increased, there was a shift in the focus of the maximum stresses toward the fracture line. In this model, simulated displaced die-punch fractures created alterations in both the magnitude and location of contact stresses in the wrist joint.

Radial instability of the metacarpophalangeal joint of the thumb. A biomechanical investigation

Human cadaver thumbs were tested to evaluate stability of the radial side of the MP joint. The contributions of the dorsal capsule, radial collateral ligament, accessory collateral ligament, and volar plate were examined with the joint in 0 degrees and 30 degrees of flexion. At 0 degrees flexion, the average joint angulation increased 4 degrees following isolated radial collateral ligament transection and 6 degrees following isolated accessory collateral ligament transection. Release of both the accessory and radial collateral ligaments produced marked instability with joint angulation of at least 46 degrees. The accessory collateral ligament helped to stabilize the extended MP joint. There were no significant contributions to stability from the dorsal capsule and volar plate when the collateral ligaments were intact. In the laboratory setting, radial-side instability of the MP joint of the thumb requires transection of both the proper and accessory radial collateral ligament.

Treatment of chronic post-traumatic dorsal subluxation of the distal ulna by hemiresection-interposition arthroplasty

Twenty-four patients were evaluated for complaints of pain in the area of the distal radioulnar joint, decreased forearm rotation, and weakness of grip. All patients had a history of trauma to the involved wrist an average of 40 months prior to presentation. Six patients had undergone previous surgery that was unsuccessful. Twenty-three patients were available for follow-up evaluation at an average of 36 months following hemiresection-interposition arthroplasty. At that time, results were excellent in 13 patients, good in 4 patients, fair in 3, and poor in 3. Two patients developed symptoms of styloidcarpal abutment (poor results), one of whom was upgraded to an excellent result after undergoing a shortening osteotomy of the ulna.

Symptomatic congenital coalition of the pisiform and hamate

Recent reports have shown that carpal coalition, previously regarded as an asymptomatic congenital anomaly, may be an unusual occult cause of wrist pain. Two cases are presented as the first reported examples of congenital piso-hamate fusion creating symptoms due to associated arthritis or occult fracture.

Radioulnar joint fusion for distal radioulnar joint instability

Each one of this small group of patients illustrates a rare indication for the radioulnar joint fusion procedure in distal radioulnar joint instability. The case histories tell of a last ditch effort to salvage function in an extremity crippled by painful radioulnar instability after excision of the distal ulna. The fusions healed slowly and two required repeat surgery to achieve union. Today we would routinely add iliac bone graft to the fusion area to hasten healing. Rarely indicated, this is a salvage procedure that is done after failure of other procedures geared to preserve the rotation of the forearm. These patients all had successful salvage of their extremities for activities of daily living, but only one returned to his labor job. All were worker's compensation cases in physical jobs. Two patients had had prior radiocarpal fusions, making them even more restricted in function. This procedure should be kept in mind to be used in the rare cases of painful instability of the distal radioulnar joint when traditional motion-preserving procedures have failed.

The treatment of chronic traumatic subluxation of the distal ulna by hemiresection interposition arthroplasty

Dorsal and palmar subluxation of the distal ulna can be difficult to both diagnose and treat. Patients often present long after their initial injuries with posttraumatic arthritic changes in the distal radioulnar joint. Hemiresection interposition arthroplasty is a salvage procedure that is reliable for both pain relief and restoration of motion.

Proximal row carpectomy: clinical evaluation

Proximal row carpectomy as a treatment of disorders of the radiocarpal joint remains controversial despite numerous reports documenting clinically successful outcomes. Criticism includes postoperative loss of grip strength, unsatisfactory range of motion, prolonged rehabilitation time, and the potential for progressive painful arthritis. Twenty-seven patients were studied to address these concerns. The average length of follow-up was 4 years. Postoperative pain relief was achieved in 26 patients, allowing 24 of the 27 patients to return to their previous activity status within an average of 4.5 months after surgery. In all cases, range of motion matched or surpassed preoperative values. Grip strength improved to an average of 80% of the contralateral side. A detailed radiographic analysis of the radii of curvature of the lunate fossa and the capitate showed that the radius of curvature of the capitate is approximately two thirds of the corresponding value of the lunate. Motion between the capitate and the radius is translational with a moving center of motion, which may dissipate load on the radius and explain the relative success of the procedure.