Comparison of the Wide-Awake Approach and Conventional Approach in Extensor Indicis Proprius-to-Extensor Pollicis Longus Tendon Transfer for Chronic Extensor Pollicis Longus Rupture.

BACKGROUND: The wide-awake approach enables surgeons to perform optimal tensioning of a transferred tendon intraoperatively. The authors hypothesized that the extensor indicis proprius-to-extensor pollicis longus tendon transfer using the wide-awake approach would yield better results than conventional surgery. METHODS: A retrospective analysis was performed of the prospectively collected data of 29 consecutive patients who underwent extensor indicis proprius-to-extensor pollicis longus tendon transfer. Patients were treated with the wide-awake approach (group A, n = 11) and conventional surgery under general anesthesia (group B, n = 18). The groups were compared retrospectively for thumb interphalangeal and metacarpophalangeal joint motion, grip and pinch strength, specific extensor indicis proprius-to-extensor pollicis longus evaluation method (SEEM), and Disabilities of the Arm, Shoulder and Hand questionnaire score at 6 weeks and 2, 4, 6, and 12 months postoperatively. RESULTS: Group A showed significantly better interphalangeal joint flexion and total arc of motion at 6 weeks and 2, 4, and 6 months, and significantly better metacarpophalangeal joint flexion and total arc of motion at all time points. Interphalangeal and metacarpophalangeal joint extension showed no difference at all time points. Group A showed significantly better specific extensor indicis proprius-to-extensor pollicis longus evaluation method scores at 2 and 4 months, and Disabilities of the Arm, Shoulder and Hand questionnaire scores at 4, 6, and 12 months. Grip and pinch strength showed no difference at all time points. The complication rate and duration until return to work were not different between groups. CONCLUSION: Compared with the conventional approach, the wide-awake approach showed significantly better results in the thumb's range of motion and functional outcomes, especially in the early postoperative periods. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Headless screw fixation through the dorsal rough surface for proximal-pole scaphoid-nonunion: a report of 15 patients.

Clinical outcomes of the dorsal-retrograde headless screw-fixation technique in 15 patients with proximal scaphoid nonunion are presented. In this technique, screws are inserted from the dorsal rough surface of the scaphoid, located between the dorsal ridge and scaphoid-trapezium-trapezoid joint. Fifteen patients underwent osteosynthesis with this technique with iliac bone graft. Seven patients required primary surgery, and eight patients with a history of failed operation required revision surgery. Among 15 patients, 13 achieved union and two with persistent nonunion were asymptomatic with average follow-up of 24 months (range 14-57). Mean time to union was 20 weeks (range 12-40). Our experience with the dorsal-retrograde headless screw fixation technique has shown encouraging results for the treatment of proximal-scaphoid nonunion, especially in revision surgery wherein secure fixation of the small proximal fragments can be difficult using conventional anterograde techniques.Level of evidence: IV.

Extended thenar flap for two adjacent fingertip amputations.

The thenar flap is a well-described technique, but reports about its use in patients with multiple fingertip injuries are limited. This study aims to introduce a surgical technique of using an extended thenar flap for two adjacent fingertip amputations and to evaluate the clinical outcomes and related complications. From October 2013 to October 2016, 12 patients (24 fingers) underwent soft tissue reconstruction of two adjacent fingers with an extended thenar flap. At the last follow-up, the patients were assessed for cold intolerance in the reconstructed fingers; two-point discrimination (2PD); range of motion (ROM); functional outcomes using the quick disabilities of the arm, shoulder, and hand (DASH) score; functional and appearance outcomes using the Michigan Hand Outcome Questionnaire (MHQ); and time taken to return to work. The mean follow-up time was 13.5 (range: 12-16) months. All flaps survived. The mean total active ROM in flexion measured at the last follow-up was 255° (range: 245°-260°). Objective sensibility in the flaps was ascertained as an average static 2PD of 6.9 (range: 3-10) mm. The mean quick DASH score was 3.3 (range: 0-9.1). The mean MHQ score was 93.8 (range: 88-100). All patients returned to work within 6.2 weeks on average. There were no complications. The extended thenar flap technique is a good alternative for simultaneous coverage of small-to-large defects in two adjacent fingertips.

Correlation between change in muscle excursion and collagen content after tendon rupture and delayed repair.

BACKGROUND: The objectives of the present study were to compare changes in muscle excursion, total collagen, and collagen subtypes after tenotomy over time and after delayed tendon repair. METHODS: Tenotomy on the extensor digitorum tendon of the right second toes of 48 New Zealand White rabbits was performed; toes on the left leg were used as controls. Passive muscle excursion, total collagen content, and type I, III, and IV collagen contents were measured at 1, 2, 4, and 6 weeks after tenotomy. Next, passive muscle excursion and total collagen content were measured at 8 weeks after delayed tendon repair at 1, 2, 4, and 6 weeks after a tenotomy. RESULTS: Passive muscle excursion decreased sequentially over time after tenotomy. Meanwhile, total collagen increased over time. These changes were significant after 4 weeks of injury. Type I collagen significantly increased, type III collagen significantly decreased, and type IV collagen had no significant change over time. Passive muscle excursion was negatively correlated with total collagen and type I collagen after tenotomy at each time point after tenotomy (p < 0.05). After tendon repair, increases in total collagen content after tenotomy were not reversed, despite early repairs at 1 and 2 weeks after tenotomy. CONCLUSIONS: Increases in type I collagen were found to be associated with decreased excursion after tendon rupture. The increase in collagen that was observed after tenotomy was not reversed by repair within 8 weeks.