Traumatic Zone II Flexor Tendon Injury Repair Through a Traumatic Dorsal Approach.

Zone II flexor tendons present unique challenges for repair because of their complex anatomy in a confined space. The approach for zone II injuries is often dictated by preexisting traumatic skin lacerations, with a midaxial or volar approach being most common. In some injuries, this approach is not viable, and alternative approaches must be considered. A 45-year-old man presented with a traumatic crush injury that caused complete disruption of the skin, tendon, capsule, collateral ligament, and volar plate and laceration of the flexor digitorum profundus in zone II near the proximal interphalangeal joint. Given the large, near-circumferential zone of injury, we used the traumatic dorsal wound for the flexor tendon for repair. There are no reports of this approach in the literature. Postoperatively, the proximal interphalangeal joint was immobilized for 6 weeks with a K-wire. The patient was followed in the clinic and prescribed occupational therapy. At the 4-month postoperative visit, the patient had a healed incision, no signs of infection, and intact median/radial sensations. Functional testing showed a loose composite fist, improved range of motion, and 2-cm tip-to-palm deficiency of the index finger. Grip strength was 85 lb in the right hand and 60 lb in the left hand. Although patients are not always expected to regain full function, their postoperative course may be further complicated by adhesion and the need for tenolysis. Given these historical complications of tendon repair and our patient's ability to return to work with satisfactory functional outcomes, this approach may be a viable option for treating this unique injury pattern. [Orthopedics. 2022;45(4):e216-e219.].

Evaluation of postoperative outcomes in patients following multi-level surgical reconstructions with the use Avive™ soft tissue membrane on nerve after traumatic injury of the upper extremity and lower extremity.

BACKGROUND: Treatment of patients with traumatic axonotmesis presents challenges. Processed human umbilical cord membrane has been recently developed with improved handling and resorption time compared to other amniotic membrane wraps, and may be beneficial in nerve reconstruction. This study evaluates postoperative outcomes after traumatic peripheral nerve injury after placement of commercially available processed human umbilical cord membrane. METHODS: We performed a prospective, single-center pilot study of patients undergoing multi-level surgical reconstruction for exposed, non-transected peripheral nerve. Functional outcomes including pain, range of motion, pinch and grip strength, and the QuickDASH and SF-36 patient-reported outcome measures were recorded, when possible, at the 1-week and 3, 6, and 9 months postop visit. One-tailed paired t-tests were performed to evaluate outcome improvement at final follow-up. RESULTS: Twenty patients had processed human umbilical cord membrane placement without surgical complications. Mean follow-up was 7.5 months (range: 3-10 months) and mean age was 39 years (range: 15-65). Twelve (67%) patients were male, and the majority of placement sites were in the upper extremity (85%). Mean preoperative visual analog scale pain score was significantly reduced at most recent follow-up, as were QuickDASH scores. All patients had improved functional outcomes at the 9-month follow-up, and SF-36 outcomes at 9 months showed improvement across all dimensions. CONCLUSION: This study indicates that processed human umbilical cord membrane may be a useful adjunct in nerve surgery with noted improvements in postoperative function, pain, and patient-reported outcome measures. Future studies are needed to assess long-term outcomes after traumatic nerve injury treated with processed human umbilical cord membrane.

Multifocal chondrosarcoma of the hand: Case report and review of the literature.

Few multifocal hand chondrosarcomas have been reported. To our knowledge, this report is the first to describe multifocal hand chondrosarcoma in a patient with no evidence of prior enchondroma, Ollier's disease, or Maffucci syndrome.

Nerve allograft histology after banking following complicated reconstruction.

Burial of nerve allografts in muscle tissue for later use is a novel technique with no prior literature discussions. This may be a safe and effective technique for short-term preservation of nerve allograft removed from a prior reconstruction.

Sutureless repair of a partially transected median nerve using Tisseel glue and Axoguard nerve protector: A case report.

Peripheral nerve injuries in which the nerve is not completely severed often result in neuromas-in-continuity. These can cause sensory and functional deficits and must be resected and reconstructed. In defects greater than 5 mm in length, nerve graft is indicated, and suture neurorrhaphy is typically used to secure the nerve ends. However, sutures may negatively impact nerve regeneration. Fibrin glue has recently been used to mitigate the inflammatory response associated with suture neurorrhaphy. Most of the literature regarding fibrin glue covers animal models and supports its use for nerve reconstruction. Tisseel, a fibrin sealant developed as an adjunct to hemostasis, has recently shown utility in peripheral nerve repair by increasing tensile strength without additional sutures. We present the successful use of Tisseel sealant in a neuroma resection and reconstruction. In this case, a 35-year-old female presented with persistent neuropathic pain and neurologic dysfunction related to the median nerve in her hand with a history of distal forearm laceration and prior carpal tunnel release. Upon exploration, a neuroma-in-continuity involving 75% of the nerve was identified, resected, and reconstructed using processed human nerve allograft, as well as Tisseel sealant and Axoguard nerve protector to secure the repair and offload tension. At 1-year follow-up, pain was resolved, with ≤8 mm static 2-point discrimination in the median nerve distribution, and excellent improvement in hand strength compared with preoperative conditions. The outcome of this case indicates that fibrin glue may be useful to avoid excess sutures in cases of neuroma-in-continuity not involving the entire cross-section of the nerve.

Distal Digital Nerve Repair Using Nerve Allograft With a Dermal Substitute: A Case Report.

Background: Distal digital nerve repairs can present unique challenges for hand surgeons due to their sensitive location and ongoing difficulty obtaining soft tissue coverage in this region. Although autografts and nerve conduits have been shown to be of benefit with nerve gaps, they can have morbidities associated with their use. Nerve allografts have become a viable option over the past decade as their use has increased and data are now showing similar outcomes, particularly in short gap segments. Flaps and skin grafts are traditional coverage options for full thickness wounds but can pose challenges with multiple digit involvement, depth of wound, and critical structures exposed. Methods: We present a case where nerve allograft was used for distal digital nerve repair. Due to the distal nature of the nerve repair in the index digit distal to the trifurcation, the distal end of the nerve graft was connected to multiple small nerve ends. Dermal substitute was placed to achieve distal coverage of the affected digits. Results: At 6-month follow-up, the patient demonstrated improved strength, normal sensation, and full return of digital function. Conclusion: Nerve allograft can be used in combination with dermal skin substitute to achieve normal sensation and return of digital function following distal digital nerve injuries.

The Impact of Obesity on Orthopedic Upper Extremity Surgery.

Obese patients have increased rates of upper extremity injury, carpal tunnel syndrome, and upper extremity osteoarthritis. Preoperative considerations include cardiovascular disease, pulmonary disease, and diabetes mellitus. Intraoperative and anesthetic considerations include specialized equipment, patient positioning, and the physiology of obese patients. Postoperative considerations should include increased risk of cardiovascular complications as well as surgical site infections and malunion. Surgery of the hand and upper extremity may be less prone to the postoperative complications seen in other regions of the body. There are currently no direct contraindications for obese patients to undergo orthopedic procedures if the appropriate considerations have been made.