Outcomes of Surgical Treatment of Peripheral Neuromas of the Hand and Forearm.

The choice of a specific technique for surgical treatment of neuromas remains a problem. The purpose of this study is to determine the overall effectiveness of surgery as well as to find out whether certain surgical procedures are more effective than others. Twenty-nine patients operated between 1998 and 2018 and followed for at least 12 months were reviewed. Clinical assessment included the identification of a pre- and postoperative Tinel sign, pain visual analog score, two-point discrimination (2PD), and grip strength. Mechanisms of injury included clean lacerations (11), crush injuries (11), and other trauma or surgery (7). Mean time from presentation to surgery was 9 months. Seven surgical procedures involving excision in 10 patients and excision and nerve repair in 19 patients were performed. Pain score improved from an average of 7.1 ± 2.3 to 1.8 ± 1.7 with 27 patients (93%) reporting mild or no postoperative pain. Nine patients complained of residual scar hypersensitivity and six patients had residual positive Tinel. No patient required an additional surgical procedure. 2PD improved from an average of 9.6 ± 4.0 to 6.8 ± 1.0. The improvement of pain score and 2PD was statistically significant. Nerve repair resulted in marginally better outcomes, in terms of 2PD and grip strength recovery, than excision alone. The mechanism of injury, zone of involvement, time to intervention, or length of follow-up did not have an impact on the outcomes. Although patient numbers in this study are large in comparison to previous studies, larger patient numbers will allow for a multivariate analysis, which can be possible with a prospective multicenter trial.

A case of scaphocapitate arthrodesis for a failed lunate prosthesis in kienbock disease - 35 year follow up.

We report on the clinical history of a young male laborer with Lichtman Stage II Kienbock disease, who underwent a scaphocapitate arthrodesis after a failed silicone lunate prosthesis. After 35 years of follow-up, no further surgical intervention has been warranted despite progression of radiocarpal and ulnocarpal arthritis.

Carpometacarpal Ligament Reconstruction, Surgical Technique and Outcomes.

Basal thumb arthritis is a common condition with the earliest stage described as a period of ligament laxity and joint instability, without radiographic signs of arthritis. The condition is usually managed conservatively but a number of individuals can present with persistence of symptoms. We would like to describe our preferred technique for the management carpometacarpal ligament instability and laxity. This technique utilizes a slip of the flexor carpi radialis tendon and offers reconstruction of the intermetacarpal, dorsoradial and anterior oblique ligaments in an anatomic fashion using standard instruments available. The author has performed this technique in 33 patients over a course of 10 years and long-term outcomes of these cases are presented in this paper.

A Modified Extensor Carpi Ulnaris Tenodesis with the Sauvé-Kapandji Procedure.

Background: Since the Sauvé-Kapandji procedure was introduced in 1936, many modifications were created using dynamic stabilizer, such as the ECU (extensor carpi ulnaris), the FCU (flexor carpi ulnaris), pronator teres to solve proximal ulnar stump pain. We believe that this modification is also another option for distal ulnar stump instability. Methods: From January 1998 to February 2017, there were 13 patients received the Sauvé-Kapandji (S-K) procedure with tenodesis of the ECU to the carpus and interosseous membrane. The average age at operation was 52 years (range, 28 to 63 years). Four had traumatic arthritis (two from distal radial fracture malunion, two had instability of distal radioulnar joint from Essex-Lopresti injury), four had primary osteoarthritis of the distal radio-ulnar joint, two had rheumatoid arthritis, one had gouty arthritis, two had madelung deformity. The average follow-up was 30 months (range, 15 to 72 months). Results: Postoperative pronation/supination of the forearm had significantly improved with the exception of the wrist flexion/extension. After surgery, the mean radioulnar distance was narrowed from 11 mm to 9 mm, but no significant difference in 12 patients. All patients had improved in wrist pain, 10 patients had no pain and 3 patients with mild pain over the distal ulnar stump. The mean grip strength had significantly improved from 51% of the contralateral side to 75%. The lateral and stress X-ray films showed no instability of the distal ulnar stump after surgery. Conclusions: In conclusion, the modified S-K procedure using the tenodesis of ECU provides a multi-directional stability and is a reliable surgical procedure for distal radioulnar disorders.

In Vitro Comparison between the Pulvertaft Weave and the Modified Core Suture Pulvertaft Weave.

Background: The Pulvertaft weave was described more than 50 years ago and is still used in tendon transfers. The aim of this study was to evaluate the strength of a modified core suture Pulvertaft weave technique and compare it to the original Pulvertaft weave traditionally used in tendon transfer surgery. Methods: 12 extensor pollicis longus tendons and extensor indices proprius tendons were harvested from fresh frozen cadavers. Six Pulvertaft weaves were performed using FiberWire 4.0 and six core suture tendon weave were performed using FiberLoop 4.0. Biomechanical analysis was performed and stifness, first failure load and ultimate failure load were measured for both set of repairs. Results: The stiffness of the core suture tendon repair (9.5 N/mm) was greater than that of the Pulvertaft repair (2.5 N/mm) The first failure load of the core suture tendon repairs (68.9 N) was greater than the Pulvertaft repairs (19.2 N) and the ultimate failure load of the core suture tendon repairs (101.8 N) was greater than the Pulvertaft repairs (21.9 N). All of these differences were statistically significant. Conclusions: The core suture Pulvertaft weave is a modification to the Pulvertaft weave used in tendon transfers. The results of this cadaveric study suggest it is 5 times stronger than the traditional Pulvertaft repair, potentially allowing it to be used with early active motion protocols after tendon transfers.

Assessing the Usability of Flexor Digiti Minimi Muscle for Opponensplasty: An Anatomic Study.

PURPOSE: The abductor digiti minimi (ADM) and flexor digiti minimi (FDM) muscles have a similar vascular and nerve supply. The purpose of this study was to assess the feasibility of transferring the FDM instead of ADM for thumb opposition. METHODS: Thirty cadaver hands were dissected under loupe magnification to assess the presence of the ADM and FDM muscles as well as their blood and nerve supply. The length of these muscles and their location in relation to the radial aspect of the thumb metacarpophalangeal joint were assessed. RESULTS: The ADM muscle was present in all cadavers whereas the FDM muscle was absent in 33% of hands. When the dimensions were suitable (53%), the more radially located FDM muscle reached the thumb metacarpophalangeal joint more easily. CONCLUSIONS: Although the dissections revealed considerable variability in FDM anatomy, when present, it can have positional advantage over the ADM for opponensplasty. CLINICAL RELEVANCE: In some cases with radial longitudinal deficiency, preservation of ADM function is essential. In these children, the FDM can potentially be explored and transferred if it is found to be suitable.

Comparison of End-to-End Technique, Helicoid Technique, and Modified Helicoid Weave Repair Technique in a Rat Sciatic Nerve Model: A Pilot Study.

Background The gold standard for nerve repair is end-to-end (ETE) repair. Helicoid technique (HT) has also been previously described. In this pilot study, HT was compared to ETE and a modified helicoid weave technique (MHWT). In MHWT, recipient nerve is passed through rather than around the donor nerve, allowing for greater nerve-to-nerve interaction. Methods Eighteen adult male Lewis rats received a 2-cm sciatic nerve transection and were divided into three groups: ETE, HT, and MHWT. Five months later, electromyography (EMG), tetanic force of contraction, and wet weight of the extensor digitorum longus muscle were recorded in both the operated and non-operated sides. Nerve biopsies were taken proximal and distal to the site of the nerve graft for histological examination. Results One rat died following repair surgery and three rats died during the second surgery. The mean threshold of stimulation for ETE, HT, and MHWT were 183.3 µA, 3707.5 µA, and 656.6 µA, respectively. EMG analysis revealed that latency and duration are both affected by surgical repair type and injured or uninjured conditions. Threshold ratio (injured:non-injured) revealed pilot-level significant differences between HT and both MHWT (p = 0.069) and ETE (p = 0.082). Nerve biopsy demonstrated fascicles distally in all three groups. Conclusions While HT and MHWT function as a nerve repair technique, they are not superior to ETE. ETE remains the gold standard for nerve repair. While mean values were in favor of ETE, no statistical significance was attained.

Percutaneous Tenodermodesis for Mallet Fingers: An Office-based Procedure.

Mallet fingers are injuries to the extensor tendon at the distal interphalangeal (DIP) joint and can present as a bony avulsion or as a soft tissue injury. Nonbony mallet fingers are frequently splinted in extension between 6 and 8 weeks. If splinted correctly, most results are good with a mean DIP joint extension lag between 5 and 10 degrees. However, decreased swelling, hygienic considerations and patient compliance can lead to splint removal and a less favorable outcome. We present a percutaneous tenodermodesis using only a digital block and a 4.0 nylon suture. This office-based procedure provides joint reduction and prevents joint movement during the immobilization period. The suture can be removed after 8 weeks, allowing active mobilization of the DIP joint. We present the results of 8 patients with a mean follow-up of 3 months and mean initial extension lag of 32 degrees, resulting in a mean final extension lag of 2 degrees and excellent outcomes using the Crawford criteria.

Microsurgical reconstruction of congenital upper extremity deformities of malformations.

We present two rare microsurgical reconstructions. A case with phocomelia was treated with lengthening of soft tissues following vascularized fibula grafting with epiphysis, and a case with cleft hand was reconstructed with spare-part toe transfer.

Chronic Reducible Scapholunate Ligament Dissociation: A Simple Surgical Technique for a Complex Injury.

PURPOSE: Report the outcomes following chondrectomy of scapholunate (SL) joint, temporary stabilization of the SL joint using Kirshner wires and extensor carpi radialis longus (ECRL) transfer to dorsal scaphoid pole to restore normal SL gap and correct dorsal intercalated ligament instability deformity. MATERIALS AND METHODS: Retrospective case series of 11 patients with a mean age of 45 years were treated by the senior author 7 months after SL injury. The SL joint cartilage was removed, the SL joint was stabilized temporarily with 2 Kirshner wires for 8 weeks and ECRL tenodesis to scaphoid dorsally. Visual analog scale, disability of the arm, shoulder, and hand score, wrist flexion and extension range of motion, grip strength, return to work, SL gap, and SL angle were evaluated preoperatively and in last follow-up visit after the procedure. Modified Mayo score and complications were evaluated in the last visit. RESULTS: Average follow-up was 15.6 months. In the last follow-up, the average visual analog scale pain score improved significantly from 6.4 to 1.5. Average postoperative grip strength improved significantly compared with preoperative strength (41 to 56 Ib). Average disability of the arm, shoulder, and hand score improved significantly postoperatively (30 to 18 points). Average Mayo score was satisfactory in the last visit. Average SL gap reduced significantly from 4.1 to 2.8 mm and average SL angle decreased significantly from 82 to 62 degrees. Postoperative extension-flexion arc of motion significantly decreased compared with preoperative measurements. SL advanced collapse developed in 1 case after 15 months follow-up. All patients return to regular work at a mean of 16 weeks. CONCLUSIONS: Chronic reducible SL dissociation can be treated affectively with SL chonderectomy, temporary SL stabilization, and ECRL tenodesis to scaphoid to restore radiologic anatomy without compromising strength or work status. LEVEL OF EVIDENCE: Therapeutic type IV.

Revascularización y reimplante digital. Revisión de conceptos actuales / Digital reimplantation adn revascularization. current concets

El reimplante es la obra maestra del cirujano de mano, donde incluye la técnica microquirúrgica para la anastomosis de arteria, vena y reparación del nervio, la osteosíntesis de los huesos y el manejo de tejidos blandos como los tendones y la piel Indicaciones absolutas, amputación del pulgar, el pulgar es quizás el elemento más importante de la mano, dado que le da funcionalidad a la extremidad, sin importar la movilidad final ni la sensibilidad debe reimplantarse el pulgar. No se debe intentar el reimplante en lesiones aplastantes de los dedos, amputación en más de un nivel, presencia de lesiones que amenacen la vida del paciente, enfermedades graves del paciente, isquemia prolongada, amputaciones en paciente con alteraciones psiquiátricas. Clasificación según Tamai es la mas utilizada. Se explica además como se debe transportar la parte amputada. La técnica microquirúrgica es lo mas importante para el desenlace. La rehabilitación física y posibles complicaciones.

Reimplantation is the masterpiece of the hand surgeon, which includes the microsurgical technique for artery anastomosis, vein and nerve repair, osteosynthesis of the bones and the management of soft tissues such as tendons and skin. Absolute indications, Amputation of the thumb: the thumb is perhaps the most important element of the hand because it gives functionality to the limb, regardless of the final mobility or sensitivity it should be reimplanted. Reimplantation should not be attempted in crushing lesions of the fingers. Crush injury of the fingers may have multilevel amputation and microcirculation injury that may not be susceptible of repair. Amputation at more than one level, the presence of life-threatening injuries, serious illnesses of the patient, prolonged ischemia, amputations in a patient with psychiatric disorders. Tamai Classification is the most used. We explain the correct way to transport the amputated part. The microsurgical technique is the most important in order to avoid complications. We also explain the physical therapy and complications.

Erratum: Trapeziometacarpal Joint Arthroplasty of the Thumb without Osseous Tunnels and Carpal Tunnel Release via a Radial Approach; Technique, and Results.

[This corrects the article DOI: 10.1055/s-0039-1697635.].

The role of B cell immunity in VCA graft rejection and acceptance.

Vascularized composite allotransplantation (VCA) has emerged as the most recent field of transplantation to offer an alternative treatment for those patients that have failed or are not suitable candidates for conventional therapy. Most of the current clinical experience in this field is with recipients of skin containing grafts such as the face, upper extremity and abdominal wall transplants. Like solid organ recipients, VCA recipients require lifelong systematic immunosuppression to maintain their grafts. To date, the most successful immunosuppressant regimens are calcineurin inhibitor based and have been targeted to the control of T cells. While these regimens have resulted in excellent short term graft survival in solid organ transplantation, achieving significant improvements in long term survival has been more challenging. The reasons are multi-factorial, but a role for B cells and humoral immunity has been proposed. Antibody mediated rejection leading to chronic rejection has been cited as the leading cause of renal graft loss. While the number of VCA transplants performed is still small, evidence to date suggests that antibody mediated rejection may occur less frequently than seen in solid organ transplants. Here we will discuss the role of B cell immunity in solid organ transplantation as it pertains and contrasts to the field of VCA and present some examples of possible sequela of B cell immunity in a series of hand transplant recipients.

Quadrilateral Space Syndrome: A Case Report.

We present a case of quadrilateral space syndrome (QSS) in a patient with left arm pain. The patient sustained a trauma to his left arm, and QSS was successfully diagnosed by physical examination, magnetic resonance image, electromyographic evaluation, and nerve conduction studies. Surgery was performed to decompress the axillary nerve and the patient recovered fully with minimal residual symptoms.

Role of pronator release in revision carpal tunnel surgery.

INTRODUCTION: The purpose of this study was to compare the result of treatment of patients with failed primary carpal tunnel surgery who suspected pronator teres syndrome (PTS) by performing revision carpal tunnel release (CTR) with pronator teres release (PTR) and revision CTR alone. METHODS: Retrospective chart review in patients who required revision CTR and suspected PTS. Group 1, treated by redo CTR with PTR and group 2, treated by redo CTR alone. Intraoperative findings, pre and postoperative numbness (2-PD), pain (VAS score), and grip strength were studied. RESULTS: There were 17 patients (20 wrists) in group 1 and 5 patients (5 wrists) in group 2. Patients in group 1 showed more chance of fully recovery of numbness and pain than group 2 (60% vs. 0%, p < 0.05 and 55.0% vs. 0%, p < 0.05, respectively). Mean grip strength was increased 16.0% in group 1 and increase 11.7% in group 2. Most common pathology at the elbow were deep head of pronator teres 90% (18/20 elbows) and lacertus fibrosus 50% (10/20 elbows). The most common finding at carpal tunnel was the reformed transverse carpal ligaments (80%, 20/25 wrists) and scar adhesion around the median nerve (40%, 10/25 wrists). DISCUSSION: Intraoperative findings from our study confirmed that there were pathology in both carpal tunnel and pronator area in failed primary CTR with suspected PTS. Our study showed that combined PTR with revision CTR provided higher chance of completely recovery from numbness and pain more than redo CTR alone.

The Risk Factors for Failure of an Upper Extremity Replantation: Is the Use of Cigarettes/Tobacco a Significant Factor?

BACKGROUND: The purpose of this study was to explore the potential risk factors associated with the failure of an upper extremity replantation with a focus on cigarette or tobacco use. PATIENTS AND METHODS: A cohort of 102 patients with 149 replants (6 extremities, 143 digits) and a mean age of 41 years (range 5 to 72 years) was enrolled in this study. The data collected included age, gender, tobacco/cigarettes use, trauma mechanism, underlying disease (e.g., hypertension (HTN), diabetes mellitus (DM), etc.), and vein graft use. An analysis with a multivariable regression was conducted to identify the risk factors of replant failure and their respective odds ratios (ORs). RESULTS: Multilevel generalized linear mixed models (GLMMs) with a binomial distribution and logit link showed that smoking did not increase the risk of replant failure (p = 0.234). In addition, the survival of replants was not affected by DM or HTN (p = 0.285 and 0.938, respectively). However, the replantation results were significantly affected by the age of the patients and the mechanism of injury. Patients older than 50 years and those with avulsion or crush injuries tended to have a higher risk of replant failure (OR = 2.29, 6.45, and 5.42, respectively; p = 0.047, 0.028, and 0.032, respectively). CONCLUSIONS: This study showed that the use of cigarettes/tobacco did not affect the replantation outcome. The main risks for replant failure included being older than 50 years and the trauma mechanism (avulsion or crush injuries).

Clinical Results of Flexor Tendon Repair in Zone II Using a six Strand Double Loop Technique.

The purpose of this study is to report the clinical results after repair of flexor tendon zone II injuries utilizing a 6-strand double-loop technique and early post-operative active rehabilitation. We retrospectively reviewed 22 patients involving 51 cases with zone II flexor tendon repair using a six strand double loop technique from September 1996 to December 2012. Most common mechanism of injuries was sharp lacerations (86.5 %). Tendon injuries occurred equally in manual and non-manual workers and were work-related in 33 % of the cases. The Strickland score for active range of motion (ROM) postoperatively was excellent and good in the majority of the cases (81 %). The rupture rate was 1.9 %. The six strand double loop technique for Zone II flexor tendon repair leads to good and excellent motion in the majority of patients and low re- rupture rate. It is clinically effective and allows for early postoperative active rehabilitation.

Carpal tunnel release using the radial sided approach compared with the two-incision approach.

We compared carpal tunnel release using a radial sided approach (RCTR) with a two-incision approach with regards to complications, grip strength, and functional outcomes. Retrospective chart review was done and data was collected pre-operatively, and post-operatively at six weeks and three months. A total of 32 and 26 patients were included in the two-incision and RCTR groups respectively. At six weeks, the RCTR group showed an increased grip strength (+32.24%) while the two-incision group was weaker (-6.75%). Both groups showed an increased strength at three months, RCTR at 98.4% while the two-incision group was significantly lower at 38.6% increase. Both techniques provided improvement in outcome scores, with no statistical difference. RCTR was associated with a significantly earlier return of grip strength and had better grip strength at six weeks and three months post-operatively. Both techniques provided symptom relief and good functional outcome.

Ulnar tunnel syndrome.

Ulnar neuropathy at or distal to the wrist, the so-called ulnar tunnel syndrome, is an uncommon but well-described condition. However, diagnosis of ulnar tunnel syndrome can be difficult. Paresthesias may be nonspecific or related to coexisting pathologies, such as carpal tunnel syndrome, cubital tunnel syndrome, thoracic outlet syndrome, C8-T1 radiculopathy, or peripheral neuropathy, which makes accurate diagnosis challenging. The advances in electrodiagnosis, ultrasonography, computed tomography, and magnetic resonance imaging have improved the diagnostic accuracy. This article offers an updated view of ulnar tunnel syndrome as well as its etiologies, diagnoses, and treatments.

Experience of a Brazilian surgeon in a hand transplant case: "What I saw, what I learned" / Experiência de um cirurgião brasileiro em cirurgia de transplante de mão: "O que vi, o que aprendi"

The Louisville VCA (Vascularized Composite Allograft) Program is one of the largest hand transplant programs in the world. During my hand surgery fellowship at the Christine M. Kleinert Institute, the team performed the eighth hand transplant on the seventh recipient in Louisville. The Louisville VCA Program has done 9 hand transplants in 8 recipients with one bilateral case. Among these are the first 5 hand transplant cases in the United States. The first case was done in 1999 and has the World's longest follow-up. The seventh case was performed in a 36-year-old male on July 10, 2011. The result achieved so far can be considered excellent with a very good patient satisfaction. There is a large multidisciplinary team involved in such procedures with all members playing a crucial role for the achievement of the best result possible. The present paper focuses on the surgical procedure for the seventh recipient, which was unique due to the level of amputation of the recipient's hand, with preservation of nerve to the thumb.

O Programa de Enxerto Alográfico Vascularizado Composto (Vascularized Composite Allograft ou VCA Program) de Louisville é um dos maiores de transplante de mão no mundo. Durante o meu fellowship em cirurgia da mão no Christine M. Kleinert Institute, o grupo fez o oitavo transplante de mão no sétimo receptor em Louisville. O VCA Program de Louisville já fez nove transplantes de mão em oito receptores (um caso bilateral). Entre esses estão os primeiros cinco casos de transplante de mão nos Estados Unidos da América. O primeiro foi feito em 1999, o que teve o mais longo seguimento em todo o mundo. O sétimo caso foi feito em um paciente do sexo masculino de 36 anos em 10 de julho de 2011. O resultado obtido até agora pode ser considerado excelente, com ótimo benefício para o paciente. Em um procedimento como esse, existe uma grande equipe multidisciplinar envolvida, cada um tem uma função crucial para o alcance do melhor resultado possível. O presente artigo será focado no procedimento cirúrgico feito no sétimo receptor, que foi considerado um caso especial, por causa do nível da amputação da mão do paciente, com preservação do nervo para o polegar.