Duretti T. Fufa

Digit Replantation: Experience of Two U.S. Academic Level-I Trauma Centers

BACKGROUND Despite advances in microsurgery, digit replantation now is performed less frequently in the U.S. compared with fifteen years ago. There has been uncertainty regarding whether previously reported U.S. replantation success rates and results reported from other countries reflect the current experience in the U.S. We hypothesized that the success of digit replantation at two academic level-I referral hospitals in the U.S. would be similar to previously published results. METHODS In this retrospective case series, we examined all cases of digit replantation that were performed from 1997 through 2010 at two institutions. The cumulative rate of viable digit replantations was determined. Binary logistic regression modeling determined the relative impact of patient, injury, and operative factors on replantation survival. RESULTS During the study period, 135 digit replantations were performed in 106 patients. Fourteen cases did not meet our inclusion criteria, yielding a cohort of 121 replantations. The thumb (n = 40) was the most commonly replanted digit, followed by the long finger (n = 31). The mechanism of injury was classified as sharp in eighty-three digits, crush in nineteen digits, and avulsion in eighteen digits. The majority of replantations were performed following Tamai level-III (n = 49) or level-IV (n = 56) amputations. Sixty-nine (57%) of the digit replantation procedures were successful. Logistic regression analysis identified replantation of the radial three digits and no history of tobacco use as significant independent predictors of replantation success. CONCLUSIONS The rate of success of digit replantation (57%) at two academic level-I trauma hospitals was lower than previously published rates. Radial-digit involvement and no prior tobacco use were associated with replantation success. This modest success rate reflects a need for additional evaluation of our current benchmarks and clinical settings for replantation surgery. These data help to better inform patients, families, and physicians who are considering digit replantation.

Sports injuries of the wrist

Sports injuries involving the hand and wrist are common and, as a result, many different practitioners (athletic trainers, physical therapists, primary care physicians, general orthopedic surgeons) will encounter these injuries. In addition to thorough evaluation, an understanding of typical pathologies seen in the athlete enhances diagnosis and facilitates appropriate, expedient management. These injuries are complex because they can be either acute traumatic or repetitive in origin and often involve both the bony skeleton and soft tissues. This article provides a review of athletic injuries to the wrist with particular focus on physical evaluation and management of the most common and challenging fractures and soft tissue injuries.

The effect of core and epitendinous suture modifications on repair of intrasynovial flexor tendons in an in-vivo canine model

PURPOSE To determine in vivo effects of modifications to core and epitendinous suture techniques in a canine intrasynovial flexor tendon repair model using clinically relevant rehabilitation. Our null hypothesis was that gap formation and rupture rates would remain consistent across repair techniques. METHODS We evaluated gap formation and rupture in 75 adult mongrel dogs that underwent repair of intrasynovial flexor tendon lacerations followed by standardized postoperative therapy. The current suture technique was a 4-0, 8-strand core suture with a purchase of 1.2 cm and a 5-0, epitendinous suture repair with a 2-mm purchase length and depth. We compared gap and failure by chi-square analysis to a historical group of in vivo repairs (n = 76) from the same canine model using 8-strand core suture repair with purchase of 0.75 cm and 6-0 epitendinous suture with a 1-mm purchase length and depth. RESULTS A total of 93% of tendons (n = 70) demonstrated gapping of less than 3 mm using the current suture technique. Five percent of tendons (n = 4) had a gap of 3 mm or greater, and there was 1 repair site failure. This was significantly improved over the comparison group of historical 8-strand core repair technique, which resulted in 82% (n = 62) of repairs with a gap of less than 3 mm and 7 failures (9%). CONCLUSIONS In an in vivo model, current modifications to suture techniques for intrasynovial flexor tendon repair demonstrated significant improvements in gap formation and rupture compared with a similar technique using shorter purchase lengths and shallower purchase depth. CLINICAL RELEVANCE Suggested repair modifications for the treatment of zone II flexor tendon transections demonstrate improvements in gap formation and tendon rupture in vivo.

Fractures of the Thumb and Finger Metacarpals in Athletes

Most metacarpal fractures are minimally displaced and are treated without surgery. Markedly displaced fractures, fractures causing finger rotation, and displaced intra-articular fractures require surgical intervention. The challenge with the elite athlete is achieving an early return to play without compromising fracture position. Casts, splints, and surgery each have a role in getting the athlete back into action as soon as possible.

Postburn Contractures of the Hand

Several functionally limiting sequelae can follow deep thermal injury to the hand. Despite appropriate initial management, contractures are common. Whereas acute burn care is often managed by multidisciplinary, specialized burn units, postburn contractures may be referred to hand surgeons, who should be familiar with the patterns of burn contracture and nonsurgical and operative options to improve function and expected outcomes. The most common and functionally limiting sequelae are contractures of the webspace, hand, and digits. Webspace contractures and postburn syndactyly are managed with scar excision and local soft tissue rearrangement or skin grafting. The burn claw hand presents as extension contracture of the metacarpophalangeal joints and flexion contractures of the proximal interphalangeal joints. The mainstays of management of these contractures include complete surgical excision of scar tissue and resurfacing of the resultant soft tissue defect, most commonly with full-thickness skin grafts. If scar contracture release results in major exposure of the tendons or joints, distant tissue transfer may be required. Early motion and rehabilitative modalities are essential to prevent initial contracture formation and recontracture after surgical release.

Epidemiology of Carpal Tunnel Syndrome in Patients With Single Versus Multiple Trigger Digits

PURPOSE Previous studies have identified the association between trigger digit and carpal tunnel syndrome (CTS). However, whether the presence of multiple trigger digits affects the prevalence of CTS is unknown. The purpose of this study was to determine the incidence of carpal tunnel symptoms in patients treated for single versus multiple trigger digits. METHODS We performed a retrospective review of 300 patients treated for trigger digit by injection or surgical release and recorded CTS symptoms, signs, and treatment for either the ipsilateral or contralateral hand documented within 24 months before trigger digit treatment and for an average of 35 months (range, 7- 66 mo) after treatment. Patients were categorized as having single (n = 160) or multiple (n = 140) trigger digits. Binary logistic regression modeled risk factors for development of CTS. Patient age, sex, number of trigger digits (single or multiple), and presence of diabetes, gout, thyroid disease, or thumb osteoarthritis were considered independent variables. RESULTS A total of 58 of 140 patients (41%) who presented with multiple trigger digits exhibited concomitant carpal tunnel symptoms, compared with 26 of 160 (16%) patients who presented with a single trigger digit. Significant independent predictors of CTS associated with trigger digits in the final regression model included multiple trigger digits (odds ratio = 3.6; subjects with multiple trigger digits had significantly higher odds of carpal tunnel presentation than subjects with a single trigger digit) and diabetes (odds ratio = 1.9; diabetic subjects had significantly higher odds of carpal tunnel presentation than nondiabetics). CONCLUSIONS A greater than 3-fold increase in the relative risk of CTS development exists in patients undergoing treatment for multiple trigger digits, compared with those undergoing treatment for a single trigger digit. Awareness of this association may aid in the early diagnosis and treatment of CTS in patients presenting with multiple trigger digits. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic III.

Management of infraclavicular (Chuang Level IV) brachial plexus injuries: A single surgeon experience with 75 cases

Infraclavicular brachial plexus injuries (Level IV in Chuang’s classification) have special characteristics, including high incidences of associated scapular fractures, glenohumeral dislocations, and vascular injuries. In addition, there are specific difficulties in surgical dissection and nerve repairs, especially if surgery is delayed (>3 months). A total of 153 patients with Level IV brachial plexus injuries underwent surgery between 1987 and 2008 with 75 patients (average age 29 years) available for a minimum of 4 years follow-up. Accompanying fractures/dislocations were suffered by 48 (64%) patients, and 17 (23%) had associated vascular injuries. The most common nerves to be injured were the axillary and musculocutaneous nerves. Nerve grafts to the axillary, musculocutaneous, and radial nerves achieved impressive results, but less reliable outcomes were achieved with the median and ulnar nerves. Decompression and/or external neurolysis were also beneficial for nerve recovery. Some surgical tips are presented, and the use of the C-loop vascularized ulnar nerve graft and functioning muscle transfers are discussed. Level of Evidence: IV

Prevention and surgical management of postburn contractures of the hand.

In addition to burn surgeons, skilled nurses, and therapists, hand surgeons are a key part of the multidisciplinary team caring for patients following thermal injury to the hand. Despite appropriate initial treatment and compressive therapy, contractures are common after deep burn. The most common and functionally limiting are web space and hand contractures. Web space contractures can be managed with excision followed by local soft tissue rearrangement or skin grafting. The classic burn claw hand deformity includes extension contracture of the metacarpophalangeal joints and flexion contractures of the proximal interphalangeal joints. The mainstay of management of these postburn contractures includes complete surgical release of scar tissue and replacement by full-thickness skin graft. In cases in which scar contracture release results in major exposure of the tendons or joints, distant tissue transfer is required. This review focuses on prevention and management of late sequelae of thermal injury to the hand focusing on contractures of the webspaces and hand.

Secondary reconstructive surgery following major upper extremity replantation.

Background: Little literature currently exists on reconstructive strategies following successful upper extremity replantation. The authors hypothesized that the type of secondary surgery would vary predictably depending on mechanism and amputation level. Methods: The authors performed a retrospective review of upper extremity replantations performed at their institution between 2003 and 2012. The mean follow-up period was 3 years. Patient, injury, and surgical demographics, as well as replantation survival rates and secondary surgical procedures, were recorded. Results: Forty-five upper extremity replantations met inclusion criteria and the survival rate was 89 percent (n = 40). In 40 cases of successful replantation, the average number of secondary surgical procedures was three per patient (range, zero to seven). The most common reconstructive procedures were soft-tissue coverage (n = 24), tenolysis (n = 24), free functioning muscle transfer (n = 18), and tendon transfer (n = 14). For upper arm replantations, soft-tissue coverage was the most common secondary surgery; free functioning muscle transfer was the most common for amputations between the elbow and mid-forearm; tenolysis was the most common secondary procedure performed for amputations of the distal forearm to wrist. Conclusions: Proximal-level amputations commonly required soft-tissue coverage. Amputations through the proximal forearm and elbow often underwent free functioning muscle transfer, and tenolysis was the most common secondary surgery following distal forearm and wrist amputations. Secondary surgery could be predicted based on the anatomic levels of injury.

Hinged external fixator placement at the elbow: navigated versus conventional technique

Introduction: During the application of a hinged external elbow fixator, exact placement of the central pin remains difficult. Proper placement often necessitates multiple drilling attempts and fluoroscopic localization, which can be time consuming. We hypothesized that use of computerized navigation would enable a more precise placement of the central axis pin and would reduce the total number of drilling attempts. Materials and Methods: Twelve elbow models incorporating soft tissue coverage were used in this study. First, the optimal placement trajectory (OPJ) of the axis pin was defined in the anterior-posterior (AP) and lateral planes of the elbow. Six elbows were used with the navigation system and the axis pin was inserted in combination with a conventional fluoroscopy system under constant two-dimensional guidance from the virtual images. The pins for the remaining six elbow specimens were implanted conventionally under fluoroscopic guidance. The distances and angular deviations from the OPJ position were measured, and the results for the conventional placement and computer navigation groups were compared. To determine the definitive axis pin placement, a CT scan of each elbow with 1-mm slice thickness was used and the results were measured based on the defined optimal pin placement. AP plane angulations and lateral plane distances were calculated in relation to the optimal insertion trajectory for each specimen. Finally, we counted the overall number of drilling attempts needed to find the optimal position for the axis pin. Results: For the AP angulations, of the six elbows implanted using the conventional technique, half (n = 3) had deviations of ≥20° from the optimal axis. In contrast, in the navigated group, all cases (n = 6) were within 20° of the optimal axis in the AP plane. The mean AP angulation deviation in the conventional group was 20.5°, compared to 15° in the navigation group (p = 0.077). For the lateral distances, the mean distance from the drilling point to the point of optimal placement was 3.83 mm in the conventional group, versus 1.83 mm in the navigation group (p = 0.042). For all navigated cases, only one drilling attempt was necessary to achieve the desired position of the axial pin. Conclusion: Compared with the conventional method of axis pin placement for an elbow fixator, two-dimensional navigation allows a reduction in the number of drilling attempts required. Furthermore, the accuracy in terms of AP angulation and lateral distance from a defined optimal placement is better when compared to that obtained with the conventional technique.