Inducing Ulnar Nerve Function while Eliminating Claw Hand and Reducing Chronic Neuropathic Pain.

Ulnar nerve injury induces chronic neuropathic pain and is frequently devastating due to loss of cupping the hand around objects (finger clawing) and diminished grip strength. There is little chance of restoring good function, eliminating finger clawing, or reducing the pain. A novel technique was tested for its efficacy in promoting ulnar nerve function and reducing finger clawing and chronic neuropathic pain. A 25-year-old subject presented 5.7 months after a wrist gunshot that created three nerve gaps proximal to the deep ulnar nerve branch. He sought restoration of function due to developing ulnar nerve injury-induced claw hand and increasingly severe chronic neuropathic pain. After resection of the scarred nerve tissue, each gap was 10 cm long. The gaps were bridged with two nonreversed sural nerve grafts within a PRP-filled NeuroMend collagen tube (Collagen Matrix, Oakland, N.J.). Some axons regenerated entirely across all three 10-cm-long repaired nerve gaps, restoring excellent topographically correct sensitivity of S4, including two-point discrimination of 4 mm, good M4 motor function, and full ROM. The ulnar nerve injury-induced finger clawing was eliminated, and the chronic neuropathic pain of 7 was reduced to 0 on a 0-10 validated scale and did not return over the following 3.75 years. Thus, this novel technique induces good sensory and motor function, despite repairing three 10-cm-long nerve gaps while eliminating ulnar nerve injury-induced hand clawing and chronic neuropathic pain. Further studies are required to determine whether the effects were due to PRP.

Prospects for Improving the Extent of Recovery following Peripheral Nerve Trauma: A Review.

Restoring function to damaged peripheral nerves with a gap remains challenging, with <50% of patients who undergo nerve repair surgery recovering function. Further, despite enormous efforts to improve existing techniques and develop new ones, the percentage of patients who recover function and their extent of recovery has not increased in almost 70 years. Thus, although sensory nerve grafts remain the clinical "gold standard" technique for attempting to restore function to nerves with a gap, they have significant limitations. They are effective in restoring good to excellent function only for gaps <3-5 cm, repairs performed <3-5 months post-trauma, and patients <20-25 years old. As the value of any of these variables increases, the extent of recovery decreases precipitously, and if the values of two or all three variables increase, there is little to no recovery. Therefore, novel techniques are required that increase the percentage of patients who recover function and the extent of their recovery. This review discusses the limitations of sensory nerve grafts and other techniques currently being used to repair nerves. It also discusses the use of autologous platelet-rich plasma (PRP), which appears to be the most promising technique for inducing sensory and motor recovery even when the values of all three variables are significantly greater than when sensory nerve grafts alone are not effective. Thus, there is finally the promise that patients who presently have limited to no chance of any recovery may recover good to excellent sensory and motor function.

Functional Recovery following Repair of Long Nerve Gaps in Senior Patient 2.6 Years Posttrauma.

Sensory nerve grafts are the clinical "gold standard" for repairing peripheral nerve gaps. However, reliable good-to-excellent recovery develops only for gaps less than 3-5 cm, repairs performed less than 3-5 months posttrauma, and patients aged less than 20-25 years. As the value of any variable increases, the extent of recovery decreases precipitously, and if the values of any two or all increase, there is little to no recovery. One 9-cm-long and two 11-cm-long nerve gaps in a 56-year-old patient were repaired 2.6 years posttrauma. They were bridged with two sensory nerve grafts within an autologous platelet-rich plasma-filled collagen tube. Both were connected to the proximal ulnar nerve stump, with one graft end to the distal motor and the other to the sensory nerve branches. Although presurgery the patient suffered chronic level 10 excruciating neuropathic pain, it was reduced to 6 within 2 months, and did not increase for more than 2 years. Motor axons regenerated across the 9-cm gap and innervated the appropriate two measured muscles, with limited muscle fiber recruitment. Sensory axons regenerated across both 11-cm gaps and restored normal topographically correct sensitivity to stimuli of all sensory modalities, including static two-point discrimination of 5 mm, and pressure of 2.83 g to all regions innervated by both sensory nerves. This novel technique induced a significant long-term reduction in chronic excruciating neuropathic pain while promoting muscle reinnervation and complete sensory recovery, despite the values of all three variables that reduce or prevent axon regeneration and recovery being simultaneously large.

Practice Variation Among Hispanic American Orthopedic Surgeons in the Management of Geriatric Distal Radius Fracture.

INTRODUCTION: There is a controversy in the management of distal radius fractures (DRF) and its criteria for surgical intervention on geriatric patients. The American Academy of Orthopedic Surgeons (AAOS) developed evidence-based guidelines for treatment of DRF. The aim of this study was to evaluate the current practice of Hispanic orthopedic surgeons in the management of geriatric DRF and examine their adherence to AAOS guidelines based on years of surgical experience. MATERIAL & METHODS: A survey was emailed to all orthopedic surgeons who live in Puerto Rico and treated DRF in their daily practice. Responses concerning demographic, management and clinical scenarios were evaluated. For each clinical scenario, treatment of choice was selected with the same fracture in a geriatric and young adult patient. Comparison between years of surgical experience and adherence to the AAOS guidelines was performed. RESULTS: A total of 65 surgeons responded the survey with 65% having >15 years in practice. A high consensus with AAOS guidelines for DRF was found. Use of preoperative radiographs was reported in all respondents, with an additional 12% routine use of preoperative computed tomography scans. Seventy-seven percent of respondents did not allow any range of motion (ROM) at immediate postoperative period, while 23% allowed active or passive ROM. Use of postoperative therapy was reported in 72.3%. Correlation between years of surgical experience showed a higher use of Vitamin C postoperatively for prophylaxis of Complex Regional Pain Syndrome among surgeons <15 years (P = 0.01). A general consensus trend toward operative fixation was noted among geriatric and young adult patients with the same fracture type in all clinical scenarios. DISCUSSION AND CONCLUSIONS: This survey demonstrates a practice variation toward surgical management of geriatric DRF among Hispanic orthopedic surgeons; despite their compliance with the AAOS AUC guidelines. The geriatric DRF management does not vary significantly among years of surgical experience.

Restoration of Neurological Function Following Peripheral Nerve Trauma.

Following peripheral nerve trauma that damages a length of the nerve, recovery of function is generally limited. This is because no material tested for bridging nerve gaps promotes good axon regeneration across the gap under conditions associated with common nerve traumas. While many materials have been tested, sensory nerve grafts remain the clinical "gold standard" technique. This is despite the significant limitations in the conditions under which they restore function. Thus, they induce reliable and good recovery only for patients < 25 years old, when gaps are <2 cm in length, and when repairs are performed <2-3 months post trauma. Repairs performed when these values are larger result in a precipitous decrease in neurological recovery. Further, when patients have more than one parameter larger than these values, there is normally no functional recovery. Clinically, there has been little progress in developing new techniques that increase the level of functional recovery following peripheral nerve injury. This paper examines the efficacies and limitations of sensory nerve grafts and various other techniques used to induce functional neurological recovery, and how these might be improved to induce more extensive functional recovery. It also discusses preliminary data from the clinical application of a novel technique that restores neurological function across long nerve gaps, when repairs are performed at long times post-trauma, and in older patients, even under all three of these conditions. Thus, it appears that function can be restored under conditions where sensory nerve grafts are not effective.

Local Hematoma Block as Postoperative Analgesia in Pediatric Supracondylar Humerus Fractures.

Purpose: Supracondylar humerus fracture (SHF) is the most common type of fracture in children. The aim of this study was to evaluate the efficacy of local hematoma block with 0.25% bupivacaine as postoperative pain control in patients with pediatric SHF who underwent closed reduction pin fixation. Methods: We performed an institutional review board-approved, prospective cohort study of 65 patients with SHF treated with closed reduction percutaneous pin fixation. For 6 months, all patients were randomly divided into 2 groups. The treatment group (35 patients) received an intraoperative local hematoma block using 0.25% bupivacaine whereas the control group (30 patients) did not receive a local hematoma block as postoperative pain management adjuvant. After surgery, all patients were prescribed opioid pain medication. To evaluate the efficacy of the hematoma block, postoperative morphine equivalent consumption and the Faces Pain Scale-Revised (FPS-R) survey were blindly recorded during postoperative day 1. Demographic data, surgical details, clinical neurovascular examination during the hospital stay, and complications were also evaluated. Results: Comparison of the control group with the treatment group showed similar morphine equivalent consumption and Face Pain Scale-Revised Survey results. No hematoma block-associated complications were reported. Conclusions: The result of this study do not favor the use of local hematoma block to improve pain control and decrease the need for opioid use on postoperative day 1 in pediatric SHF after patients undergo closed reduction percutaneous pin fixation. These results can lay the foundation for future studies while suggesting new, novel opioid-free pain control strategies in patients with SHF. Type of study/level of evidence: Therapeutic II.

Carpal Wedge Osteotomy in the Arthrogrypotic Patient.

INTRODUCTION: Carpal wedge osteotomy in an arthrogrypotic patient repositions the wrist in neutral alignment while preserving available wrist motion. STEP 1 MARK THE LOCATIONS OF THE INCISIONS: The location of the incisions allows excellent exposure of the wrist on both the volar and the dorsal surface. STEP 2 RELEASE TIGHT PALMAR STRUCTURES: After making the incision, carefully assess tight flexor structures and perform release and/or lengthening as appropriate. STEP 3 DORSAL EXPOSURE: Make a dorsal transverse skin incision at the level of the carpus to allow identification and preservation of whichever thumb, finger, and wrist extensors are present. STEP 4 CARPAL OSTEOTOMY: After careful exposure of the carpus, make the proximal and distal osteotomy cuts and then evaluate the resulting wrist position and stabilization. STEP 5 TRANSFER THE EXTENSOR CARPI ULNARIS TENDON: Pass the extensor carpi ulnaris tendon to the radial wrist extensors and suture the tendon to the extensors. STEP 6 POSTOPERATIVE CARE: Cast immobilization for six to eight weeks is followed by splinting for six months. RESULTS: Our recently published study of patients with amyoplasia who underwent carpal wedge osteotomy showed that the corrected position was maintained and the individuals were satisfied with the results over the long term.IndicationsContraindicationsPitfalls & Challenges.

Comparison of magnification in primary digital nerve repair: literature review, survey of practice trends, and assessment of 90 cadaveric repairs.

PURPOSE: To review published clinical outcomes and current practice trends and to assess the quality of cadaveric digital nerve repairs using either loupe or microscopic magnification. METHODS: Published clinical outcomes of digital nerve repair accounting for magnification level were reviewed. Members of the American Society for Surgery of the Hand were surveyed regarding their current surgical practices. Ninety cadaveric digital nerve repairs were performed by 9 hand surgeons using loupe or microscopic magnification and evaluated by a visual grading scale. Univariate and multivariate analyses were used to evaluate repairs. RESULTS: We examined 6 publications involving 130 repairs with loupes (4-6×) and 255 repairs with microscopes. Univariate analysis revealed no statistically superior clinical outcomes using high-powered loupes (4-6×) versus microscopic magnification, with no data on lower-magnification loupes more commonly used in practice. Survey data indicated that 52% of hand surgeons use microscopes and 48% use loupes, with 78% using 2.5 to 3.5× magnification. Univariate analysis of the cadaveric repairs demonstrated excellent repairs in 60% of microscope repairs versus 29% of loupe repairs. Multivariate analysis determined that microscopic magnification was 3.9 times more likely than loupes to yield an excellent repair. The surgeon, level of training, repair time, and stitches per repair were not significantly related to an excellent repair. CONCLUSIONS: Our study indicated that microscope use produces superior quality digital nerve repair. Approximately half of hand surgeons use loupes in current practice, mostly at low magnification (2.5-3.5×). In this context, a higher level of magnification may be positively correlated with better clinical outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Long-term outcome following carpal wedge osteotomy in the arthrogrypotic patient.

BACKGROUND: Wrist flexion and ulnar deviation deformity is a common presentation in children with amyoplasia congenita. Multiple surgical procedures have been reported to correct the deformity to enhance functional independence and improve quality of life. We performed a retrospective review to detail our long-term results with carpal wedge osteotomy in these patients. METHODS: Medical records of all patients with the amyoplasia form of arthrogryposis who underwent carpal wedge osteotomy between 1994 and 2008 were reviewed. Patients with a follow-up of two years or less were excluded. Preoperative and postoperative resting position and range of motion of the wrist were recorded. Interviews and questionnaires were completed to assess the mean overall satisfaction level of the parent or guardian with the outcome of surgery, function, and task completion with use of parent-guardian surveys, the Manual Ability Classification System, and the ABILHAND-Kids measure of manual ability. RESULTS: Seventy-five wrists in forty-six patients who met the inclusion criteria were reviewed. The average age of the patients at the time of surgery was 4.3 years (range, nine months to eighteen years; median, 2.7 years). The average duration of follow-up was 5.7 years (range, two to 10.3 years; median, 5.3 years). The average resting position of the wrist postoperatively (11° of flexion) was significantly different from that measured preoperatively (55° of flexion) (p < 0.001). The arc of wrist motion measured preoperatively (32°) did not differ significantly from that measured postoperatively (22°) (p = 0.4903). The location of the motion arc was significantly improved to a more functional position. The average active extension of the wrist changed from -37° of extension preoperatively to -11° of extension postoperatively (p < 0.001). Active wrist flexion also significantly changed from 69° preoperatively to 33° postoperatively (p < 0.001). Parent-guardian surveys indicated that the mean overall satisfaction score after surgery was 9.1 of 10 possible points and that the mean ranking for task completion in activities of daily living was 4 (easier following surgery). CONCLUSIONS: Long-term outcomes reveal that surgical correction of wrist flexion posture in children with amyoplasia congenita results in improvement that is sustained over time. The surveys and questionnaires completed by parents or guardians indicated that they were satisfied with the results of the operation.

Knee pain and leg-length discrepancy after retrograde femoral nailing.

We retrospectively studied postoperative knee function and leg-length discrepancy (LLD) in 31 patients with femoral diaphyseal fractures treated with retrograde intramedullary nailing (IMN) between October 1998 and April 2000. Mean follow-up was 25 months, mean knee range of motion was 126 degrees, mean Hospital for Special Surgery knee scores were 89.2 (pain) and 78.3 (function), and mean LLD was 1.19 cm. Despite the theoretically higher knee pain and LLD rates associated with retrograde IMN, we believe it may offer a viable treatment option when the antegrade nailing technique is restricted.