Impact of Timing of Targeted Muscle Reinnervation on Pain and Opioid Intake Following Major Limb Amputation

BACKGROUND

Targeted muscle reinnervation (TMR) has been shown to play an important role in managing neuromas. However, the impact of the timing of TMR on pain visual analogue scale (VAS) scores or patient opioid use has not been thoroughly explored. We hypothesized that TMR performed acutely would lead to lower VAS scores and decreased opioid intake.

METHODS

Prospectively collected data from an amputation registry at a single institution were utilized to identify patients who underwent TMR. Acute TMR was defined as TMR performed within 1 month of the major limb amputation. Primary outcomes included VAS pain scores and patient-reported opioid consumption.

RESULTS

In all, 25 patients (26 limbs) were identified in the acute group, and 18 patients (18 limbs) were identified in the delayed group. At intermediate follow-up (between 4 and 8 months postoperatively) and at final follow-up, the average pain VAS score in the delayed TMR group was significantly higher than that in the acute group (5.2 vs. 1.9 at intermediate P = .01 and 6.2 vs. 1.9 at final P = .002). In all, 84% of the amputees overall were not consuming opioid medications at the time of final follow-up (79% acute, 88% delayed, P = .72). There were no statistically significant differences in opioid consumption between the acute and delayed group at intermediate follow-up (P = .35) or at final follow-up (P = .68).

CONCLUSIONS

TMR is an effective procedure to reduce pain following major limb amputation. Patients with TMR performed acutely had significantly lower VAS pain scores at both intermediate and final follow-up than patients with TMR performed in a delayed setting.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Hand Fractures-Management and the Complications That Inevitably Occur: Metacarpal Fractures

Metacarpal fractures are among the most common hand fractures. To properly manage these injuries, surgeons must understand the anatomy, biomechanics, clinical assessment, surgical and nonsurgical treatment options, and potential complications. Metacarpal head fractures often require surgical treatment to restore the joint surface by using a variety of techniques. Metacarpal neck fractures are usually stable injuries that do not require surgical intervention, but surgeons must know when surgical intervention is indicated. Fractures of the metacarpal shaft can be treated surgically and nonsurgically and may be associated with large bone defects or soft-tissue injuries that require careful consideration. Finally, fractures involving the carpometacarpal joints must be promptly managed to avoid long-term complications, potentially requiring salvage procedures.

Proximal Interphalangeal Joint Fractures

Multiple fracture patterns can occur around the proximal interphalangeal joint and require surgeons to have a thorough understanding of the anatomy, clinical and radiographic examination, common fracture patterns, surgical and nonsurgical treatment options, and potential complications. Proximal phalangeal condylar fractures are typically managed surgically, because even nondisplaced fractures have a propensity for displacement. Middle phalangeal base fractures most commonly present as a volar lip fracture with or without dorsal subluxation or dislocation. Treatment options include extension block splinting or pinning, transarticular pinning, open reduction and internal fixation, external fixation, volar plate arthroplasty, and hemihamate arthroplasty. Less common fractures include dorsal lip fractures with or without volar subluxation or dislocation (the central slip fracture), lateral plateau impaction or avulsion injuries, and pilon fractures. The main goals in the management of middle phalangeal base fractures are to restore articular congruency and initial early range of motion, which are more important than obtaining an anatomic reduction.

Phalangeal Fractures and Fingertip Injuries

A comprehensive analysis of the assessment, diagnosis, and management of phalangeal fractures and fingertip injuries should emphasize the importance of achieving the right balance between undertreatment and overtreatment. Phalangeal injuries are complex, requiring an in-depth understanding of hand anatomy, fracture patterns, and treatment options to optimize patient outcomes. A thorough examination of proximal and middle phalangeal fractures and fingertip injuries, including those to the nail bed and distal phalanx, is important. A systematic approach to addressing the most prevalent injuries in this category should be implemented while highlighting the need for patient-specific approaches to treatment and a multidisciplinary perspective to ensure the best possible outcomes for patients.

The Prevalence of Depression and PTSD in Adults With Surgically Managed Traumatic Upper-Extremity Amputations

BACKGROUND

Upper-extremity limb loss has been associated with serious psychological sequelae. Despite advancements in surgical procedures and prostheses for upper limb amputees, it is critical to recognize the psychosocial component of these patients' care. Although the role of psychological factors in outcomes is increasingly acknowledged, little is known about the prevalence of depression and post-traumatic stress disorder (PTSD) in the civilian population after traumatic upper-extremity amputation.

METHODS

In this retrospective observational single-center study, adult patients evaluated for traumatic upper limb amputations from 2016 to 2019 completed the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, Visual Analogue Scale, the Center for Epidemiologic Studies Depression Scale, and the Primary Care PTSD Screen during visits. All data underwent descriptive statistical analysis.

RESULTS

Thirty-nine adult patients treated for upper-extremity traumatic amputation completed patient-reported outcomes (PROs) questionnaires. The median final follow-up time for our cohort was 17 months from amputation. Twenty patients (51%) screened positive for depression and 27 (69%) for PTSD during follow-up. The median time from amputation to first positive screening was 6.5 months for depression and 10 months for PTSD. The physical component score of Veterans RAND 12-Item Health Survey (VR-12) was significantly worse for patients with depression. The Median DASH and mental component score of VR-12 were significantly worse for patients with PTSD.

CONCLUSION

Upper-extremity limb loss has a significant impact on mental health, which in turn affects PROs. The high prevalence of depression and PTSD in traumatic upper-extremity amputees underscores the necessity for screening and multidisciplinary treatment.

Pediatric Phalanx Fractures

Phalangeal fractures are extremely common in the pediatric and adolescent populations. The incidence of phalangeal fractures peaks in children ages 10 to 14 years, corresponding to the age in which children begin contact sports. Younger children are more likely to experience crush injuries, whereas older children often sustain phalangeal fractures during sports. The physis is particularly susceptible to fracture because of the biomechanically weak nature of the physis compared with the surrounding ligaments and bone. Phalangeal fractures are identified through a thorough physical examination and are subsequently confirmed with radiographic evaluation. Management of pediatric phalangeal fractures is dependent on the age of the child, the severity of the injury, and the degree of fracture displacement. Nondisplaced fractures are often managed nonsurgically with immobilization, whereas unstable, displaced fractures may require surgery, which is often a closed rather than open reduction and percutaneous pinning.

A Consensus Approach for Targeted Muscle Reinnervation in Amputees

Amputations have been performed with few modifications since the dawn of surgery. Blood vessels are ligated, bones are shortened, and nerves are cut. In a percentage of people, this can result in severe neuropathic, residual limb, and phantom limb pain. Targeted muscle reinnervation is a surgical procedure initially conceived to optimize function for myoelectric prostheses in amputees. Recently, it has been adopted more widely by surgeons for the prevention and treatment of neuropathic pain. Perhaps as a function of its relatively recent development, many authors perform this operation differently, and there has been no overall agreement regarding the principles, indications, technical specifics, and postoperative management guidelines. This article is written as a consensus statement by surgeons focused on the treatment of neuropathic pain and those with extensive experience performing targeted muscle reinnervation. It is designed to serve as a roadmap and template for extremity surgeons to consider when performing targeted muscle reinnervation.

Soft Tissue Management of Partial Hand Amputation

Conventional teaching in the management of partial hand amputations prioritizes residual limb length, often through local, regional, or distant flaps. While multiple options exist to provide durable soft tissue coverage, only a few flaps are thin and pliable enough to match that of the dorsal hand skin. Despite debulking, excessive soft tissues from previous flap reconstructions can interfere with residual limb function, prosthesis fit, and surface electrode recording for myoelectric prostheses. With rapid advances in prosthetic technology and nerve transfer techniques, patients can achieve very high levels of function following prosthetic rehabilitation that rival, or even outpace, traditional soft tissue reconstruction. Therefore, our reconstruction algorithm for partial hand amputations has evolved to the thinnest coverage possible, providing adequate durability. This evolution has provided our patients with faster and more secure prosthesis fitting with better surface electrode detection, enabling earlier and improved use of simple and advanced partial hand prostheses.

The Starfish Procedure for Independent Digital Control of a Myoelectric Prosthesis

Management of partial hand amputations is a notable clinical challenge. Historically, myoelectric prostheses have not allowed for independent digital control, resulting in unsatisfactory function and high rejection rates among upper extremity amputees. The Starfish Procedure was developed for patients who sustained loss of multiple digits through the level of the base of the proximal phalanx or distal metacarpal. The procedure involves the pedicled transfer of 1 or more dorsal interosseous muscles to a subcutaneous location. This allows for a myoelectric sensor to capture the signals generated by these transferred muscles, thereby enabling intuitive, independent, digital prosthetic flexion and extension. In this article, we detail the relevant anatomy, indications, and technique for performing the Starfish Procedure. Given our patients' promising outcomes to date, we hope this technique paper will encourage upper extremity surgeons of all training backgrounds to perform this relatively straightforward procedure, thereby allowing patients with life-altering finger amputations to regain meaningful function by enhancing control of digital prostheses.

Retrospective Comparison of Capitolunate Arthrodesis Using Headless Compression Screws Versus Nitinol Memory Staples for SLAC and SNAC Wrist: Radiographic, Functional, and Patient-Reported Outcomes

BACKGROUND

Nitinol memory compression staples have been proposed as an effective alternative to compression screws for capitolunate arthrodesis (CLA) for scaphoid nonunion advanced collapse (SNAC) and scapholunate advanced collapse (SLAC) wrist. The purpose of this study was to compare the clinical outcomes of CLA for SNAC or SLAC wrist treatment using either compression screws or nitinol staples.

METHODS

In all, 47 patients with CLA for SLAC or SNAC wrist with screws or nitinol staples were retrospectively identified. Primary outcome was fusion on radiographs and/or computed tomography. Secondary outcomes were hardware-related complications (HWCs) and other complications, range of motion, grip strength, and patient-reported outcome measures (PROMs), including Visual Analogue Pain scale; Disabilities of the Arm, Shoulder, and Hand score; and patient-rated wrist evaluation.

RESULTS

Of the 47 eligible patients, 40 (85%) were included: 31 patients in the staple group and 9 patients in the screw group. The average age was 49 (17-80) years. There was an 89% union rate for the screw group and a 97% union rate for the staple group. Two patients had screw backout: one who went onto union after screw removal and the other who went onto nonunion after hardware removal. There were 2 (6.5%) HWCs in the staple group. One patient had staple loosening requiring revision and the other dorsal impingement requiring staple removal after radiographic union. In all subsequent cases, the staples were countersunk with no impingement. No significant differences existed between any additional outcomes.

CONCLUSIONS

We found no differences between nitinol staples and screws for CLA regarding HWCs or PROMs. Nitinol staples may offer additional benefits as a safe and effective alternative to compression screws for wrist fusions.

Feasibility of Nerve Transfer to Palmaris Longus in Forearm-Level TMR: Anatomic Study and Clinical Series

BACKGROUND

Targeted muscle re-innervation (TMR) is increasingly being used for treatment of postamputation pain and myoelectric prosthesis (MYP) control. Palmaris longus (PL) is a potential target following transradial amputation. The purpose of this study was to determine the branching pattern of the median nerve (MN) as it pertains to the PL motor branch entry point (MEP) and to present clinical results of patients who had PL used as a target.

METHODS

Eight cadaveric arms were dissected and branching patterns of the MN were documented. Additionally, we reviewed adult patients from a prospectively collected database who underwent TMR using PL. We recorded patient-reported outcomes and signal strength generated by the PL.

RESULTS

The average distance from the medial epicondyle to PL MEP was 53 mm. All palmaris motor branches passed through a chiasm within the flexor digitorum superficialis muscle belly, which was a mean of 18 mm away from the MN proper. Patients with long-term follow-up reported an average Pain visual analog scale of 3.3 and Disabilities of the Arm, Shoulder and Hand of 46.2. All but one patient were using an MYP, and all generated at least 10 mV of signal from the PL, which is ample signal for surface electrode detection and MYP control. There were no postoperative neuromas and only one patient-reported postoperative phantom limb pain.

CONCLUSIONS

Palmaris longus is a suitable target for TMR. Our objective measurements and anatomic relationships may help surgeons consistently find the PL's motor branch. Our series of patients reveal sufficient signal strength and acceptable clinical outcomes following TMR using the PL.

Complications after traumatic distal triceps tears: an analysis of 107 cases

Background

The major complication and reoperation rates after distal triceps repair are poorly defined. The purpose of this large retrospective cohort study of distal triceps repairs performed by multiple surgeons within a large orthopedic group was to more clearly define the rates and risk factors of clinically impactful major complications and reoperations.

Methods

All distal triceps tendon repairs for traumatic injuries performed from January 2006 to April 2017 with a minimum 2-month follow-up were identified using the Current Procedural Terminology code 24342. A total of 107 patients were included in this study. The primary outcome measure was total major complication rate. Reoperations, minor complications, and risk factors were also tracked.

Results

Repairs were performed via bone tunnels (63.5%), suture anchors (13%), or a combination of the two (17.8%). A 14% complication rate and 13.1% reoperation rate were observed. Indication for reoperation included 9 reruptures, 3 infections, and 2 others. The time between injury and surgery was not found to be a risk factor for tendon rerupture. Smoking status, gender, utilization of a splint or controlled motion brace, and time to first active mobilization were not shown to influence rates or rerupture.

Conclusion

Distal triceps repair for traumatic injuries is associated with 14% complication and 13.1% reoperation rates. Patient, rehabilitation, and surgeon-specific factors did not influence the complication rate.

Distal Biceps Repairs in Females: A Large Single-Center Case Series

BACKGROUND

Distal biceps repair is a commonly reported procedure in male patients, with reliable outcomes and minimal long-term complications. Information on female patients, however, is limited, and variation in presentation and clinical outcomes is unknown.

QUESTIONS/PURPOSE

We sought to report on the presentation, treatment algorithm, and outcomes of a case series of female patients with distal biceps pathology.

METHODS

A retrospective evaluation was performed from a large, single specialty orthopedic group from 2005 to 2017. Inclusion criteria were surgical treatment of the distal biceps in female patients, with minimum 3 months of follow-up. The primary outcome variable was the Mayo Elbow Performance Score (MEPS).

RESULTS

Of 26 patients who met inclusion criteria, 18 (70%) were available for follow-up with patient-reported outcomes. Median age at time of injury was 56.1 years; 46.2% of patients presented with a complete tear of the distal biceps, and the remaining 53.8% presented with a partial tear that failed nonoperative treatment. Six patients had lateral antebrachial cutaneous neuritis in early follow-up, which ultimately resolved. Median MEPS score was 100 (interquartile range: 20).

CONCLUSION

This study represents the largest case series to date describing the presentation, treatment, and outcomes of female patients with distal biceps repair. Women tend to be older than men, have more insidious onset of pain, present with partial tearing, and may benefit from nonoperative treatment. Ultimately, based on this case series we believe distal biceps repair in female patients is a successful operation with minimal complications and high patient satisfaction.

Metacarpal Fractures in the National Football League: Injury Characteristics, Management, and Return to Play

PURPOSE

This study investigated metacarpal fracture occurrences, characteristics, treatments, and return-to-play times for National Football League (NFL) athletes.

METHODS

NFL players who sustained metacarpal fractures during the 2012 to 2018 seasons were reviewed. All players on the 32 NFL team active rosters with metacarpal fractures recorded through the NFL Injury Database were included. Player age, time in the league, player position, injury setting, injury mechanism, fractured ray, management, and return-to-play were recorded.

RESULTS

There were 208 injury occurrences resulting in 1 or more metacarpal fractures, identified in 205 players. Of these, 81 (39%) injuries were operated. Return-to-play data were available for 173 (83%) injured players. The median return-to-play time for all athletes was 15 days (interquartile range, 1-55 days). Of the injured players, 130 (71%) missed time but returned the same season. Within this 130-player subset, 69 (53%) were treated nonsurgically and 61 (47%) operatively with median return-to-play times of 16 days (interquartile range, 6-30 days) and 20 days (interquartile range, 16-42 days) respectively. Eighteen individuals in this 130-player subgroup sustained a thumb metacarpal fracture. The return-to-play time was slower for patients sustaining thumb metacarpal fractures compared to other metacarpal fractures, and was significantly longer (median, 55 days) following nonsurgical treatment of thumb fractures compared with operative intervention (median, 24 days). A regression analysis revealed no trend or difference in return to football with respect to player age, time in the league, injury setting (practice vs game), injury mechanism, articular involvement, multiple concomitant injuries, or player position.

CONCLUSIONS

Most NFL players who sustain metacarpal fractures miss less than 3 weeks and return to play the same season. The only variables that lessen the return-to-play time are involvement of lesser digit metacarpals and operative intervention for treatment of thumb metacarpal fractures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Digital Nerve Management and Neuroma Prevention in Hand Amputations

BACKGROUND

Hand and digit amputations represent a relatively common injury affecting an active patient population. Neuroma formation following amputation at the level of the digital nerve can cause significant disability and lead to revision surgery. One method for managing digital nerves in primary and revision partial hand amputations is to perform interdigital end-to-end nerve coaptations to prevent neuroma formation.

METHODS

All patients with an amputation at the level of the common or proper digital nerves that had appropriate follow-up at our institution from 2010 to 2020 were included. Common or proper digital nerves were managed with either traction neurectomy or digital end-to-end neurorrhaphy. The primary outcome was the development of a neuroma. Secondary outcomes included revision surgery, complications, and visual analog pain scores.

RESULTS

A total of 289 nerves in 54 patients underwent hand or digital amputation in the study period. Thirteen hands with 78 nerves (27%) underwent direct end-to-end coaptation with a postoperative neuroma incidence of 12.8% compared with 22.7% in the 211 nerves that did not have a coaptation performed. Significantly fewer patients reported persistent pain if an end-to-end coaptation was performed (0% vs. 11.8%, P < .01). The prevalence of depression and workers compensation status was significantly higher in in patients with symptomatic neuromas than in patients without symptomatic neuromas (P < .01).

CONCLUSIONS

Digital nerve end-to-end neurorrhaphy is a method for neuroma prevention in partial hand amputations that results in decreased residual hand pain without increase complications. Depression and worker's compensations status were significantly associated with symptomatic neuroma formation.

Central Slip Reconstruction With a Distally Based Flexor Digitorum Superficialis Slip: A Biomechanical Study

PURPOSE

The ideal method of central slip reconstruction is difficult to determine due to the multitude of techniques, nonstandardized outcome reporting, and small patient series in the literature. Although most boutonniere deformities may be treated with nonsurgical measures, chronic, subacute, or open injuries may require operative intervention. To aid surgeons in the choice of the ideal central slip reconstruction method, this biomechanical study compared the 3 most common methods performed at our institution: direct repair, lateral band centralization, and distally-based flexor digitorum superficialis (FDS) slip repair.

METHODS

A boutonniere deformity was induced in 35 fresh-frozen cadaver digits. The central slip was repaired in 9 digits using a primary suture repair, in 9 digits using a lateral band centralization technique, and in 9 digits using a distally-based FDS slip reconstruction. A control group without injury was tested in 8 digits. Following repair or reconstruction, each digit was tested for load to failure, strain, and stiffness at the repair.

RESULTS

The average load to failure after central slip reconstruction was significantly greater for a distally based FDS slip method at 82.1 ± 14.6 N (95% CI, 62.2-101.9 N) than all other repair types. Although the FDS slip reconstruction was not as strong as the intact state (82.1 N vs 156.2 N, respectively), it was 2.6 times stronger than the lateral band centralization (82.1 N vs 31.6 N, respectively) and 3 times stronger than a primary repair (82.1 N vs 27.6 N, respectively).

CONCLUSIONS

Reconstruction of the central slip using a distally-based FDS slip provided the greatest biomechanical strength compared with the direct repair or lateral band centralization.

CLINICAL RELEVANCE

The use of a distally based reconstruction using FDS may allow for safer early motion.

Complications Following Transosseous Repair of Zone I Flexor Tendon Injuries

PURPOSE

Multiple techniques are described for repair of zone I flexor tendon injuries, many of which are fraught with complications. This study evaluated the clinical complications after a transosseous repair technique.

METHODS

A retrospective review of a single institutional database identified all zone I flexor digitorum profundus (FDP) injuries repaired using a transosseous technique. In this technique, 2 nonabsorbable sutures were passed from volar to dorsal through transosseous tunnels and tied dorsally over the distal phalanx proximal to the germinal matrix. Demographics, injury characteristics, operative details, and complications were reviewed.

RESULTS

Eight patients met the inclusion criteria. Average age was 31 years (range, 15-66 years) and all patients were male. Eight fingers were included: ring (4), small (3), and middle (1). Seven injuries were closed and one was open. Average time between injury and surgery was 13 days (range, 4-34 days). Five patients experienced complications, including osteomyelitis, chronic draining granuloma, and abnormal nail growth. Three patients required an additional operative procedure for management of complications.

CONCLUSIONS

Transosseous repair of zone I flexor digitorum profundus injuries with a buried dorsal suture is associated with a high rate of clinical complications.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Environmentally Responsible Hand Surgery: Past, Present, and Future

Health care is an important contributor to environmental waste. In 2013, the health care sector was responsible for substantial fractions of national air pollution emissions and impacts, including acid rain (12%), greenhouse gas emissions (10%), smog formation (10%), air pollutants (9%), stratospheric ozone depletion (1%), and carcinogenic and noncarcinogenic air toxins (1% to 2%). Operating rooms produce between 20% and 70% of total hospital waste. Hand surgery, with short, high-volume cases, is a notable contributor to this environmental and subsequent financial burden. This article aims to highlight the Lean and Green initiative proposed by the American Association for Hand Surgery along with the American Society for Surgery of the Hand, the American Society for Peripheral Nerve Surgery, and the American Society of Reconstructive Microsurgery in 2015, to reduce the amount of waste generated by hand surgery. We have reviewed the literature to propose multiple ways to reduce both material and nonmaterial waste-energy consumption, sterilization techniques, reprocessing of devices, patient transportation, production of surgical supply, anesthesia, and sanitation in hand surgery.

Targeted Muscle Reinnervation for Prosthesis Optimization and Neuroma Management in the Setting of Transradial Amputation

Targeted muscle reinnervation (TMR) is a surgical technique that improves modern myoelectric prosthesis functionality and plays an important role in the prevention and treatment of painful postamputation neuromas. Originally described for transhumeral amputations and shoulder disarticulations, the technique is being adapted for treatment of transtibial, transfemoral, transradial, and partial hand amputees. We describe a new technique for forearm TMR following transradial amputation with an emphasis on selecting nerve transfer patterns, managing sensory nerves, improving terminal soft tissue coverage, and employing pattern recognition technology.

Excision of Incomplete Hook of the Hamate Fractures

Incomplete hook of the hamate fractures are difficult to diagnose and should be promptly removed to expedite return to sport. From January 2000 to November 2016, 143 excisions of the hook of the hamate were performed following fracture of the hamulus. Of these 143 excisions, 17 were performed because of a preoperative diagnosis of incomplete fracture. The inclusion criteria for diagnosis were as follows: (1) history of ulnar-sided wrist pain; (2) positive result on hook of the hamate pull test on physical examination; and (3) evidence on computed tomography or magnetic resonance imaging of an incomplete fracture of the hook of the hamate. Time to diagnosis and treatment, return to sport, postoperative complications, preoperative treatment, and effectiveness were recorded. Seventeen diagnoses of partially united hook of the hamate fractures had been made since January 2000. All of these patients underwent excision of the hamulus. The mean time to diagnosis was 11.1 weeks. The mean delay in surgical treatment was 6.2 weeks. All 17 patients were able to return to sport at a mean of 6.8 weeks. Patients initially seen by 1 of the senior authors had a 7.9-week earlier return to sport. Eight patients received preoperative treatment. Preoperative treatment failed for all 8, and they underwent subsequent hamulus excision. The diagnosis of an incomplete hook of the hamate fracture is difficult and often delayed. These fractures should be managed with early excision, as they do well with early return to sport and are prone to fail nonoperative treatment. Delay in diagnosis and treatment prolongs return to sport. [Orthopedics. 2019; 42(2):e232-e235.].

A Novel Muscle Transfer for Independent Digital Control of a Myoelectric Prosthesis: The Starfish Procedure

Control of independent digital flexion and extension has remained an elusive goal in myoelectric prosthetics for upper extremity amputees. We first performed a cadaver study to determine the feasibility of transferring the interossei muscles for each digit to the dorsum of the hand without damaging the neurovascular pedicles. Once this capability was ensured, a clinical case was performed transferring the interossei of the middle and ring fingers to the dorsum of the hand where they could serve as a myoelectric signal for a partial hand amputee to allow individual digital control with a myoelectric prosthesis. Before surgery, it was impossible to detect an independent signal for each interossei; however, after the surgery, signals were reliably detected, which allowed these muscles to serve as myosites for finger flexion using a myoelectric prosthesis and move each digit independently. This concept of salvaging innervated and perfused muscles from an amputated part and transferring them into the more proximal and superficial portion of a salvaged limb has broad applications for improved myoelectric prosthetic control.

Major complications after distal biceps tendon repairs: retrospective cohort analysis of 970 cases

BACKGROUND

The major complication and reoperation rates after distal biceps repair are poorly defined. The purpose of this large retrospective cohort study of distal biceps repairs performed by multiple surgeons within a large orthopedic group was to more clearly define the rates and risk factors of clinically impactful major complications and reoperations.

METHODS

All distal biceps tendon repairs performed from January 2005 through April 2017 with a minimum 2-month follow-up were identified using Current Procedural Terminology code 24342. We included 970 patients. The primary outcome measure was the total major complication rate. Reoperations, minor complications, and risk factors were also tracked.

RESULTS

Repairs were performed via a single anterior incision in 652 cases and a 2-incision exposure in 318 cases. A 7.5% major complication rate and 4.5% reoperation rate were observed overall. Major complications occurred at the following rates: proximal radioulnar synostosis, 1.0%; heterotopic ossification or loss of range of motion with reoperation, 0.9%; tendon rerupture, 1.6%; deep infection, 0.5%; posterior interosseous nerve palsy, 1.9%; and complex regional pain syndrome, 0.6%. The 2-incision exposure was identified as a significant risk factor for the development of proximal radioulnar synostosis when compared with single-incision repair techniques (P = .0003; odds ratio, 19), occurring in 2.8% of 2-incision exposure cases. Lateral antebrachial cutaneous nerve neuritis or numbness and radial sensory nerve neuritis or numbness were documented more frequently in the postoperative period among patients treated with a single-incision exposure (P < .0001 and P = .034, respectively).

CONCLUSIONS

Distal biceps repair is associated with a 7.5% major complication rate and 4.5% reoperation rate. The use of a 2-incision technique for repair increases the risk of radioulnar synostosis.

Current Concepts in Upper-Extremity Amputation

Advances in motor vehicle safety, trauma care, combat body armor, and cancer treatment have enhanced the life expectancy and functional expectations of patients with upper-extremity amputations. Upper-extremity surgeons have multiple surgical options to optimize the potential of emerging prosthetic technologies for this diverse patient group. Targeted muscle reinnervation is an evolving technique that improves control of myoelectric prostheses and can prevent or treat symptomatic neuromas. This review addresses current strategies for the care of patients with amputations proximal to the wrist with an emphasis on recent advancements in surgical techniques and prostheses.

High-Pressure Water Injection Injuries of the Hand May Not Be Trivial

High-pressure water injection injuries of the hand are uncommon, and there is limited literature to guide their treatment. The ideal management of these injuries, whether nonoperative with close observation or early surgical debridement, remains unknown. The authors retrospectively identified a cohort of patients with high-pressure water injection injuries to the hand during a 16-year period. Data collected included demographics, location of injection, hand dominance, type of treatment, need for additional surgery, and complications. The authors attempted to reach all patients by phone and email to assess long-term motion loss, sensation loss, and chronic pain. Nineteen patients met the inclusion criteria. The nondominant hand was involved in 84% and the index finger in nearly half. Two of 10 patients in the early surgery group required additional procedures, including a trigger finger release and serial debridements for Pseudomonas infection. Three of 9 patients without early debridement eventually required surgery, including debridement of a septic flexor tenosynovitis, fingertip amputation, and metacarpophalangeal disarticulation. Sixteen percent of patients developed infection, and 1 patient developed compartment syndrome. This is the largest reported cohort of both operatively and nonoperatively treated high-pressure water injection injuries to the hand. This is the first report of amputation as a complication. Infection and delayed presentation portend a poor outcome. Complications may arise even after early surgical debridement, and long-term sequelae are common. These injuries are not inherently benign and warrant immediate medical attention, early antibiotics, and a low threshold for close observation or surgical debridement. [Orthopedics. 2018; 41(2):e245-e251.].

Efficacy and safety of collagenase clostridium histolyticum for Dupuytren disease nodules: a randomized controlled trial

Background

To determine the safety and efficacy of collagenase clostridium histolyticum (CCH) injection for the treatment of palmar Dupuytren disease nodules.

Methods

In this 8-week, double-blind trial, palpable palmar nodules on one hand of adults with Dupuytren disease were selected for treatment. Patients were randomly assigned using an interactive web response system to receive a dose of 0.25 mg, 0.40 mg, or 0.60 mg (1:1:1 ratio) and then allocated to active treatment (CCH) or placebo (4:1 ratio). All patients and investigators were blinded to treatment. One injection was made in the selected nodule on Day 1. Caliper measurements of nodule length and width were performed at screening and at Weeks 4 and 8. Investigator-reported nodular consistency and hardness were evaluated at baseline and Weeks 1, 4, and 8. Investigator-rated patient improvement (1 [very much improved] to 7 [very much worse]) and patient satisfaction were assessed at study end.

Results

In the efficacy population (n = 74), percentage changes in area were significantly greater with CCH 0.40 mg (−80.1%, P = 0.0002) and CCH 0.60 mg (−78.2%, P = 0.0003), but not CCH 0.25 mg (−58.3%, P = 0.079), versus placebo (−42.2%) at post-treatment Week 8. Mean change in nodular consistency and hardness were significantly improved with CCH versus placebo at Weeks 4 and 8 (P ≤ 0.0139 for all). At Week 8, investigator global assessment of improvement was significantly greater with CCH 0.40 mg and 0.60 mg (P ≤ 0.0014) but not statistically significant with CCH 0.25 mg versus placebo (P = 0.13). Most patients were “very satisfied” or “quite satisfied” with CCH 0.40 mg and 0.60 mg. Contusion/bruising (50.0% to 59.1%) was the most common adverse event with CCH treatment.

Conclusion

In patients with Dupuytren disease, a single CCH injection significantly improved palmar nodule size and hardness. The safety of CCH was similar to that observed previously in patients with Dupuytren contracture.

Trial registration

ClinicalTrials.gov identifier: NCT02193828. Date of trial registration: July 2, 2014 to December 5, 2014

Acute Scaphoid Fractures: A Critical Analysis Review

Nondisplaced scaphoid fractures can be effectively treated nonoperatively, with union rates approaching or, in some series, exceeding the rates attained with operative intervention. The evidence supports equal outcomes when using a short arm or long arm cast for the closed treatment of nondisplaced scaphoid fractures. Also, equivalent outcomes have been demonstrated with or without a thumb spica component to the cast. Operative intervention is the recommended treatment for displaced scaphoid fractures. Advanced imaging should be obtained if clinical suspicion is present for a scaphoid fracture with negative radiographs more than 2 weeks after the injury. In some settings, it may even be more cost-effective to obtain advanced imaging sooner.

Low Median Nerve Transfers (Opponensplasty)

Opposition is the placement of the thumb opposite the fingers into a position from which it can work. This motion requires thumb palmar abduction, flexion, and pronation, which are provided by the abductor pollicis brevis, flexor pollicis brevis (FPB), and opponens pollicis. In the setting of a median nerve palsy, this function is typically lost, although anatomic variations and the dual innervation of the FPB may prevent complete loss at times. There are multiple well described and accepted tendon transfers to restore opposition, none of which have been proven to be superior to the others.

Ulnar Nerve Tendon Transfers for Pinch

Power and tip pinch are an integral part of intrinsic hand function that can be significantly compromised with dysfunction of the ulnar nerve. Loss of power pinch is one component that can significantly affect an individual's ability to perform simple daily tasks. Tip pinch is less affected, as this task has significant contributions from the median nerve. To restore power pinch, the primary focus must be on restoring the action of the adductor pollicis primarily, and if indicated the first dorsal interosseous muscle and flexor pollicis brevis.

Complications With the Use of BMP-2 in Scaphoid Nonunion Surgery

PURPOSE

In an effort to improve fracture healing and decrease the need for autologous bone graft, products such as recombinant human bone morphogenetic protein (rhBMP-2) have been developed and used in both spine and nonspine surgery. There is a paucity of literature regarding the use of rhBMP-2 in scaphoid nonunion surgery with very little reporting on the complications associated with its use. The objective of this study was to retrospectively review the complications documented for a case series of patients treated with revision fixation, bone graft, and rhBMP-2 in revision scaphoid nonunion surgery.

METHODS

We retrospectively reviewed 6 cases of scaphoid nonunion revision surgery comprising open reduction and internal fixation (ORIF). All cases were performed for persistent nonunion after a previous scaphoid ORIF. All patients were treated with revision screw fixation, bone graft, and rhBMP-2. Union was determined by computed tomography in all cases. Complications of nonunion, heterotopic bone formation, delayed wound healing, functional loss of motion, and need for revision surgery are reported.

RESULTS

Between 2011 and 2014, 6 cases in which rhBMP-2 was used in revision scaphoid nonunion surgery were identified. All patients had failed an initial attempt at ORIF after delayed union or nonunion. The time from injury to index ORIF ranged from 3 months to 4 years (mean, 24 months). Revision surgery with rhBMP-2 was performed at an average of 6 months from the index ORIF. Of the 6 cases, 2 had resultant persistent nonunion. Both underwent scaphoid excision and midcarpal arthrodesis. Four cases developed notable heterotopic ossification (one of which required revision surgery). One patient had a loss of functional motion after the revision surgery. There were no cases of delayed wound healing. Only one of the 6 patients healed without complications.

CONCLUSIONS

In this case series, the use of rhBMP-2 in scaphoid nonunions was associated with a higher complication rate than reported in previous studies. Surgeons performing off-label use of rhBMP-2 should be aware of the potential for complications including heterotopic ossification.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Upper Extremity Injuries in NASCAR Drivers and Pit Crew

Background:

Understanding the position-specific musculoskeletal forces placed on the body of athletes facilitates treatment, prevention, and return-to-play decisions. While position-specific injuries are well documented in most major sports, little is known about the epidemiology of position-specific injuries in National Association for Stock Car Automobile Racing (NASCAR) drivers and pit crew.

Purpose:

To investigate position-specific upper extremity injuries in NASCAR drivers and pit crew members.

Study Design:

Descriptive epidemiological study.

Methods:

A retrospective chart review was performed to assess position-specific injuries in NASCAR drivers and pit crew members. Included in the study were patients seen by a single institution between July 2003 and October 2014 with upper extremity injuries from race-related NASCAR events or practices. Charts were reviewed to identify the diagnosis, mechanism of injury, and position of each patient.

Results:

A total of 226 NASCAR team members were treated between July 2003 and October 2014. Of these, 118 injuries (52%) occurred during NASCAR racing events or practices. The majority of these injuries occurred in NASCAR changers (42%), followed by injuries in drivers (16%), carriers (14%), jack men (11%), fuel men (9%), and utility men (8%). The majority of the pit crew positions are at risk for epicondylitis, while drivers are most likely to experience neuropathies, such as hand-arm vibration syndrome. The changer sustains the most hand-related injuries (42%) on the pit crew team, while carriers commonly sustain injuries to their digits (29%).

Conclusion:

Orthopaedic injuries in NASCAR vary between positions. Injuries in NASCAR drivers and pit crew members are a consequence of the distinctive forces associated with each position throughout the course of the racing season. Understanding these forces and position-associated injuries is important for preventive measures and facilitates diagnosis and return-to-play decisions so that each team can function at its maximal efficiency.

The Efficacy and Safety of Concurrent Collagenase Clostridium Histolyticum Injections for 2 Dupuytren Contractures in the Same Hand: A Prospective, Multicenter Study

PURPOSE

To evaluate efficacy and safety of concurrent administration of 2 collagenase clostridium histolyticum (CCH) injections to treat 2 joints in the same hand with Dupuytren fixed flexion contractures (FFCs).

METHODS

Patients with 2 or more contractures in the same hand caused by palpable cords participated in a 60-day, multicenter, open-label, phase 3b study. Two 0.58 mg CCH doses were injected into 1 or 2 cords in the same hand (1 injection per affected joint) during the same visit. Finger extension was performed approximately 24, 48, or 72 or more hours later. Changes in FFC and range of motion, incidence of clinical success (FFC ≤ 5°), and adverse events (AEs) were summarized.

RESULTS

The study enrolled 715 patients (725 treated joint pairs), and 714 patients (724 joint pairs) were analyzed for efficacy. At day 31, mean total FFC (sum of 2 treated joints) decreased 74%, from 98° to 27°. Mean total range of motion increased from 90° to 156°. The incidence of clinical success was 65% in metacarpophalangeal joints and 29% in proximal interphalangeal joints. Most treatment-related AEs were mild to moderate, resolving without intervention; the most common were swelling of treated extremity, contusion, and pain in extremity. The incidence of skin lacerations was 22% (160 of 715). Efficacy and safety were similar regardless of time to finger extension.

CONCLUSIONS

Collagenase clostridium histolyticum can be used to effectively treat 2 affected joints concurrently without a greater risk of AEs than treatment of a single joint, with the exception of skin laceration. The incidence of clinical success in this study after 1 injection per joint was comparable to phase 3 study results after 3 or more injections per joint. Two concurrent CCH injections may allow more rapid overall treatment of multiple affected joints, and the ability to vary the time between CCH injection and finger extension may allow physicians and patients greater flexibility with scheduling treatment.

Management of complications of wrist fractures

This article reviews the most common complications associated with the management of carpal fractures. Discussion focuses on the recognition of commonly "missed" fractures and fracture patterns and the negative sequelae that can result from these delayed diagnoses. The pitfalls of conservative treatment of specific carpal fractures are reviewed, and the most common complications resulting from the operative management of carpal injuries are described.

Trigger finger: assessment of surgeon and patient preferences and priorities for decision making

PURPOSE

To test the null hypothesis that there are no differences in the priorities and preferences of patients with idiopathic trigger finger (TF) and hand surgeons.

METHODS

One hundred five hand surgeons of the Science of Variation Group and 84 patients with TF completed a survey about their priorities and preferences in decision making regarding the management of TF. The questionnaire was structured according the Ottawa Decision Support Framework for the development of a decision aid.

RESULTS

Patients desired orthotics more and surgery less than physicians. Patients and physicians disagreed on the main advantage of several treatment options for TFs and on disadvantages of the treatment options. Patients preferred to decide for themselves after receiving advice, whereas physicians preferred a shared decision. Patients preferred booklets, and physicians opted for Internet and video decision aids.

CONCLUSIONS

Comparing patients and hand surgeons, there were some differences in treatment preferences and perceived advantages and disadvantages regarding idiopathic TF-differences that might be addressed by a decision aid.

CLINICAL RELEVANCE

Information that helps inform patients of their options based on current best evidence might help them understand their own preferences and values, reduce decisional conflict, limit surgeon-to-surgeon variations, and improve health.

Reattachment of flexor digitorum profundus avulsion: biomechanical performance of 3 techniques

PURPOSE

To investigate whether inclusion of the volar plate in repair of flexor digitorum profundus avulsions increases the strength of the repair and resists gapping.

METHODS

Cadaveric fingers (n = 18) were divided into 3 equal groups. The first technique involved 2 micro-suture anchors only (A). The second used only volar plate repair (VP). The third group was a hybrid, combining a micro-suture anchor with volar plate augmentation (AVP). Specimens were loaded cyclically to simulate passive motion rehabilitation before being loaded to failure. Clinical failure was defined as 3 mm of gapping, and physical failure as the highest load associated with hardware failure, suture breakage, anchor pullout, or volar plate avulsion.

RESULTS

Gapping throughout cycling was significantly greater for the A group than VP and AVP with no difference detected between VP and AVP groups. Gapping exceeded 3 mm during cycling of 3 A specimens, but in none of the VP or AVP specimens. Load at clinical and physical failure for A was significantly lower than for VP and AVP, whereas no difference was detected between VP and AVP.

CONCLUSIONS

In this cadaveric model, incorporating the volar plate conferred a significant advantage in strength, increasing the mean load to physical failure by approximately 100 N.

CLINICAL RELEVANCE

According to previous biomechanical studies, current reconstructive strategies for flexor digitorum profundus zone I avulsions are not strong enough to withstand active motion rehabilitation. We demonstrated the potential use of volar plate augmentation and the prospective advantageous increase in strength in this cadaveric model. In vivo performance and effects on digital motion are not known.

Sports-specific injuries of the hand and wrist

This article provides a philosophic overview of the management of athletes at all levels from high school to professional. It further reviews sports-specific injury patterns and position-specific injury patterns. This aspect is crucial, as many injuries may be relatively common for specific sports but rare in the general population, so recognition of these injuries requires a high degree of suspicion. The guiding principles of management are also discussed.

Carpal tunnel syndrome: assessment of surgeon and patient preferences and priorities for decision-making

PURPOSE

This study tested the null hypothesis that there are no differences between the preferences of hand surgeons and those patients with carpal tunnel syndrome (CTS) facing decisions about management of CTS (ie, the preferred content of a decision aid).

METHODS

One hundred three hand surgeons of the Science of Variation Group and 79 patients with CTS completed a survey about their priorities and preferences in decision making regarding the management of CTS. The questionnaire was structured according the Ottawa Decision Support Framework for the development of a decision aid.

RESULTS

Important areas on which patient and hand surgeon interests differed included a preference for nonpainful, nonoperative treatment and confirmation of the diagnosis with electrodiagnostic testing. For patients, the main disadvantage of nonoperative treatment was that it was likely to be only palliative and temporary. Patients preferred, on average, to take the lead in decision making, whereas physicians preferred shared decision making. Patients and physicians agreed on the value of support from family and other physicians in the decision-making process.

CONCLUSIONS

There were some differences between patient and surgeon priorities and preferences regarding decision making for CTS, particularly the risks and benefits of diagnostic and therapeutic procedures.

CLINICAL RELEVANCE

Information that helps inform patients of their options based on current best evidence might help patients understand their own preferences and values, reduce decisional conflict, limit surgeon-to-surgeon variations, and improve health.

Arthroscopic wafer procedure for ulnar impaction syndrome

Ulnar impaction syndrome is abutment of the ulna on the lunate and triquetrum that increases stress and load, causing ulnar-sided wrist pain. Typically, ulnar-positive or -neutral variance is seen on a posteroanterior radiograph of the wrist. The management of ulnar impaction syndrome varies from conservative, symptomatic treatment to open procedures to shorten the ulna. Arthroscopic management has become increasingly popular for management of ulnar impaction with ulnar-positive variance of less than 3 mm and concomitant central triangular fibrocartilage complex tears. This method avoids complications associated with open procedures, such as nonunion and symptomatic hardware. The arthroscopic wafer procedure involves debridement of the central triangular fibrocartilage complex tear, along with debridement of the distal pole of the ulna causing the impaction. Debridement of the ulna arthroscopically is taken down to a level at which the patient is ulnar neutral or slightly ulnar negative. Previous studies have shown good results with relief of patient symptoms while avoiding complications seen with open procedures.

An outcome study for ulnar neuropathy at the elbow: a multicenter study by the surgery for ulnar nerve (SUN) study group

BACKGROUND

Many instruments have been developed to measure upper extremity disability, but few have been applied to ulnar neuropathy at the elbow (UNE).

OBJECTIVE

We measured patient outcomes following ulnar nerve decompression to (1) identify the most appropriate outcomes tools for UNE and (2) to describe outcomes following ulnar nerve decompression.

METHODS

Thirty-nine patients from 5 centers were followed prospectively after nerve decompression. Outcomes were measured preoperatively and at 6 weeks, 3 months, 6 months, and 12 months postoperatively. Each patient completed the Michigan Hand Questionnaire (MHQ), Carpal Tunnel Questionnaire (CTQ), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires. Grip, key-pinch strength, Semmes-Weinstein monofilament, and 2-point discrimination were measured. Construct validity was calculated by using Spearman correlation coefficients between questionnaire scores and physical and sensory measures. Responsiveness was assessed by standardized response means.

RESULTS

Key-pinch (P = .008) and Semmes-Weinstein monofilament testing of the ulnar ring (P < .001) and small finger (radial: P = .004; ulnar: P < .001) improved following decompression. Two-point discrimination improved significantly across the radial (P = .009) and ulnar (P = .007) small finger. Improved symptoms and function were noted by the CTQ (preoperative CTQ symptom score 2.73 vs 1.90 postoperatively, P < .001), DASH (P < .001), and MHQ: function (P < .001), activities of daily living (P = .003), work (P = .006), pain (P < .001), and satisfaction (P < .001). All surveys demonstrated strong construct validity, defined by correlation with functional outcomes, but MHQ and CTQ symptom instruments demonstrated the highest responsiveness.

CONCLUSION

Patient-reported outcomes improve following ulnar nerve decompression, including pain, function, and satisfaction. The MHQ and CTQ are more responsive than the DASH for isolated UNE treated with decompression.

Predictors of functional outcomes after simple decompression for ulnar neuropathy at the elbow: a multicenter study by the SUN study group

OBJECTIVE

To identify predictors of surgical outcome for ulnar neuropathy at the elbow (UNE).

DESIGN

Prospective cohort followed for 1 year.

SETTING

Clinics.

PARTICIPANTS

Patients diagnosed with UNE (N=55).

INTERVENTION

All subjects had simple decompression surgery.

MAIN OUTCOME MEASURES

The primary outcome measure was patient-reported outcomes, such as overall hand function through the Michigan Hand Outcomes Questionnaire (MHQ). Predictors included age, duration of symptoms, disease severity, and motor conduction velocity across the elbow.

RESULTS

Multiple regression models with change in the overall MHQ score as the dependent variable showed that at 3 months postoperative time, patients with <3 months duration of symptoms showed 12 points (95% confidence interval [CI], 0.9-23.5) greater improvement in MHQ scores than those with ≥3 months symptom duration. Less than 3 months of symptoms was again associated with 13 points (95% CI, 2.9-24) greater improvement in MHQ scores at 6 months postoperative, but it was no longer associated with better outcomes at 12 months. A worse baseline MHQ score was associated with significant improvement in MHQ scores at 3 months (coefficient, -0.38; 95% CI, -.67 to -.09), and baseline MHQ score was the only significant predictor of 12 month MHQ scores (coefficient, -.40; 95% CI, -.79 to -.01).

CONCLUSIONS

Subjects with <3 months of symptoms and worse baseline MHQ scores showed significantly greater improvement in functional outcomes as reported by the MHQ. However, duration of symptoms was only predictive at 3 or 6 months because most patients recovered within 3 to 6 months after surgery.

Fractures of the lesser sesamoids: case series

We present 3 cases of sesamoid fractures involving the index, ring, and little finger metacarpophalangeal joints. These injuries present similar to more common sprains of the finger metacarpophalangeal joint and may be difficult at times to appreciate on standard posteroanterior and lateral x-rays. Oblique images can aid in making the diagnosis at times. Whereas we still recommend immobilization as the initial treatment for these injuries, all 3 of our cases failed nonoperative management and eventually required sesamoid excision.

A novel technique for the treatment of recurrent cubital tunnel syndrome: ulnar nerve wrapping with a tissue engineered bioscaffold

The purpose of this study was to assess subjective and objective outcomes in treating recurrent cubital tunnel at secondary neurolysis by nerve wrapping with a tissue engineered three-dimensional biomatrix. Five patients with a mean age of 44.1 years and an average follow-up of 13.3 months were included in the study. All patients had improvement in visual analogue scales. Four patients that had preoperative intrinsic atrophy with clawing had no clawing or intrinsic atrophy at final follow-up. Postoperatively, four of the five patients had two-point discrimination of 5 mm. Grip strength on average increased 90%. Three patients had an excellent outcome, one patient had a good outcome, and one patient had a fair outcome. All five patients said they would have surgery again.