Management of Brachial Plexus Birth Palsies: The Stanford Experience

The start of Stanford's brachial plexus birth palsy (BPBP) experience dates back to 1983, when Dr. Vincent Rod Hentz visited Dr. Alain Gilbert on sabbatical. Since then, our principles of care for patients with BPBP have evolved based on our group's longitudinal experience caring for children with the entire spectrum of sequelae that arise in children with BPBP. We base our clinical decision making on frequent serial examinations and use intraoperative evoked potentials to guide surgical decisions. Here, we discuss our current principles on surgical indications, timing of surgery, and preferred techniques for secondary surgery in patients with BPBP.

Surgical restoration of the upper limb in cervical spinal cord injury patients

Prior to the 1950s, relatively few patients who suffered a transection of the cervical spinal cord survived their injury. Improved medical care and better coordination have resulted in greater numbers of patients surviving and leaving the hospital. The pioneering work of individual surgeons during the 1960s and 1970s stimulated interest in surgical restoration of upper limb function in tetraplegic patients. Since the publication of Moberg's monograph in 1978, surgical improvement of the upper limbs is regarded as one of the options that should be offered to tetraplegic individuals to improve their function. Patients are classified according to the level of spinal cord injury and the residual motor function (international classification: groups 1 to 9). Surgical procedures are adapted to the motor level for each group of patients. Indications for these procedures are well standardized, the techniques are well mastered, and predictable results can be expected. New nerve transfer techniques have been developed in recent years; they are currently being evaluated.

Electromyographic Analysis of Grip

This prospective cohort study used video electromyography synchronized analysis to determine the dynamic use of extrinsic and intrinsic finger flexion during grasp. Light fist formation primarily involved the flexor digitorum profundus with either the flexor digitorum superficialis or intrinsics. In contrast, both the flexor digitorum superficialis and intrinsics were recruited in all tight fist video electromyography. However, the sequence of recruitment differed between patients in tight fist formation. Injured patients demonstrated a unique pattern of recruitment based on injury. The authors conclude that the flexor digitorum profundus is the workhorse in composite fist formation but the roles of the flexor digitorum superficialis and the intrinsic muscles are less consistent across patients. [Orthopedics. 2019; 42(6):e555-e558.].

Tendon transfers after peripheral nerve injuries: my preferred techniques

While there is now keen interest in restoring function lost through irreparable nerve injury by performing nerve-to-nerve transfer, for some time to come, tendon transfers will remain the primary reconstructive procedure for paralytic injuries of the upper limb. A career spanning more than 50 years has permitted the author to try many tendon transfers promoted by past and present colleagues for the three common nerve injuries (median, radial and ulnar) affecting hand function and, eventually, to settle upon those which have provided the most predictable and consistent outcomes. This article describes the author's preferred tendon transfers for high radial and low median and ulnar palsies, providing the rationale behind these choices, operative details supplemented with illustrations, technical tips and advice regarding postoperative rehabilitation.

The Vascularity and Osteogenesis of a Vascularized Flap for the Treatment of Scaphoid Nonunion: The Pedicle Volar Distal Radial Periosteal Flap

Background: Vascularized periosteal flaps from the distal radius have been previously proposed. The purpose of this study was to investigate the vascularity and osteogenic potential of a vascularized volar distal radial periosteal flap for the treatment of scaphoid nonunion. Methods: In 5 fresh frozen cadavers, a rectangular periosteal flap was elevated from the distal radius with the pedicle just proximal to the watershed line. Latex dye was injected into the radial artery proximally and the vascularity of the flap characterized by microscopic evaluation. Patients with scaphoid nonunion were then treated with open reduction, internal fixation, and distal radius cancellous bone graft. Two groups of patients with midwaist nonunion scaphoid were then evaluated. The first group received the vascularized periosteal flap and the second group received a nonvascularized periosteal flap. A third group of proximal pole nonunions also received the vascularized flap. Results: Cadaveric dissections revealed that all of the injected flaps demonstrated vascularity to the distal edge of the flap. Vascularized flaps formed visible bone on imaging in 55% of cases. None of the nonvascularized flaps formed visible bone. In group 1, 12/12 midwaist nonunions united. In group 2, union was achieved in 6/6 of patients who completed the follow-up. In group 3, 6/7 proximal pole fractures united. Conclusions: Previously proposed vascularized periosteal flaps from the distal radius appear to possess notable osteogenic potential that may be of interest to surgeons treating scaphoid nonunion.

Multicenter Survey of the Effects of Rehabilitation Practices on Pinch Force Strength After Tendon Transfer to Restore Pinch in Tetraplegia

OBJECTIVE

To identify key components of conventional therapy after brachioradialis (BR) to flexor pollicis longus (FPL) transfer, a common procedure to restore pinch strength, and evaluate whether any of the key components of therapy were associated with pinch strength outcomes.

DESIGN

Rehabilitation protocols were surveyed in 7 spinal cord injury (SCI) centers after BR to FPL tendon transfer. Key components of therapy, including duration of immobilization, participation, and date of initiating therapy activities (mobilization, strengthening, muscle reeducation, functional activities, and home exercise), were recorded by the patient's therapist. Pinch outcomes were recorded with identical equipment at 1-year follow-up.

SETTING

Seven SCI rehabilitation centers where the BR to FPL surgery is performed on a routine basis.

PARTICIPANTS

Thirty-eight arms from individuals with C5-7 level SCI injury who underwent BR to FPL transfer surgery (N=34).

INTERVENTION

Conventional therapy according to established protocol in each center.

MAIN OUTCOME MEASURES

The frequency of specific activities and their time of initiation (relative to surgery) were expressed as means and 95% confidence intervals. Outcome measures included pinch strength and the Canadian Occupational Performance Measure (COPM). Spearman rank-order correlations determined significant relations between pinch strength and components of therapy.

RESULTS

There was similarity in the key components of therapy and in the progression of activities. Early cast removal was associated with pinch force (Spearman ρ=-.40, P=.0269). Pinch force was associated with improved COPM performance (Spearman ρ=.48, P=.0048) and satisfaction (Spearman ρ=.45, P=.0083) scores.

CONCLUSIONS

Initiating therapy early after surgery is beneficial after BR to FPL surgery. Postoperative therapy protocols have the potential to significantly influence the outcome of tendon transfers after tetraplegia.

Capacity of small groups of muscles to accomplish precision grasping tasks

An understanding of the capacity or ability of various muscle groups to generate endpoint forces that enable grasping tasks could provide a stronger biomechanical basis for the design of reconstructive surgery or rehabilitation for the treatment of the paralyzed or paretic hand. We quantified two-dimensional endpoint force distributions for every combination of the muscles of the index finger, in cadaveric specimens, to understand the capability of muscle groups to produce endpoint forces that accomplish three common types of grasps-tripod, tip and lateral pinch-characterized by a representative level of Coulomb friction. We found that muscle groups of 4 or fewer muscles were capable of generating endpoint forces that enabled performance of each of the grasping tasks examined. We also found that flexor muscles were crucial to accomplish tripod pinch; intrinsic muscles, tip pinch; and the dorsal interosseus muscle, lateral pinch. The results of this study provide a basis for decision making in the design of reconstructive surgeries and rehabilitation approaches that attempt to restore the ability to perform grasping tasks with small groups of muscles.

Access to surgical upper extremity care for people with tetraplegia: an international perspective

STUDY DESIGN

Survey.

OBJECTIVES

To determine whether upper extremity reconstruction in patients with tetraplegia is underutilized internationally and, if so, what are the barriers to care.

SETTING

International-attendees of a meeting in Paris, France.

METHODS

One hundred and seventy attendees at the Tetrahand meeting in Paris in 2010 were sent a 13-question survey to determine the access and utilization of upper limb reconstruction in tetraplegic patients in their practice.

RESULTS

Respondents ranged the globe including North America, South America, Europe, Asia and Australia. Fifty-nine percent of respondents had been practicing for more than 10 years. Sixty-four percent of respondents felt that at least 25% of people with tetraplegia would be candidates for surgery. Yet the majority of respondents found that <15% of potential patients underwent upper extremity reconstruction. Throughout the world direct patient referral was the main avenue of surgeons meeting patients with peer networking a distant second. Designated as the top three barriers to this care were lack of knowledge of surgical options by patients, lack of desire for surgery and poor referral patterns to appropriate upper extremity surgeons.

CONCLUSION

The results of this survey, of a worldwide audience, indicate that many of the same barriers to care exist regardless of the patient's address. This was a preliminary opinion survey and thus the results are subjective. However, these results provide a roadmap to improving access to care by improving patient education and interdisciplinary physician communication.

Technical tips for collagenase injection treatment for Dupuytren contracture

We describe technical tips for injecting collagenase into Dupuytren cords based on experience acquired during the prerelease Food and Drug Administration clinical trials and with subsequent clinical practice. These tips include techniques for extracting the reconstituted enzyme efficiently from the vial, injecting the cord(s) with increased safety to the tendons, and anesthetizing the hand before manipulation. The tips are intended to supplement but by no means replace the manufacturer's prescribing information and training video.

The fragmented proximal pole scaphoid nonunion treated with rib autograft: case series and review of the literature

Nonunions of the proximal pole of the scaphoid are a challenge to treat given the limited vascular supply. This challenge is potentiated when the proximal pole is unsalvageable. When the proximal pole of the scaphoid is fragmented or otherwise unsalvageable, traditional reconstructive procedures such as vascularized or nonvascularized bone grafting are not possible. Salvage procedures such as proximal row carpectomy or scaphoid excision and partial wrist fusion would not be ideal in the case of an unsalvageable proximal pole scaphoid nonunion in the absence of radiocarpal arthrosis. In this relatively uncommon circumstance, we favor the use of rib osteochondral autograft reconstruction of the proximal pole of the scaphoid. We report 3 cases with greater than 2-years of follow-up evaluation and also review the literature.

Essential hand surgery procedures for mastery by graduating orthopedic surgery residents: a survey of program directors

PURPOSE

To establish the essential hand surgery procedures that should be mastered by graduating orthopedic surgery residents. This framework can then be used as a guideline for developing an Objective Structured Assessment of Technical Skill to teach and document technical skill in hand surgery.

METHODS

A select group of 10 expert hand surgeons was surveyed regarding the essential hand surgery procedures that should be mastered by graduating orthopedic surgery residents. The top 10 procedures from this survey were then used to survey all 155 American Council of Graduate Medical Education-approved orthopedic surgery program directors regarding the essential procedures that should be mastered by graduating orthopedic surgery residents.

RESULTS

We had a 39% response rate to the program director survey. The top 8 hand surgery procedures as determined by the orthopedic surgery program directors included open carpal tunnel release, open A1 pulley release, open reduction internal fixation of distal radius fracture, flexor tendon sheath steroid injection, excision of dorsal or volar ganglion, closed reduction and percutaneous pinning of metacarpal fracture, open cubital tunnel release, and incision and drainage of flexor tendon sheath for flexor tenosynovitis.

CONCLUSIONS

Surgical educators need to develop objective methods to teach and document technical skill. The Objective Structured Assessment of Technical Skill is a valid method to accomplish this task. However, there has been no consensus regarding which hand surgery procedures should be mastered by graduating orthopedic surgery residents. We have identified 8 procedures that were overwhelmingly supported by orthopedic surgery program directors. These 8 procedures can be used as a guideline for developing an Objective Structured Assessment of Technical Skill to teach and document technical skill in hand surgery.

CLINICAL RELEVANCE

This study addresses the future of orthopedic surgery education as it pertains to hand surgery.

Advances in the management of Dupuytren disease: collagenase

Dupuytren disease (DD) is a benign, generally painless connective tissue disorder affecting the palmar fascia that leads to progressive hand contractures. Mediated by myofibroblasts, the disease most commonly begins as a nodule in the palm or finger, and can progress where pathologic cords form leading to progressive flexion deformity of the involved fingers. The palmar skin overlying the cords may become excessively calloused and contracted and involved joints may develop periarticular fibrosis. Although there is no cure, the sequellae of this affliction can be corrected. This article focuses on the role of collagen in DD and the development of a collagen-specific enzymatic treatment for DD contractures.

The treatment of Dupuytren disease

The treatment of progressive Dupuytren contractures has historically been and continues to be largely surgical. Although a number of surgical interventions do exist, limited palmar fasciectomy continues to be the most common and widely accepted treatment option. Until recently, nonsurgical options were limited and clinically ineffective. However, the commercial availability and recent approval of collagenase clostridium histolyticum now provides practitioners with a nonsurgical approach to this disease. This article presents a comprehensive review of the surgical and nonsurgical treatments of Dupuytren disease, with a focus on collagenase.

Biceps-to-triceps transfer technique

Lack of voluntary active elbow extension inhibits many important functions in persons with tetraplegia. Biceps-to-triceps transfer can restore this function in selected patients. This article outlines the basic problem, indications and contraindications, surgical technique, and postoperative rehabilitation protocol for biceps-to-triceps transfer using the medial routing technique with suture anchoring of the biceps muscle tendon unit into the triceps aponeurosis and olecranon.

Comparison of wrist and elbow stabilization following pinch reconstruction in tetraplegia

PURPOSE

Individuals with spinal cord injuries resulting in tetraplegia may receive tendon transfer surgery to restore grasp and pinch function. These procedures often involve rerouting the brachioradialis (Br) and the extensor carpi radialis longus tendons volar to the flexion-extension axis of the wrist, leaving the extensor carpi radialis brevis (ECRB) muscle to provide wrist extension strength. The purpose of this study was to determine whether externally stabilizing the wrist after transfer procedures would improve the ability to activate the transferred Br and resulting pinch force, similar to the effect observed when the elbow is externally stabilized.

METHODS

We used a one-way repeated-measures study design to determine the effect of 3 support conditions on muscle activation and lateral pinch force magnitude in 8 individuals with tetraplegia and previous tendon transfer surgeries. Muscle activation was recorded from Br and ECRB with intramuscular electrodes and from biceps and triceps muscles with surface electrodes. We quantified pinch strength with a 6-axis force sensor and custom grip. We recorded measurements in 3 support conditions: with the arm self-stabilized, with elbow stabilization, and with elbow and wrist stabilization. Pairwise differences were tested using Wilcoxon signed-rank tests.

RESULTS

Maximum effort pinch force magnitude and Br activation were significantly increased in both supported conditions compared with the self-supported trials. The addition of wrist stabilization had no significant effect compared with elbow stabilization alone.

CONCLUSIONS

A strong ECRB has adequate strength to extend the wrist, even after multiple transfers that contribute an additional flexion moment from strong activation of donor muscles. Anatomical and functional differences between the wrist and elbow musculature are important determinants for self-stabilizing joints proximal to the tendon transfer. The ability to increase Br activation and resulting pinch force may be determined, in part, by the individual's ability to develop new coordination strategies.

A simulation analysis of the combined effects of muscle strength and surgical tensioning on lateral pinch force following brachioradialis to flexor pollicis longus transfer

Biomechanical simulations of tendon transfers performed following tetraplegia suggest that surgical tensioning influences clinical outcomes. However, previous studies have focused on the biomechanical properties of only the transferred muscle. We developed simulations of the tetraplegic upper limb following transfer of the brachioradialis (BR) to the flexor pollicis longus (FPL) to examine the influence of residual upper limb strength on predictions of post-operative transferred muscle function. Our simulations included the transfer, ECRB, ECRL, the three heads of the triceps, brachialis, and both heads of the biceps. Simulations were integrated with experimental data, including EMG and joint posture data collected from five individuals with tetraplegia and BR-FPL tendon transfers during maximal lateral pinch force exertions. Given a measured co-activation pattern for the non-paralyzed muscles in the tetraplegic upper limb, we computed the highest activation for the transferred BR for which neither the elbow nor the wrist flexor moment was larger than the respective joint extensor moment. In this context, the effects of surgical tensioning were evaluated by comparing the resulting pinch force produced at different muscle strength levels, including patient-specific scaling. Our simulations suggest that extensor muscle weakness in the tetraplegic limb limits the potential to augment total pinch force through surgical tensioning. Incorporating patient-specific muscle volume, EMG activity, joint posture, and strength measurements generated simulation results that were comparable to experimental results. Our study suggests that scaling models to the population of interest facilitates accurate simulation of post-operative outcomes, and carries utility for guiding and developing rehabilitation training protocols.

Collagenase clostridium histolyticum for Dupuytren's contracture

IMPORTANCE OF THE FIELD

Dupuytren's disease is a non-malignant, progressive disorder of the hands that can severely limit hand function and diminish overall quality of life. With global life expectancy increasing, the prevalence of this disease appears to be increasing amongst all ethnic groups. Treatment has traditionally remained surgical with few effective, nonsurgical options. However, with the introduction of collagenase clostridium histolyticum to treat Dupuytren's contractures, physicians and surgeons may be provided with a new, office-based, non-surgical option to treat this disease.

AREAS COVERED IN THIS REVIEW

The literature behind the use of collagenase to treat Dupuytren's disease; including its mechanism of action, safety, efficacy and clinical evidence behind its recent FDA approval.

WHAT THE READER WILL GAIN

The latest information available on collagenase through a comprehensive review of PubMed and the websites of licensing organizations for medicinal products.

TAKE HOME MESSAGE

Phase III, clinical trials on collagenase for treatment of Dupuytren's contractures have recently been completed. Meeting primary and secondary objectives, collagenase has obtained FDA approval for clinical use. Collagenase now provides a non-operative option for Dupuytren's disease. Although short-term results show that collagenase is safe and efficacious, long-term effects of repeat injections and contracture recurrence rates have yet to be examined.

Collagenase injection as nonsurgical treatment of Dupuytren's disease: 8-year follow-up

PURPOSE

Collagenase has been investigated in phase II and phase III clinical trials for the treatment of Dupuytren's disease. The purpose of this study is to report 8-year follow-up results in a subset of patients who had collagenase injection for the treatment of Dupuytren's contracture.

METHODS

Twenty-three patients who participated in the phase II clinical trial of injectable collagenase were contacted by letter and phone. Eight patients were enrolled, completed a Dupuytren's disease questionnaire, and had independent examination of joint motion by a single examiner.

RESULTS

Eight patients completed the 8-year follow-up study: 6 had been treated for isolated metacarpophalangeal (MCP) joint contracture, and 2 had been treated for isolated proximal interphalangeal (PIP) joint contracture. Average preinjection contracture was 57 degrees in the MCP group. Average contracture was 9 degrees at 1 week, 11 degrees at 1 year, and 23 degrees at 8-year follow-up. Four of 6 patients experienced recurrence, and 2 of 6 had no evidence of disease recurrence at 8-year follow-up. Average preinjection contracture was 45 degrees in the PIP group. Average contracture was 8 degrees at 1 weeks, 15 degrees at 1 year, and 60 degrees at 8-year follow-up. Both patients experienced recurrence at 8-year follow-up. No patients had had further intervention on the treated finger in either the MCP or the PIP group. Patients subjectively rated the overall clinical success at 60%, and 88% of patients stated that they would pursue further injection for the treatment of their recurrent or progressive Dupuytren's disease.

CONCLUSIONS

Enzymatic fasciotomy is safe and efficacious, with initial response to injection resulting in reduction of joint contracture to within 0 degrees -5 degrees of normal in 72 out of 80 patients. Initial evaluation of long-term recurrence rates suggests disease recurrence or progression in 4 out of 6 patients with MCP contractures and 2 patients with PIP contractures; however, recurrence was generally less severe than the initial contracture in the MCP group. In addition, patient satisfaction was high.

Injectable collagenase clostridium histolyticum for Dupuytren's contracture

BACKGROUND

Dupuytren's disease limits hand function, diminishes the quality of life, and may ultimately disable the hand. Surgery followed by hand therapy is standard treatment, but it is associated with serious potential complications. Injection of collagenase clostridium histolyticum, an office-based, nonsurgical option, may reduce joint contractures caused by Dupuytren's disease.

METHODS

We enrolled 308 patients with joint contractures of 20 degrees or more in this prospective, randomized, double-blind, placebo-controlled, multicenter trial. The primary metacarpophalangeal or proximal interphalangeal joints of these patients were randomly assigned to receive up to three injections of collagenase clostridium histolyticum (at a dose of 0.58 mg per injection) or placebo in the contracted collagen cord at 30-day intervals. One day after injection, the joints were manipulated. The primary end point was a reduction in contracture to 0 to 5 degrees of full extension 30 days after the last injection. Twenty-six secondary end points were evaluated, and data on adverse events were collected.

RESULTS

Collagenase treatment significantly improved outcomes. More cords that were injected with collagenase than cords injected with placebo met the primary end point (64.0% vs. 6.8%, P < 0.001), as well as all secondary end points (P < or = 0.002). Overall, the range of motion in the joints was significantly improved after injection with collagenase as compared with placebo (from 43.9 to 80.7 degrees vs. from 45.3 to 49.5 degrees, P < 0.001). The most commonly reported adverse events were localized swelling, pain, bruising, pruritus, and transient regional lymph-node enlargement and tenderness. Three treatment-related serious adverse events were reported: two tendon ruptures and one case of complex regional pain syndrome. No significant changes in flexion or grip strength, no systemic allergic reactions, and no nerve injuries were observed.

CONCLUSIONS

Collagenase clostridium histolyticum significantly reduced contractures and improved the range of motion in joints affected by advanced Dupuytren's disease. (ClinicalTrials.gov number, NCT00528606.)

Surgical treatment of thumb carpometacarpal joint arthritis: a single institution experience from 1995-2005

There are numerous techniques for the surgical management of thumb carpometacarpal (CMC) joint arthritis. The four senior authors of this study employ three such techniques: trapeziectomy with hematoma distraction arthroplasty, hemitrapeziectomy with osteochondral allograft, and ligament reconstruction tendon interposition (LRTI). This study examines the three commonly utilized procedures at a single institution. This study examines the 10-year experience from 1995-2005 with a minimum 3-month follow-up. Disabilities of the arm, shoulder, and hand (DASH) scores, pre-and postoperative pinch strength, and operative time were examined. After approval from the institutional review board of our institution was obtained, all patients treated surgically by three of the senior authors were contacted via mail and phone. Each patient was asked to complete and return a DASH questionnaire. Of the 115 patients treated during that period, 60 participated in this study. Each patient's final postoperative pinch measurement was obtained from occupational therapy and clinic records. This pinch strength was compared to the preoperative pinch and contralateral pinch strength. Lastly, the total operative time for each procedure was obtained from the operative record. The only significant finding in this study was a shorter mean operative time with the trapeziectomy group (76.90 min) and osteochondral allograft group (90.45 min) when compared to the LRTI group (139.00 min; p = 0.001 and p = 0.001, respectively). We found no significant difference between groups in terms of DASH score and pinch strength. There was no difference between the techniques in terms of postoperative pinch strength and patient satisfaction measured by DASH scores. The operative times for trapeziectomy and hematoma interposition as well as the osteochondral allograft were significantly shorter than that of the LRTI. This presents further evidence that potentially, "less is more" in the treatment of thumb CMC arthritis. We used a retrospective study design to evaluate potential differences between the three surgical techniques described above, therapeutic, levels III-IV.

The management of the upper limb in incomplete lesions of the cervical spinal cord

Patients with incomplete cervical spinal cord injuries present unique challenges for the reconstructive surgeon. For example, their patterns of injury don't easily fit into the International Classification system familiar to surgeons; they don't lend themselves to a "recipe" approach to surgical decision-making; and they frequently have developed upper limb deformities that must be addressed before any consideration is made for functional surgery. Meanwhile, little has been published regarding surgery for these patients. This article summarizes issues related to evaluating and planning surgical procedures for the upper limb in incomplete lesions of the cervical spinal cord.

Use of intrinsic thumb muscles may help to improve lateral pinch function restored by tendon transfer

BACKGROUND

For surgical reconstruction of lateral pinch following tetraplegia, the function of the paralyzed flexor pollicis longus is commonly restored. The purpose of this study was to investigate if one of the intrinsic muscles could generate a more suitably directed thumb-tip force during lateral pinch than that of flexor pollicis longus.

METHODS

Endpoint force resulting from 10 N applied to each thumb muscle was measured in eleven upper extremity cadaveric specimens. We utilized the Kruskal-Wallis test (alpha=0.05) to determine whether thumb-tip forces of intrinsic muscles were less directed toward the base of the thumb, i.e., proximally directed, than the thumb-tip force produced by flexor pollicis longus. Additionally, a biomechanical model was used to assess the effect of an increase in tendon force on intrinsic muscle endpoint forces.

FINDINGS

All of the intrinsic muscles produced thumb-tip force vectors, ranging from 127 degrees to 156 degrees , that were significantly (P<0.009) less proximally directed than that of flexor pollicis longus (66 degrees (46 degrees )). A biomechanical model predicted that intrinsic muscle thumb-tip forces would vary non-linearly with tendon force. A 2-fold increase in tendon force produced, on average, a 2.3-fold increase in force magnitude and an 8 degrees shift in force direction across all intrinsic muscles.

INTERPRETATION

This study suggests the possibility of using an intrinsic muscle, e.g., the flexor pollicis brevis (ulnar head), instead of flexor pollicis longus, to produce a more advantageously directed thumb-tip force during lateral pinch in the surgically-reconstructed tetraplegic thumb and thus potentially enhance function.

Dupuytren's disease: history, diagnosis, and treatment

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the clinical features of the disease. 2. Describe the pathoanatomical structures in Dupuytren's disease. 3. Outline the various factors associated with Dupuytren's disease. 4. Describe the modalities for surgical and nonsurgical treatment of the condition. 5. Outline recent biomolecular knowledge about the basis of Dupuytren's disease.

SUMMARY

Dupuytren's disease is characterized by nodule formation and contracture of the palmar fascia, resulting in flexion deformity of the fingers and loss of hand function. The authors review the historical background, clinical features, and current therapy of Dupuytren's disease; preview treatment innovations; and present molecular data related to Dupuytren's disease. These new findings may improve screening for Dupuytren's disease and provide a better understanding of the disease's pathogenesis.

Late reconstruction for ulnar nerve palsy

Long term paralysis of the ulnar nerve is associated with an array of specific deficits and deformities. The numerous options for reconstruction are reviewed, as well as the specific patient considerations in selecting a strategy. An approach to late reconstruction for late ulnar nerve palsy is presented based upon the authors' experience and the available literature.

Tumours of the hand

Hand tumours of soft-tissue and bony origin are frequently encountered, and clinicians must be able to distinguish typical benign entities from life-threatening or limb-threatening malignant diseases. In this Review, we present a diagnostic approach to hand tumours and describe selected cancers and their treatments. Soft-tissue tumours include ganglion cysts, giant-cell cancers and fibromas of the tendon sheath, epidermal inclusion cysts, lipomas, vascular lesions, peripheral-nerve tumours, skin cancers, and soft-tissue sarcomas. Bony tumours encompass enchondromas, aneurysmal bone cysts, osteoid osteomas, giant-cell lesions of bone, bone sarcomas, and metastases. We look at rates of recurrence and 5-year survival, and recommendations for adjunct chemotherapy and radiotherapy for malignant lesions.

Is microsurgical treatment of brachial plexus palsy better than conventional treatment?

There are some plexus injuries for which microneural plexus reconstruction provides the only good possibility of achieving useful limb function. These injuries include complete plexus palsies in the adult and baby, and incomplete upper plexus lesions in the adult. There are plexus injuries for which there is little to no role for microneurosurgery, such as the isolated C8, T1 injury in the adult (this is an extremely rare injury in babies). This article explores conventional versus microneurosurgical reconstruction for adult traumatic and birth-related brachial plexus palsies.

Variability in surgical technique for brachioradialis tendon transfer. Evidence and implications

BACKGROUND

Transfer of the tendon of the brachioradialis muscle to the tendon of the flexor pollicis longus restores lateral pinch function after cervical spinal cord injury. However, the outcomes of the procedure are unpredictable, and the reasons for this are not understood. The purpose of this study was to document the degree of variability observed in the performance of this tendon transfer.

METHODS

The surgical technique used for the brachioradialis tendon transfer was assessed in two ways. First, the surgical attachment length of the brachioradialis was quantified, after transfer to the flexor pollicis longus, with use of intraoperative laser diffraction to measure muscle sarcomere length in eleven individuals (twelve limbs) with tetraplegia. Second, ten surgeons who regularly performed this procedure were surveyed regarding their tensioning preferences. Using a biomechanical model of the upper extremity, we investigated theoretically the effect of different surgical approaches on the active muscle-force-generating capacity of the transferred brachioradialis in functionally relevant elbow, wrist, and hand postures.

RESULTS

The average sarcomere length (and standard deviation) of the transferred brachioradialis was 3.5 +/- 0.3 mum. That length was significantly correlated to the in situ sarcomere length (r(2) = 0.53, p < 0.05). Surgical tensioning preferences varied considerably; however, six of the ten surgeons positioned the patient's elbow between full extension (0 degrees of elbow flexion) and 50 degrees of flexion when selecting the attachment length, and six of the ten stated that their goal was to tension the transfer slightly tighter than its resting tension. The computer simulations suggested that a "tighter" brachioradialis transfer would produce its peak active force in an elbow position that is more flexed than the elbow position in which a "looser" transfer would produce its peak active force.

CONCLUSIONS

This study provides evidence that experienced surgeons perform this tendon transfer differently from one another. Biomechanical simulations suggested that these differences could result in substantial variability in the active force that the transferred brachioradialis can produce in functionally relevant postures.

CLINICAL RELEVANCE

The surgical attachment length and the position of the patient's limb at the time of tendon transfer are both controllable and measurable parameters. Understanding the relationship between surgical technique and postoperative muscle function may provide surgeons with more control of clinical outcomes.

Congenital brachial plexus exploration

Stanford's experience in the management of obstetrical brachial plexus palsy dates from 1983. A formal clinic service began in 1992. The tenets of management include early evaluations, a dependency on sequential evolution for decision-making, and very early neural surgery for babies with abnormal hands. We watch babies with normal hands for a longer time before advising surgery. At exploration, common patterns of injury are observed. Intraoperative evoked potentials are used to make surgical decisions. Reconstructive goals for upper plexus injuries include shoulder and elbow control. The paramount goal for babies with global palsies is hand function. Therapy throughout the child's growth years is vital. Sequelae, particularly shoulder contractures, require early surgical intervention. Secondary reconstructive procedures are typically beneficial in improving function. Since 1992, over 400 children have been examined, 62 have had neural reconstruction, and 102 have undergone secondary procedures. Surgery has been remarkably complication free. All children having neural reconstruction except 2 have been benefited.

Activation of brachioradialis muscles transferred to restore lateral pinch in tetraplegia

PURPOSE

Surgical transfers of muscles are used to restore lateral pinch in tetraplegia; however, outcomes are variable. The purpose of this study was to compare activation of the brachioradialis (Br) after transfer to the flexor pollicis longus during maximum effort in its primary function (elbow flexion) with maximum effort in its postoperative function (lateral pinch) and to record Br activation during functional tasks.

METHODS

Fine-wire electrodes recorded activation of the Br in 11 arms with tetraplegia. Subjects produced maximum lateral pinch force with and without elbow stabilization and were classified according to elbow strength. The elbow was stabilized by supporting the arm and limiting elbow motion. A force sensor mounted on a custom grip recorded the pinch force. Electromyographic (EMG) signals recorded during lateral pinch were expressed as a percentage of the maximum voluntary contraction recorded during maximum-effort elbow flexion.

RESULTS

The EMG activation was significantly lower during lateral pinch compared with resisted elbow flexion. The mean EMG during lateral pinch in the self-supported elbow condition was 34% of the maximum voluntary contraction; with the elbow stabilized the EMG increased to 55% of the maximum voluntary contraction. Postoperative pinch-force magnitude was 14 N with self-support and 20 N with the elbow stabilized. Subjects with weak elbow extension strength produced significantly lower pinch forces compared with subjects with strong elbow extension but had similar ability to activate the Br. The Br activation was higher when the pinch tasks were performed successfully.

CONCLUSIONS

These findings suggest a reduced ability to activate the transferred muscle fully in lateral pinch function after surgery, even with the addition of elbow support. The Br activation is linked to successful performance of lateral pinch tasks. The subjects' inability to activate the transferred muscle fully may be affected by postoperative muscle re-education and contribute to postoperative weakness.

Biomechanical properties of the brachioradialis muscle: Implications for surgical tendon transfer

PURPOSE

To understand the mechanical properties of the brachioradialis (BR) muscle and to use this information to simulate a BR-to-flexor pollicis longus (FPL) tendon transfer for restoration of lateral pinch.

METHODS

The BR mechanical properties were measured intraoperatively. Passive elastic properties were measured by elongating BR muscles at constant velocity while they were attached directly to a dual-mode servomotor. Sarcomere length was measured intraoperatively and in situ by laser diffraction with the elbow fully extended. Then both the mechanical and structural properties were programmed into a surgical simulator to test the hand surgeon's decision making when tensioning muscles in a simulated BR-to-FPL tendon transfer.

RESULTS

Passive mechanical BR properties were highly nonlinear. Under slack conditions sarcomere length (mean +/- standard deviation) was 2.81 +/- 0.10 microm (n = 4), corresponding to an active force of 93% maximum. Sarcomere length of the BR measured in situ with the elbow fully extended and the forearm in neutral rotation was 3.90 +/- 0.27 microm (n = 8), corresponding to an active force of only 23% maximum. Surgeons, who tensioned the BR for transfer into the FPL using only tactile feedback from the surgical simulator, attached the muscle at a passive tension of 5.87 +/- 0.97 N, which corresponded to a sarcomere length of 3.84 microm and an active muscle force of 27% maximum. Passive BR tension when both tactile and visual information were provided to the surgeon was significantly lower (2.42 +/- 0.72 N), corresponding to a sarcomere length of 3.56 mum and a much higher active muscle force of 45% maximum.

CONCLUSIONS

When these data were used to model pretransfer and posttransfer function dramatic differences in predicted function were obtained depending on the tensioning protocol chosen. This emphasizes the point that the decision-making process used during muscle tensioning has a profound effect on the functional outcome of the transfer.

The effect of percutaneous pin fixation of the interphalangeal joint on the thumb-tip force produced by the flexor pollicis longus: a cadaver study

PURPOSE

Interphalangeal joint stabilization often is performed concomitantly with tendon transfers that restore key pinch (lateral pinch) to the paralyzed thumb. The goal of this study was to measure the effect of interphalangeal joint stabilization via percutaneous pin fixation on the thumb-tip force produced by the flexor pollicis longus (FPL).

METHODS

We applied 10 N of force to the tendon of the FPL in 7 cadaveric specimens and measured the resulting thumb-tip force in the intact thumb and after stabilization of the interphalangeal joint.

RESULTS

The nominal thumb-tip force was approximately 6 times less than the applied force and was directed primarily in the thumb's plane of flexion-extension at an oblique angle of 44 degrees relative to the palmar direction (the direction that is perpendicular to the thumb tip in the plane). Joint stabilization increased significantly the nominal force and oriented the force more toward the palmar direction (ie, decreased the obliqueness of the force).

CONCLUSIONS

After paralysis and a tendon transfer to the paralyzed FPL the FPL is often the only muscle actuating the thumb. We conclude that the oblique nominal force direction is prone to cause the thumb to slip during pinch. Joint stabilization, however, has the capacity to reduce the tendency for slippage because it rotates the force toward the palmar direction.

Biomechanics of the Steindler flexorplasty surgery: a computer simulation study

PURPOSE

Our goal was to investigate the capacity of a Steindler flexorplasty to restore elbow flexion to persons with C5-C6 brachial plexus palsy. In this procedure the origin of the flexor-pronator mass is moved proximally onto the humeral shaft. We examined how the choice of the proximal attachment site for the flexor-pronator mass affects elbow flexion restoration, especially considering possible side effects including limited wrist and forearm motion owing to passive restraint from stretched muscles.

METHODS

A computer model of the upper extremity was used to simulate the biomechanical consequences of various surgical alterations. Unimpaired, preoperative, and postoperative conditions were simulated. Seven possible transfer locations were used to investigate the effects of choice of transfer location.

RESULTS

Each transfer site produced a large increase in elbow flexion strength. Transfer to more proximal attachment sites also produced large increases in passive resistance to wrist extension and forearm supination.

CONCLUSIONS

To reduce detrimental side effects while achieving clinical goals our theoretical analysis suggests a transfer to the distal limit of the traditional transfer region.

Three-dimensional hyaluronic acid grafts promote healing and reduce scar formation in skin incision wounds

Hyaluronic acid (HA) has been found to play important roles in tissue regeneration and wound-healing processes. Fetal tissue with a high concentration of HA heals rapidly without scarring. The present study employed HA formed into three-dimensional strands with or without keratinocytes to treat full-thickness skin incision wounds in rats. Wound closure rates of HA strand grafts both with and without keratinocytes were substantially enhanced. The closure times of both HA grafts were less than 1 day (average 16 h), about 1/7 that of the contralateral control incisions (114 h, p <.01). Average wound areas after 10 days were HA-only graft: 0.151 mm2 +/- 0.035; HA + cell grafts: 0.143 mm2 +/- 0.036 and controls: 14.434 mm2 +/- 1.175, experimental areas were 1% of the controls (p < 0.01). Transforming growth factor (TGF) beta1 measured by immunostaining was remarkably reduced in HA-treated wounds compared to the controls. In conclusion, HA grafts appeared to produce a fetal-like environment with reduced TGF-beta1, which is known to be elevated in incipient scars. The HA strands with or without cultured cells may potentially improve clinical wound healing as well as reduce scar formation.

Releasing the A3 pulley and leaving flexor superficialis intact increases pinch force following the Zancolli lasso procedures to prevent claw deformity in the intrinsic palsied finger

Objective estimates of fingertip force magnitude following surgery to prevent digital metacarpophalangeal (MCP) hyperextension (clawing) in cases of paralysis of the hand's intrinsic muscles will assist clinicians in setting realistic expectations for post-operative pinch strength. We used a cadaveric/optimization approach to predict and confirm the maximal biomechanically possible fingertip force in the intrinsic palsied hand before and after two popular tendon transfer methods to the volar plate of the MCP joint. Both surgeries were also evaluated after release of the A3 pulley-a modification predicted by our published computer model of the forefinger to increase fingertip force magnitude. We predicted maximal static fingertip force by mounting eight fresh cadaveric hands on a frame, placing their forefinger in a functional posture (neutral abduction, 45 degrees of flexion at the MCP and proximal interphalangeal joints, and 10 degrees at the distal interphalangeal joint) and pinning the distal phalanx to a 3D dynamometer. We pulled on individual tendons with tensions up to 25% of maximal isometric force of their associated muscle and measured fingertip force and torque output. Using these measurements, we predicted the optimal combination of tendon tensions that maximized palmar force (analogous to pinch force, directed perpendicularly from the midpoint of the distal phalanx, and in the plane of finger flexion-extension) for four cases: (i) the non-paretic case (all muscles available), (ii) intrinsic palsied hand (no intrinsic muscles functioning), (iii) transfer of flexor superficialis tendon to the volar plate of the MCP (Zancolli lasso) in the intrinsic palsied hand, and (iv) leaving flexor superficialis intact and transferring a tendon of comparable strength to the volar plate of the MCP in the intrinsic palsied hand. Lastly, we applied these optimal combinations of tension to the cadaveric tendons and measured fingertip output. With the A3 pulley intact, the maximal palmar force in cases (ii)-(iv) averaged 48 +/- 23% SD (non-paretic = 100%; case (iv) (61 +/- 25%) > cases (ii) and (iii) (43 +/- 23% and 39 +/- 19%, respectively), p < 0.05). Releasing the A3 pulley significantly increased the average palmar force in cases (ii)-(iv) (73 +/- 42%, p < 0.05), with no significant differences among them. Thus, releasing the A3 pulley may improve palmar force magnitude when it is necessary to transfer the digit's own flexor superficialis tendon to the volar plate of the MCP to prevent clawing in the intrinsic palsied hand.

Injury to the dorsal sensory branch of the ulnar nerve in the arthroscopic repair of ulnar-sided triangular fibrocartilage tears using an inside-out technique: a cadaver study

This anatomic study of the commonly described inside-out Tuohy needle technique was performed to better define the course of needle passage relative to the anatomic structures in this region including the dorsal sensory branch of the ulnar nerve (DBUN) and extensor carpi ulnaris (ECU) tendon. Ten fresh-frozen cadaver specimens had arthroscopic-guided passage of a Tuohy needle through the triangular fibrocartilage (TFC). Dissection of the ulnar side of the wrist was performed and various measurements were recorded. The average minimum distance between suture A (the suture closest to the nerve) and the DBUN was 1.9 mm. The average minimum distance between suture B and the DBUN was 2.7 mm. The distance between the 2 sutures at the level of the capsule averaged 6.2 mm. The distance between the DBUN and the ECU averaged 7.2 mm. In 5 of 10 specimens the sutures exited on opposite sides of the DBUN. The DBUN is variable in its course but in every case it passes in close proximity to the sutures that exit the ulnar side of the wrist in arthroscopic repair of ulnar-sided TFC tears.

Collagen as a clinical target: nonoperative treatment of Dupuytren's disease

The cellular events leading to abnormal synthesis of collagen are important to our understanding of pathologic processes leading to impaired joint function. The contracture of Dupuytren's disease is a notable example. In a series of controlled phase-2 clinical trials, excessive collagen deposition in Dupuytren's disease has been targeted by a unique nonoperative method using enzyme (Clostridial collagenase) injection therapy to lyse and rupture finger cords causing metacarpophalangeal and/or proximal interphalangeal joint contractures. Forty-nine patients were treated in a random, placebo-controlled trial of one dose of collagenase versus placebo at one center. Subsequently 80 patients were treated in a random, placebo-controlled, dose-response study of collagenase at 2 test centers. The results of these studies indicate that nonoperative collagenase injection therapy for Dupuytren's disease is both a safe and effective method of treating this disorder in the majority of patients as an alternative to surgical fasciectomy. Phase-3 efficacy trials are now being planned to further develop and test this method under Food and Drug Administration regulatory guidelines. The findings of our study may lead to simpler and less invasive nonoperative treatments of joint limitation in which collagen plays a major pathologic role.

Surgical strategy: matching the patient with the procedure

The general indications, timing, and choice of procedure can be determined by asking and answering the following questions appropriately: 1. Has the patient achieved neurologic, emotional, and social stability? 2. What is the patient's current level of motor and sensory resources and function? The number and strength of muscles remaining under good voluntary control are the most important variables. 3. Are the patient's expectations realistic? 4. Does the patient possess the necessary intelligence and motivation? Some procedures, such as arthrodesis of a specific joint, require little motivation to succeed; however, a complex set of muscle-tendon transfers requires a great deal of motor reeducation for the patient to achieve an optimal result. 5. Does the patient have the necessary time to invest in achieving a good result? The patient must be able to set aside the time necessary for postoperative immobilization in a cast or splint and for therapy and reeducation. 6. Are the necessary support services and personnel available and committed? 7. Have all preoperative obstacles to success been considered and has a plan developed to overcome any remaining obstacles? 8. Does the patient understand the potential complications and benefits? 9. Can the patient and professional team tolerate a complication, failure, or suboptimal result? Both the medical staff and the patient must be prepared for complications that may lead to a suboptimal outcome or frank failure. 10. Are the patient's current health and well-being ideal? 11. Is the surgical plan consistent with the patient's physical resources, goals, and expectations? 12. Does an alternate plan exist? 13. Does the surgeon understand the scope of the complications and how to salvage an acceptable result should a complication occur?

Reconstruction of the hand in Apert syndrome: a simplified approach

Children born with Apert acrocephalosyndactyly pose great challenges to the pediatric hand surgeon. Reconstructive dilemmas consist of shortened, deviated phalanges and extensive skin deficits following syndactyly release. We present a 10-year review of patients with Apert acrocephalosyndactyly who were treated with a simplified surgical approach. Between 1986 and 1996, 10 patients with Apert syndrome underwent reconstructive surgery of their hands. The overall strategy involved early bilateral separation of syndactylous border digits at 1 year of age, followed by sequential unilateral middle syndactyly mass separation with thumb osteotomy and bone grafting as needed. In these 10 patients, a total of 53 web spaces were released, 49 of which involved osteotomies for complex syndactyly. Only local flaps and full-thickness skin grafts from the groin were used in all cases to achieve soft-tissue coverage. To date, seven of the 53 web spaces have needed revision (revision rate, 13 percent). Eleven thumb osteotomies (nine opening wedge and two closing wedge) were performed. Bone grafts from the proximal ulna or from other digits were used in all cases. To date, none of these thumb osteotomies have needed revision. This early, simplified approach to the complex hand anomalies of Apert acrocephalosyndactyly has been successful in achieving low revision rates and excellent functional outcomes as measured by gross grasp and pinch and by patient and parent satisfaction.

Gene expression of transforming growth factor beta isoforms in interposition nerve grafting

Scar production and neuroma formation at nerve graft coaptation sites may limit axonal regeneration and impair functional outcome. Transforming growth factor beta (TGF-beta) is a family of growth factors that is involved in scar formation, wound healing, and nerve regeneration. Fifteen adult Sprague-Dawley rats underwent autogenous nerve grafting. The nerve grafts were analyzed by in situ hybridization to determine the temporal and spatial expression of TGF-beta1 and TGF-beta3 messenger RNA (mRNA). The grafted nerves showed increased expression of TGF-beta1 and TGF-beta3 mRNA in the nerve and the surrounding connective tissue during the first postoperative week. These data suggest that modulation of TGF-beta levels in the first postoperative week may be effective in helping to control scar formation and improve nerve regeneration.

Efficacy of an implanted neuroprosthesis for restoring hand grasp in tetraplegia: a multicenter study

OBJECTIVE

To evaluate an implanted neuroprosthesis that allows tetraplegic users to control grasp and release in 1 hand.

DESIGN

Multicenter cohort trial with at least 3 years of follow-up. Function for each participant was compared before and after implantation, and with and without the neuroprosthesis activated.

SETTING

Tertiary spinal cord injury (SCI) care centers, 8 in the United States, 1 in the United Kingdom, and 1 in Australia.

PARTICIPANTS

Fifty-one tetraplegic adults with C5 or C6 SCIs.

INTERVENTION

An implanted neuroprosthetic system, in which electric stimulation of the grasping muscles of 1 arm are controlled by using contralateral shoulder movements, and concurrent tendon transfer surgery. Assessed participants' ability to grasp, move, and release standardized objects; degree of assistance required to perform activities of daily living (ADLs), device usage; and user satisfaction.

MAIN OUTCOME MEASURES

Pinch force; grasp and release tests; ADL abilities test and ADL assessment test; and user satisfaction survey.

RESULTS

Pinch force was significantly greater with the neuroprosthesis in all available 50 participants, and grasp-release abilities were improved in 49. All tested participants (49/49) were more independent in performing ADLs with the neuroprosthesis than they were without it. Home use of the device for regular function and exercise was reported by over 90% of the participants, and satisfaction with the neuroprosthesis was high.

CONCLUSIONS

The grasping ability provided by the neuroprosthesis is substantial and lasting. The neuroprosthesis is safe, well accepted by users, and offers improved independence for a population without comparable alternatives.

Surgeon-patient barrier efficiency monitored with an electronic device in three surgical settings

Blood-borne viral pathogens are an occupational threat to health care workers (HCWs), particularly those in the operating room. A major risk is posed by accidental penetrating injury, but skin contamination with body fluids from an infected patient, with prolonged intimate cutaneous contact, is a frequent occurrence during surgery, carrying further risk of transdermal infection. We have monitored barrier failure in three surgical settings (microsurgery, orthopedic surgery, general surgery) by means of an electronic surveillance device. A total of 111 surgical procedures were monitored: 67 microsurgeries, 22 orthopedic surgeries, and 22 general surgeries. Of the 278 electronic alarms signaling barrier failure, 44 (15.8%) were associated with glove perforation, 39 of which (88.6%) were not perceived by the operator. In 16 of those, the skin was visibly stained with the patient's blood. Altogether, 76 of the alarms (27.3%) were consequent to contacts caused by soaked gowns/sleeves, and 121 (43.5%) were attributed to hydration of latex porosities; 37 alarms (13.4%) were unexplained false positives. On only one occasion did a surgeon observe blood stains on his hands without a previous alarm; this event was classified as a device failure due to incorrect wiring. Double-gloving offered satisfactory protection against skin contamination during microsurgery but not during orthopedic surgery. The data presented here indicate that electronic monitoring of the surgical barrier enables prompt detection of barrier failure, especially at the level of the gloves, thereby limiting skin contamination with patients' body fluids during surgery.

Activation patterns of the thumb muscles during stable and unstable pinch tasks

The ability to direct forces between the thumb and fingers is important to secure objects in the hand. We compared the coordination of thumb musculature in key and opposition pinch postures between stable and unstable tasks. The unstable task (producing thumb-tip force wearing a beaded thimble) required well-directed forces; the stable task (producing thumb-tip force against a pinch meter) did not. Fine-wire electromyography of thumb muscles and thumb-tip force magnitudes were recorded. We found no statistical differences in thumb-tip force between postures or stable versus unstable tasks, indicating that the highest magnitudes of force can be accurately directed. Abductor pollicis brevis and extensor pollicis longus were significantly more activated in the unstable tasks, suggesting their importance in directing thumb-tip force. Understanding how pinch forces are directed might influence the choice of muscle-tendon transfers performed to restore function to the severely paralyzed thumb. We introduce a device to quantify the ability to control pinch force magnitude and direction simultaneously.