Second Harmonic Generation Microscopy as a Novel Intraoperative Assessment of Rat Median Nerve Injury.

PURPOSE: Nerves that are functionally injured but appear macroscopically intact pose the biggest clinical dilemma. Second Harmonic Generation (SHG) Microscopy may provide a real-time assessment of nerve damage, with the ultimate goal of allowing surgeons to accurately quantify the degree of nerve damage present. The aim of this study was to demonstrate the utility of SHG microscopy to detect nerve damage in vivo in an animal model. METHODS: Ten Sprague-Dawley rats were anesthetized and prepared for surgery. After surgical exposure and using a custom-made stretch applicator, the right median nerves were stretched by 20%, corresponding to a high strain injury, and held for 5 minutes. The left median nerve served as a sham control (SC), only being placed in the applicator for 5 minutes with no stretch. A nerve stimulator was used to assess the amount of stimulation required to induce a flicker and contraction of the paw. Nerves were then imaged using a multiphoton laser scanning microscope. RESULTS: Immediately after injury (day 0), SHG images of SC median nerves exhibited parallel collagen fibers with linear, organized alignment. In comparison with SC nerves, high strain nerves demonstrated artifacts indicative of nerve damage consisting of wavy, undulating fibers with crossing fibers and tears, as well as a decrease in the linear organization, which correlated with an increase in the mean stimulation required to induce a flicker and contraction of the paw. CONCLUSIONS: Second Harmonic Generation microscopy may provide the ability to detect an acute neural stretch injury in the rat median nerve. Epineurial collagen disorganization correlated with the stimulation required for nerve function. CLINICAL RELEVANCE: In the future, SHG may provide the ability to visualize nerve damage intraoperatively, allowing for better clinical decision-making. However, this is currently a research tool and requires further validation before translating to the clinical setting.

Does Construct Type Matter? A Retrospective Review Comparing Outcomes of Distal Radius Fractures Treated with Standard Volar Plating versus Fragment-Specific Fixation.

Background Treatment of intra-articular distal radius fractures (DRFs) rests on anatomic internal fixation. Fragment-specific fixation (FSF) is applied when fracture pattern is too complex for standard volar plating (SVP), oftentimes with potential increased risk of complications. We hypothesized that patients undergoing FSF would achieve less wrist range of motion (ROM) with higher risk of complications compared with SVP. Methods We conducted a retrospective review of 159 consecutive patients undergoing DRF fixation from 2017 to 2020. Patients < 18 years old, < 8 weeks' follow-up, open fractures, ipsilateral trauma, and fractures requiring dorsal spanning plate were excluded. Patient demographics, specific construct type, AO fracture classification, ROM, and complications were assessed. ROM was calculated using average flexion, extension, supination, and pronation. t -Tests were used to determine differences in ROM among construct types. Results Ninety-two patients met all inclusion criteria: 59 underwent SVP and 33 underwent FSF. Average wrist ROM for patients undergoing SVP was 57 degrees/50 degrees flexion-extension and 87 degrees/88 degrees supination-pronation; average ROM for patients undergoing FSF was 55 degrees/49 degrees flexion-extension and 88 degrees/89 degrees supination-pronation. No significant differences were identified when comparing final wrist flexion ( p = 0.08), extension ( p = 0.33), supination ( p = 0.35), or pronation ( p = 0.21). Overall reoperation rate was 5% and higher for FSF (12%) versus SVP (2%). Highest reoperation rate was observed in the double volar hook cohort (80%; N = 4). Conclusion Construct type does not appear to affect final ROM if stable internal fixation is achieved. SVP and FSF had similar complication rates; however, double volar hook constructs resulted in increased reoperations likely from fixation failure and plate prominence. Level of Evidence Level IV, retrospective review.

Outcomes of Arthroscopic Elbow Contracture Release: Improvement for Severe Prosupination and Flexion Contracture.

PURPOSE: The purpose of this study was to investigate outcomes following arthroscopic elbow contracture release to describe the use of arthroscopy for improvement in extension/flexion and pronation/supination arcs of motion at a single institution for degenerative and posttraumatic etiologies. METHODS: Consecutive arthroscopic elbow arthrolysis performed between 2003 and 2015 were retrospectively reviewed. Basic patient demographics, indications for surgery, preoperative and postoperative elbow range of motion, postoperative patient outcome score, and all complications were recorded and analyzed. RESULTS: Fifty-two patients were included with an average follow-up of 5.1 years (range 1.4 to 9.4). Severe contractures made up 50% of cases, followed by 23% moderate, and 27% mild. Average extension/flexion for the post-traumatic group (n = 30) increased by 63° ± 31 and by 29° ± 24 for the degenerative group (n = 22). Average gain in pronosupination was 38° ± 62 in the post-traumatic group and 13°±23 in the degenerative group. Postoperative DASH scores were 17.5 ± 18.4 for post-traumatic cases and 12.8 ± 19.3 for degenerative cases. CONCLUSION: Arthroscopic elbow contracture release is an effective intervention for degenerative and post-traumatic elbow contracture for both flexion/extension and pronosupination contracture. Furthermore, a two-stage release should be considered when both flexion and pronosupinaton contractures are present. LEVEL OF EVIDENCE: IV, case series, treatment study.

A Novel Algorithmic Approach to Chronic Forearm Longitudinal Instability.

Essex-Lopresti Lesions are rare injuries that are often missed in the acute setting. Delayed intervention may lead to chronic wrist and elbow pain and overall poor outcomes. The literature currently supports treatments that involve shortening of the ulna to reduce the relative degree of ulnar impaction, followed by attempted reduction of the distal radioulnar joint. Although such techniques may help to temporarily reduce wrist pain secondary to ulnar impaction, they do not address the proximal migration of the radius and ipsilateral radial head dislocation at the elbow. Subsequent procedures are often needed to replace or resect the radial head. We present a novel approach to chronic Essex-Lopresti lesions resulting in anatomic restoration of forearm length with return of elbow and wrist flexion/extension as well as improved forearm pronation/supination.

Acute Hand Ischemia Following Elective Venous Sclerotherapy for Dorsal Hand Varicose Veins.

Venous sclerotherapy is an emerging cosmetic treatment option for dorsal hand varicose veins. Although venous sclerotherapy is considered a safe and effective procedure for treatment of venous malformations and varicosities in both the upper and lower extremities, inadvertent injection of the sclerosing agent into the arterial system has led to reported instances of acute ischemic events and distal limb necrosis. This is a rare but well-documented complication of lower-extremity venous sclerotherapy. Only 2 cases have been reported in upper-extremity venous sclerotherapy, both of which occurred during treatment of complex vascular malformations. We report an instance of acute, distal digit ischemia after elective venous sclerotherapy for a dorsal hand varicosity. As this procedure grows in popularity, it is essential for hand surgeons to be aware of this rare but potentially devastating complication.

Does the load-sharing classification predict ligamentous injury, neurological injury, and the need for surgery in patients with thoracolumbar burst fractures?: Clinical article.

OBJECT: The load-sharing score (LSS) of vertebral body comminution is predictive of results after short-segment posterior instrumentation of thoracolumbar burst fractures. Some authors have posited that an LSS > 6 is predictive of neurological injury, ligamentous injury, and the need for surgical intervention. However, the authors of the present study hypothesized that the LSS does not predict ligamentous or neurological injury. METHODS: The prospectively collected spinal cord injury database from a single institution was queried for thoracolumbar burst fractures. Study inclusion criteria were acute (< 24 hours) burst fractures between T-10 and L-2 with preoperative CT and MRI. Flexion-distraction injuries and pathological fractures were excluded. Four experienced spine surgeons determined the LSS and posterior ligamentous complex (PLC) integrity. Neurological status was assessed from a review of the medical records. RESULTS: Forty-four patients were included in the study. There were 4 patients for whom all observers assigned an LSS > 6, recommending operative treatment. Eleven patients had LSSs ≤ 6 across all observers, suggesting that nonoperative treatment would be appropriate. There was moderate interobserver agreement (0.43) for the overall LSS and fair agreement (0.24) for an LSS > 6. Correlations between the LSS and the PLC score averaged 0.18 across all observers (range -0.02 to 0.34, p value range 0.02-0.89). Correlations between the LSS and the American Spinal Injury Association motor score averaged -0.12 across all observers (range -0.25 to -0.03, p value range 0.1-0.87). Correlations describing the relationship between an LSS > 6 and the treating physician's decision to operate averaged 0.17 across all observers (range 0.11-0.24, p value range 0.12-0.47). CONCLUSIONS: The LSS does not uniformly correlate with the PLC injury, neurological status, or empirical clinical decision making. The LSSs of only one observer correlated significantly with PLC injury. There were no significant correlations between the LSS as determined by any observer and neurological status or clinical decision making.