Staple Technology for Fracture Fixation and Joint Arthrodesis.

The use of staple technology in the upper extremity has continued to evolve with the development of shape-memory alloys (SMAs) such as Nitinol that display superelastic properties that can be exploited for persistent compression. Clinical and biomechanical studies support the use of SMA staples for upper extremity fracture fixation and joint arthrodesis. To optimize biomechanical strength and clinical outcomes, it is recommended to place two staples, if possible, at the site of interest as well as to trough the staples to prevent hardware prominence.

Complications of Early Versus Delayed Total Elbow Arthroplasty for the Treatment of Distal Humerus Fractures.

PURPOSE: The purpose of this study was to compare the rates of wound complications and heterotopic ossification (HO) between patients who underwent acute total elbow arthroplasty (TEA) and those who underwent delayed TEA performed for the treatment of distal humerus fractures. Our hypothesis was that delayed surgery will have fewer wound complications but a higher rate of HO. METHODS: We retrospectively reviewed 104 patients who had undergone TEA performed at 1 of 3 institutions following a distal humerus fracture. The acute cohort, comprising 69 patients, underwent TEA within 2 weeks; the delayed cohort, comprising 35 patients, received treatment between 2 weeks and 6 months. The rates of wound complications, HO, clinically relevant HO (requiring excision or resulting in loss of functional range of motion), and reoperation were recorded. These patients were followed up for an average of 52 (interquartile range, 18.5-117) weeks. RESULTS: Wound complications occurred in 10 patients (14.5%) in the early group and 7 (20.0%) in the delayed group. The overall rate of HO was 56.7% (59 patients). The rate of clinically relevant HO was 26.0% (27 patients), which was similar between the groups. Reoperation occurred in 20 patients (19.2%), which was similar between the groups. In the early group, 3 reoperations were performed for wound complications and 4 for HO. No patients required reoperation for these indications in the delayed group. The mean flexion-extension and supination-pronation arcs were 20°-130° and 80°-80°, respectively, which were similar between the groups. Rheumatoid arthritis and younger age were associated with increased odds of wound complications and reoperation. CONCLUSIONS: The rates of reoperation, wound complications, and HO were overall higher than those previously reported; however, the study was underpowered to determine a difference between early and delayed treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Two-Year Clinical and Radiographic Evaluation of Scheker Prosthesis (Aptis) Distal Radioulnar Joint Arthroplasty.

PURPOSE: To evaluate the clinical and radiographic outcomes of patients who underwent semiconstrained distal radioulnar joint arthroplasty. METHODS: A retrospective analysis was performed on a series of patients who underwent distal radioulnar joint arthroplasty with more than a 23-month follow up. The quantitative outcome variables included the visual analog scale for pain; Disability of the Arm, Shoulder, and Hand (DASH) score; Patient-Rated Wrist Evaluation (PRWE); and Mayo wrist score. The range of motion, grip strength, torque, and lifting capacity were measured at final follow up and compared with that of the nonsurgical extremity. Complications related to the prosthesis were assessed. RESULTS: Twenty-one patients (mean age 57 years) were assessed at an average 41-month follow up (23-73 months). Fifteen underwent prior hand, wrist, or elbow procedures. Four patients required 5 reoperations. The postoperative median visual analog scale pain score was 0.6 at rest and 2.1 with activity. The median postoperative DASH score was 26.7, PRWE 41, and Mayo wrist score was 65. Upon comparing the supination torque of the operative and intact sides, the operative side was found to average 87% of the intact side on a work simulator and 77% on the simulator's D-ring. Eight of 20 patients had lysis around the collar of the ulnar component (40%), as detected using radiography. Three of 21 (14%) radial plates were malpositioned, with 2 resulting in a fracture. The overall complication rate was 29%. CONCLUSIONS: Distal radioulnar joint arthroplasty using the Scheker prosthesis demonstrated good patient pain scores and the restoration of supination strength. The collar lysis resulted in weaker supination and grip strength. Still, the patients experienced mild levels of pain and moderate disability. A moderate complication rate persisted, as reported by other authors. Accurate radial component placement is important. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Examination of Ulnar-sided Wrist Pain.

This article reviews the pertinent history and physical examination maneuvers necessary to arrive at the proper diagnosis of patients with ulnar-sided wrist pain. Surface anatomy is stressed along with provocative maneuvers for maximal efficacy.

Starfish Procedure.

For those patients with partial hand level amputation who would benefit from myoelectric prosthetic digits for enhanced prehensile function, the Starfish Procedure provides muscle transfers, which allow for the generation of intuitively controlled electromyographic signals for individual digital control with minimal myoelectric cross-talk. Thoughtful preoperative planning allows for creation of multiple sources of high-quality myoelectric signal in a single operation, which does not require microsurgery, providing for wide applicability to hand surgeons of all backgrounds.

Scapholunate ligament 360° procedure.

AIMS: The purpose was to evaluate early clinical, patient-reported, and radiological outcomes of the scapholunate ligament 360° tenodesis (SL 360) technique for treatment of scapholunate (SL) instability. METHODS: We studied the results of nine patients (eight males and one female with a mean age of 44.7 years (26 to 55)) who underwent the SL 360 procedure for reducible SL instability between January 2016 and June 2019, and who were identified from retrospective review of electronic medical records. Final follow-up of any kind was a mean of 33.7 months (12.0 to 51.3). Clinical, radiological, and patient-reported outcome data included visual analogue scale (VAS) for pain, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Mayo Wrist Score (MWS), and Patient-Rated Wrist Examination (PRWE). Means were analyzed using paired t-test. RESULTS: Before surgery, patients with SL instability were significantly impaired with respect to wrist flexion, extension, and grip strength (mean flexion, 51° (20° to 85°) vs 73° (45° to 90°); mean extension, 46° (15° to 70°) vs 66° (45° to 80°); mean grip strength, 25 kg (20 to 31) vs 50 kg (35 to 68) compared to the unaffected side). The mean SL gap (4.9 mm (2.3 to 7.3) vs 2.1 mm (1.6 to 2.9)) and mean SL angle (71° (59° to 105°) vs 50° (38° to 64°) were also significantly greater in the affected wrist. At final follow-up, there was mean improvement regarding clinical, radiological, and functional outcomes comparing preoperative to final postoperative values for the VAS for pain scale, QuickDASH, MWS, PRWE, and SL gap and SL angle. CONCLUSION: In our small series, the SL 360 procedure for reducible SL instability has favourable early clinical, patient-reported, and radiological outcomes at a mean of 33.7 months (12.0 to 51.3). The suture tape and tendon construct confers robust stability, permitting earlier mobilization without the inherent disadvantages of Kirschner wire stabilization. Cite this article: Bone Joint J 2021;103-B(5):939-945.

Surgical and technological advances in the management of upper limb amputees.

Upper limb amputations, ranging from transhumeral to partial hand, can be devastating for patients, their families, and society. Modern paradigm shifts have focused on reconstructive options after upper extremity limb loss, rather than considering the amputation an ablative procedure. Surgical advancements such as targeted muscle reinnervation and regenerative peripheral nerve interface, in combination with technological development of modern prosthetics, have expanded options for patients after amputation. In the near future, advances such as osseointegration, implantable myoelectric sensors, and implantable nerve cuffs may become more widely used and may expand the options for prosthetic integration, myoelectric signal detection, and restoration of sensation. This review summarizes the current advancements in surgical techniques and prosthetics for upper limb amputees. Cite this article: Bone Joint J 2021;103-B(3):430-439.

Thumb Metacarpophalangeal Ulnar and Radial Collateral Ligament Injuries.

Thumb metacarpophalangeal collateral ligament injuries are common in athletes and occur via forced abduction or hyperextension. Management primarily depends on the grade of ligamentous injury and the presence of a Stener lesion or large avulsion fracture. Surgeons should consider the athlete's position, hand dominance, duration of season remaining, and goals. Shared decision making regarding timing of surgery is imperative. Acutely, primary ligamentous repair with or without augmentation is achievable. Chronic collateral ligament injuries are effectively treated with ligament reconstruction. Numerous surgical techniques have been described without 1 showing superiority. Postoperative rehabilitation protocols vary based on repair quality and sports-specific considerations.

Continued growth after limited physeal bridging.

BACKGROUND: After any physeal injury, the primary concern is the possibility of some pattern of growth alteration, particularly transphyseal bridging that may cause lasting deformities and impact subsequent patient care. Small areas of physeal bridging, however, may be associated with continued growth, rather than impairment. METHODS: Seven patients with small central physeal bridges of the distal femur were identified. Demographic data and imaging studies were reviewed. RESULTS: Radiography identified small, relatively centrally located transphyseal osseous bridging that was associated with a linear (longitudinal) region of osseous density extending from the physeal bridge proximally into the metaphysis. This linear striation disappeared at the metaphyseal/diaphyseal gradation, an area of progression proximally from metaphysis to diaphysis. Only 1 patient had a significant leg length inequality. Magnetic resonance imaging confirmed the intrametaphyseal linear sclerotic bone and its disappearance with diaphyseal remodeling. CONCLUSIONS: Small, central transphyseal osseous bridges may form after radiologically confirmed acute physeal injury. Normal physiological (hydrostatic) growth forces can be sufficient to overcome such limited central bridging and allow continued, essentially normal, longitudinal growth. LEVEL OF EVIDENCE: Level IV (retrospective case series); anatomic study.

The use of temporary screw augmentation for the treatment of scapholunate injuries.

INTRODUCTION: Injuries to the scapholunate (SL) interosseous ligament can have devastating consequences to carpal stability. The purpose of this study is to provide a technique for screw augmentation to SL reconstruction, while comparing radiographic outcomes to a traditional Kirschner wire fixation cohort. METHODS: A retrospective review of all patients treated by screw fixation for SL ligament injuries was cross-matched to a cohort of patients treated with pin fixation for age and length of time from the time of injury to surgical fixation. Outcomes were the values of SL gap and SL angle on plain radiographs as averaged between 2 independent reviewers, as well as complications. RESULTS: Seven patients who received screw augmentation had an average follow-up of 8.7 months. When compared with the Kirschner wire cohort, there was improvement of immediate postoperative gap in the screw cohort of 3.1 versus 1.3 mm. There was also better reduction in SL angle in the screw group (22 vs. 10.4 degrees correction). At 4 months follow-up, both the SL gap and SL angle were maintained better in the screw group. There was 1 infection in each cohort, 1 pin migration in a screw/pin combination patient counted in the screw group, and 1 pin migration in the pin cohort. CONCLUSIONS: Our study suggests that temporary screw augmentation for SL ligament injuries results in more effective SL gap and SL angle correction both immediately and in short-term follow-up than does pin fixation. Longer follow-up is needed to evaluate longevity of reduction, and larger, prospective studies with clinical outcomes are needed to show statistically significant benefits to screw augmentation.

Collateral ligament injuries of the metacarpophalangeal joints of the fingers.

Although complete collateral ligament tear and instability involving the metacarpophalangeal joints of the fingers, especially those on the radial aspect of the index finger, are rare, they may be underdiagnosed, underestimated, and potentially disabling. Awareness and suspicion of the injury, coupled with careful physical and imaging examinations, confirm the diagnosis and its extent. Early operative repair results in favorable outcomes in most cases. Chronic instability may lead to pain, weakness, and arthritis. Late ligament repair or reconstruction is typically slightly less reliable than acute repair, yet often improves outcomes. Arthritic joints may require reconstruction.