The Top 100 Cited Articles in the Microsurgical Treatment for Lymphedema.

BACKGROUND: Evidence-based medicine uses the current best evidence for decisions about patient care. Lymphedema is a chronic debilitating medical condition caused by a dysfunctional lymphatic system. This study analyzes the most cited articles, including the levels of evidence, for the surgical treatment of lymphedema. METHODS: The Web of Science Sci-Expanded Index was utilized to search for surgical treatment of lymphedema. Articles were examined by three independent reviewers and the top 100 articles were determined. The corresponding author, citation count, publication year, topic, study design, level of evidence, journal, country, and institution were analyzed. RESULTS: Since 1970, the top 100 articles have been cited 7,300 times. The average citation count was 68 and standard deviation was 55. The majority was case series (71), followed by retrospective cohort (8), prospective cohort (7), retrospective case-control (5), and randomized controlled trials (2). Based on the "Level of Evidence Pyramid," 71 articles were level IV, 13 articles were level III, and 9 articles were level II. On the Grading of Recommendations Assessment, Development, and Evaluation Scale, there were 71 articles with "very low," 20 articles with "low," and 2 articles with "moderate" quality of evidence. CONCLUSION: The top 100 cited articles were mostly case series and lacked high levels of evidence. Most studies are retrospective case series with short-term outcomes. However, low level evidence for new surgical procedures is to be expected. Current trends suggest the treatment and understanding of lymphedema will continue to improve.

Abductor Digiti Minimi Flap for Vascularized Coverage in the Surgical Management of Complex Regional Pain Syndrome Following Carpal Tunnel Release.

BACKGROUND: The development of Complex Regional Pain Syndrome (CRPS) represents a potentially devastating complication following carpal tunnel release. In the presence of a suspected incomplete release of the transverse carpal ligament or direct injury to the median nerve, neurolysis as well as nerve coverage to prevent recurrent scar has been shown to be effective. METHODS: Retrospective chart review and telephone interview was conducted for patients who underwent abductor digiti minimi flap coverage and neurolysis of the median nerve for CRPS following carpal tunnel release. RESULTS: Fourteen wrists in 12 patients were reviewed. Mean patient age was 64 years (range, 49-83 years), and the mean follow-up was 44 months. Carpal tunnel outcome instrument scores were 47.4 ± 6.8 preoperatively and 27.1 ± 10.6 at follow-up ( P < .001). Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores at follow-up were 29.4 ± 26. No significant postoperative complications were identified. CONCLUSIONS: The abductor digiti minimi flap is a reliable option with minimal donor site morbidity. It provides predictable coverage when treating CRPS following carpal tunnel syndrome.

Intramedullary Fixation of Metacarpal Fractures Using Headless Compression Screws.

Introduction The purpose of this study is to examine the clinical results of retrograde intramedullary headless screw (IMHS) fixation for metacarpal fractures. Methods A retrospective review was performed on 16 patients with 18 metacarpal fractures who underwent IMHS fixation at a single institution. The average age was 32 years. The indications for surgery included rotational malalignment (five patients), multiple metacarpal fractures (five patients), angular deformity (four patients), and shortening greater than 5 mm (two patients). The average length of follow-up was 19.4 weeks (median 10.2 weeks). Results Functional outcome was considered excellent in all patients with total active motion in excess of 240 degrees. Active motion was initiated within 1 week of surgery. No secondary surgeries were performed related to a complication of IMHS fixation. Conclusion IMHS fixation of metacarpal fractures is an efficacious treatment modality for patients with comminution, multiple fractures, malrotation, and those who require rapid mobilization. It obviates the need for immobilization or more extensive plate and screw fixation techniques with excellent clinical results.

Foot web free flaps for single-stage reconstruction of hand webs.

PURPOSE: To present a method for reconstructing the digital web in posttraumatic defects using a free tissue transfer of the web from the foot and to present the functional and aesthetic results. METHODS: Nine web free flaps were performed; 8 were used to reconstruct posttraumatic web losses and 1 was used to reconstruct a defect resulting from to infection. All cases involved the first (3) or second (6) webs of the hand. Web flaps were taken from the foot first web (2 patients), from the second (6 cases), and from the third (1 case) in a patient with congenital syndactyly of second foot web space. The donor site was managed by skin grafting from the instep (1 case), creation of a syndactyly (7 cases), or both (1 case). RESULTS: All flaps survived without complications. Finger abduction and flexion-extension were similar to the contralateral side. No functional limitations, pain, or contracture were reported. One donor site healed with hypertrophic scars; otherwise, no donor site complications occurred. On a visual analog scale (0-10), the patient assessed appearance of the hand and the donor foot as 9.0 and 9.0, respectively, on average. One web was not well-positioned in the first operation and required revision. CONCLUSIONS: The foot web free flap reconstructs the hand web by replacing it with a similar functional subunit rather than attempting to recreate the complex geometry, and allows for full function and excellent appearance of the hand. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Exposure of the forearm and distal radius.

Approaches to the forearm use internervous planes to allow adequate bone exposure and prevent muscle denervation. The Henry approach utilizes the plane between muscles supplied by the median and radial nerves. The Thompson approach utilizes the plane between muscles supplied by the radial and posterior interosseous nerves. The distal radius may be approached volarly. The extended flexor carpi radialis approach is useful for intraarticular fractures, subacute fractures, and malunions. The distal radius can be approached dorsally by releasing the third dorsal compartment and continuing the dissection subperiosteally. Choice of approach depends on the injury pattern and the need for exposure.

Arthroscopic reduction of comminuted intra-articular distal radius fractures with diaphyseal-metaphyseal comminution.

PURPOSE: In the setting of severely comminuted diaphyseal-metaphyseal fractures of the distal radius, arthroscopic reduction of the joint surface is difficult and often results in shortening and collapse. Yet, several authors have shown the benefits of arthroscopy in articular distal radius fractures. We present a method that safely allows a combination of arthroscopic reduction and rigid fixation and describe the outcomes in a small group of patients. METHODS: Four consecutive patients with severely comminuted diaphyseal-metaphyseal articular fractures of the distal radius were treated using the stable reference fragment technique. For all cases, we used an extra-long volar locking plate applied to the diaphysis of the radius. Preoperative computed tomography scanning was used to identify the largest articular fragment. This reference fragment was reduced and stabilized with locking pegs or screws to the volar plate under fluoroscopic guidance. The articular reduction continued arthroscopically, using the reference fragment as a guide. Once the articular reduction was complete, the comminuted metaphysis was addressed and secured to the plate. RESULTS: All patients achieved excellent clinical and radiological results. Flexion-extension averaged 124° and pronation-supination averaged 174°. One patient showed minor signs of radiocarpal osteoarthritis on radiographs at 3 years. CONCLUSIONS: By securing the reference fragment before addressing the metaphyseal comminution, a stable platform was created. Thus, intra-articular reduction was achieved while maintaining extra-articular alignment. Although the results were excellent, the number of cases was small. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Vascularized graft from the metatarsal base for reconstructing major osteochondral distal radius defects.

PURPOSE: To present our experience of reconstructing distal radius articular defects with a vascularized osteochondral graft from the metatarsal base and to present the mid-term outcomes. METHODS: Seven patients (average age, 36 y; range, 26-55 y) who had reconstruction of major defects of the articular surface of the radius are presented. In 5, the lunate facet and sigmoid notch were reconstructed; in 1, an isolated defect on the surface of the lunate facet was reconstructed; and in 1, the scaphoid facet was reconstructed. In 6, the base of the third metatarsal was transferred, and in 1, the base of the second was transferred. RESULTS: All flaps survived without complications. At the latest follow-up (range, 20 mo to 8 y), the flexion-extension arc improved an average of 50°, and the pain on a visual analog scale decreased from 8 to 1 on average. Disabilities of the Arm, Shoulder, and Hand score improved from 54 to 11 on average. One patient did not improve. No major complaints related to the donor site were mentioned (average American Orthopedic Foot and Ankle Society score of 96/100). CONCLUSIONS: Our mid-term results are promising; however, the decision-making process and the operation are complex. The operation is not indicated when the carpals are devoid of cartilage or when the defect involves the whole radius surface.

Reconstruction of Ollier disease in a severely involved hand.

Ollier disease is a nonhereditary disorder characterized by multiple enchondromata, with a random asymmetrical distribution. We report an unusual case of massive ulcerating multiple enchondromata of the left hand of an 11-year-old male patient. A methodical approach to treating such a massive tumor burden and steps in reconstructing the hand are described. This case report demonstrates a radical expression of this disease; however, no malignancy was identified despite the aggressive and chronic nature of the disease. Unlike previously reported cases with less severe involvement, this patient did not undergo amputation, and this approach demonstrates a strategy for limb salvage not previously described. In particular, despite bony defects of 6 cm, no autograph was necessary for the reconstruction of the hand.

Volar plate fixation of intra-articular distal radius fractures: a retrospective study.

Background Intra-articular fractures of the distal radius represent a therapeutic challenge as compared with the unstable extra-articular fractures. With the recent development of specifically designed internal fixation materials for the distal radius, treatment of these fractures by fragment-specific implants using two or more incisions has been advocated. Purpose The purpose of this study was to investigate the efficacy of a fixed-angle locking plate applied through a single volar approach in maintaining the radiographic alignment of unstable intra-articular fractures as well as to report the clinical outcomes. We only excluded those with massive comminution, as is discussed in greater detail in the text. Patients and Methods This is a multicentered, retrospective study involving three hospitals situated in Spain, Switzerland, and the United States. In the period between January 2000 and March 2006, 97 patients with 101 intra-articular distal radius fractures, including 13 volarly displaced and 88 dorsally angulated fractures were analyzed. Over 80% were C2/C3 fractures, based on the AO classification. 16 open fractures were noted. Results With an average follow-up of 28 months (range 24-70 months), the range of movement of the wrist was very satisfactory, and the mean grip strength was 81% of the opposite wrist. The Disabilities of the Arm, Shoulder, and Hand (DASH) score was 8. The complications rate was < 5%, including loss of reduction in two patients. All fractures healed by 3 months postinjury. Conclusions Irrespective of the direction and amount of initial displacement, a great majority of intra-articular fractures of the distal radius can be managed with a fixed-angle volar plate through a single volar approach. Level IV retrospective case series.

Arthroscopic resection arthroplasty for malunited intra-articular distal radius fractures.

PURPOSE: Cartilage damage of the carpals is a contraindication for corrective osteotomy of the malunited intra-articular distal radius fracture and typically is treated in the symptomatic patient with a salvage procedure. Here, we present our experience and early results with arthroscopic resection arthroplasty of the radiocarpal joint. METHODS: We treated 10 patients (age, 17-68 y; average, 53 y) who had intra-articular malunion of the distal radius with mirror erosion on the carpals. The original fracture occurred 4 to 36 months (average, 9 mo) before our intervention. We performed arthroscopic arthrolysis and resected the offending portion of the radial malunited fragment, eliminating the stepoff and creating a smoother joint surface. Range of motion was started immediately after the operation, except in 2 patients. RESULTS: The locations of the malunions were evenly distributed between the scaphoid fossa, the lunate fossa, or both. Stepoffs varied from 2 to 6 mm. We resected up to 60% of the entire radial articular surface to obtain a smooth surface (average, 28%; range, 20% to 60%). All patients reported immediate relief of pain and improvement in motion (particularly extension). At the latest follow-up (average, 28 mo; range, 13-42 mo), average extension improved from 24° to 54°, average grip strength improved from 47% to 89% of the contralateral wrist, average Disabilities of the Arm, Shoulder, and Hand score improved from 74 to 18, and average Patient-Rated Wrist Hand Evaluation score improved from 79 to 15. CONCLUSIONS: The aim of the operation was to relieve patients' pain by providing a smooth, although fibrocartilaginous, surface for the carpus to glide on the radius. The follow-up was short and the results may be short-lived. However, for the younger patient, it may provide a temporary alternative to partial wrist arthrodesis with minimal morbidity, and for the less demanding patients, it may be a definitive procedure.

Early experience with (dry) arthroscopic 4-corner arthrodesis: from a 4-hour operation to a tourniquet time.

PURPOSE: Scaphoidectomy and 4-corner arthrodesis (4CA) is an effective procedure for treating several degenerative conditions of the wrist. Recently, the arthroscopic approach to this operation was described. Although it is conceptually appealing, certain aspects make its application difficult. We present our technique for dry arthroscopic scaphoidectomy and 4CA, which reduces the operative time to less than 2 hours. METHODS: Four consecutive patients underwent scaphoidectomy and 4CA. In each case, we performed the operation with a dry arthroscopic technique using cannulated screws for rigid fixation. We performed bone grafting from the distal radius in 2 patients and from the scaphoid itself in the other two. The relevant operative details are the use of a scapholunate portal, the resection of the scaphoid with a pituitary rongeur, and the placement of bone graft in a dry arthroscopic environment. Range of motion exercises are started 2 to 3 weeks after the operation. RESULTS: The first operation took 4 hours. The last 2 were completed in 1 hour 45 minutes and 1 hour 55 minutes, respectively. No complications occurred. No operations were converted to an open procedure. CONCLUSIONS: Although the operation has a steep learning curve, it is conceptually appealing. It is too early to prove that the arthroscopic procedure has better results than the open 4CA; nevertheless, in our opinion it represents the future of wrist surgery.

Scaphocapitolunate arthrodesis and radial styloidectomy: a treatment option for posttraumatic degenerative wrist disease.

Longstanding scaphoid nonunion, scaphoid malunion, and chronic scapholunate dissociation result in malalignment of the carpal bones, progressive carpal collapse, instability, and osteoarthritis of the wrist. The most commonly used procedures to treat scaphoid nonunion advanced collapse (SNAC) and scapholunate advanced collapse (SLAC) wrists are the four-corner fusion (4CF) and the proximal row carpectomy (PRC). Here we describe a different treatment option: radial styloidectomy and scaphocapitolunate (SCL) arthrodesis. This treatment option is chosen in an effort to maintain the joint contact surface and load transmission across the radiocarpal joint. Twenty patients were treated by the senior author (DLF) with this method with a mean follow-up of 4.6 years. Pain decreased in all patients, and 13 patients were pain-free postoperatively. The average Disabilities of the Arm, Shoulder, and Hand (DASH) scores decreased from 44 preoperatively to 23 postoperatively. One patient's course was complicated by nonunion, which was successfully treated with revision of the SCL arthrodesis. On follow-up radiographs, no patient had progressive osteoarthritis. This method preserves the normal ulnar-sided joints of the carpus, which are sacrificed during 4CF, and maintains a more physiologic joint surface for radiocarpal load sharing.

Scaphocapitolunate arthrodesis and radial styloidectomy for posttraumatic degenerative wrist disease.

Long-standing scaphoid nonunion, scaphoid malunion, and chronic scapholunate dissociation result in malalignment of the carpal bones, progressive carpal collapse, instability, and osteoarthritis of the wrist. The most commonly used procedures to treat scaphoid nonunion advanced collapse (SNAC) and scapholunate advanced collapse (SLAC) wrists are the four-corner fusion (4CF) and the proximal row carpectomy (PRC). The purpose of this study was to evaluate the clinical outcome of a different treatment modality: radial styloidectomy and scaphocapitolunate (SCL) arthrodesis. This treatment option is chosen in an effort to maintain the joint contact surface and load transmission across the radiocarpal joint. We conducted a retrospective review of 20 patients (average age 62 years, range: 27 to 75 years) treated from 1994 to 2010. Seven patients were treated for SNAC, 12 patients for SLAC wrists, and 1 for degenerative joint disease following a transscapho-transcapitate perilunar dislocation. Sixteen patients had Herbert screw fixation, and four had Spider plate fixation. All patients had autologous bone graft used for the arthrodesis. The mean follow-up was 4.6 years (range: 2 to 9.6 years). Patients were evaluated clinically and radiographically. Nineteen of 20 arthrodeses healed on an average of 9.6 weeks. One patient was reoperated 8 months after the initial operation with salvage of the SCL arthrodesis with a spider plate with an adequate result. The mean active flexion-extension arc was 70 degrees and the radioulnar deviation arc was 23 degrees. Pain decreased in all patients, 13 of whom were pain free postoperatively. The average postoperative disabilities of arm, shoulder, and hand score was 24. Radiographically, neither radiolunate nor radioscaphoid arthritis was noted on follow-up. SCL arthrodesis with radial styloidectomy resulted in an adequate residual range of motion and pain relief. This method preserves the normal ulnar sided joints of the carpus and maintains a more physiologic joint surface for radiocarpal load sharing.