Jeffrey Yao

Tumours of the hand

Hand tumours of soft-tissue and bony origin are frequently encountered, and clinicians must be able to distinguish typical benign entities from life-threatening or limb-threatening malignant diseases. In this Review, we present a diagnostic approach to hand tumours and describe selected cancers and their treatments. Soft-tissue tumours include ganglion cysts, giant-cell cancers and fibromas of the tendon sheath, epidermal inclusion cysts, lipomas, vascular lesions, peripheral-nerve tumours, skin cancers, and soft-tissue sarcomas. Bony tumours encompass enchondromas, aneurysmal bone cysts, osteoid osteomas, giant-cell lesions of bone, bone sarcomas, and metastases. We look at rates of recurrence and 5-year survival, and recommendations for adjunct chemotherapy and radiotherapy for malignant lesions.

Early Treatment of Degenerative Arthritis of the Thumb Carpometacarpal Joint

Degenerative arthritis of the thumb carpometacarpal (CMC) joint is a common disorder that may affect anyone but most frequently affects the postmenopausal female population. Because of its high prevalence, the management of the condition has been a popular topic among hand surgeons and therapists worldwide. There are many decisions to consider when devising the appropriate treatment plan for each patient. In particular, early stages of thumb CMC joint arthritis may be treated nonoperatively or with less invasive surgical techniques to relieve symptoms, restore function and strength, stop the progression of the disease, and even potentially reverse the process. This article explores treatment options at the disposal of primary care physicians and hand surgeons for early thumb CMC arthritis.

Arthroscopic Treatment of Triangular Fibrocartilage Wrist Injuries in the Athlete

Background Triangular fibrocartilage (TFC) injuries are an increasingly recognized cause of ulnar-sided wrist pain and can be particularly disabling in the competitive athlete. Previous studies show that arthroscopic debridement or repair can improve symptoms, but the results of arthroscopic treatment of TFC injuries in high-level athletes have not yet been reported. Hypothesis Arthroscopic debridement or repair of wrist TFC injury will allow a high rate of return to full function in the elite athlete. Study Design Case series; Level of evidence, 4. Methods Between 2001 and 2005, 16 competitive athletes (mean age, 23.4 years) with wrist TFC injuries underwent arthroscopic surgery. Repair was performed in unstable tears, and all others underwent debridement alone. Presurgery and post-surgery mini-DASH (Disabilities of the Arm, Shoulder, and Hand) scores were recorded for each athlete through medical record review and clinical evaluation. The mean duration of follow-up was 32.8 months (range, 24-51 months). Results The TFC was repaired in 11 (68.8%) and debrided in 5 (31.3%) patients. The tear was ulnar-sided in 12 (75%), radial-sided in 2 (12.5%), combined radial-ulnar in 1, and central-sided in 1 patient. Mean mini-DASH scores improved from 47.3 (range, 25-65.9) to 0 (all patients) (P =. 002), and the mean mini-DASH sports module improved from 79.7 (range, 68.8-100) to 1.95 (range, 0-18.8) (P =. 002). Return to play averaged 3.3 months (range, 3-7 months). Associated conditions in the 2 patients unable to return to play at 3 months were distal radioulnar joint (DRUJ) instability with ulnar-carpal abutment (n = 1) and extensor carpi ulnaris (ECU) tendinosis (n = 1). Conclusion Arthroscopic debridement or repair of wrist TFC injury provides predictable pain relief and return to play in competitive athletes. Return to play may be delayed in athletes with concomitant ulnar-sided wrist injuries.

The Effect of Suture Coated With Mesenchymal Stem Cells and Bioactive Substrate on Tendon Repair Strength in a Rat Model

PURPOSE Exogenously administered mesenchymal stem cells and bioactive molecules are known to enhance tendon healing. Biomolecules have been successfully delivered using sutures that elute growth factors over time. We sought to evaluate the histologic and biomechanical effect of delivering both cells and bioactive substrates on a suture delivery vehicle in comparison with sutures coated with bioactive substrates alone. METHODS Bone marrow-derived stem cells were harvested from Sprague-Dawley rat femurs. Experimental cell and substrate-coated, coated suture (CS) group sutures were precoated with intercellular cell adhesion molecule 1 and poly-L-lysine and seeded with labeled bone marrow-derived stem cells. Control (substrate-only [SO] coated) group sutures were coated with intercellular cell adhesion molecule 1 and poly-L-lysine only. Using a matched-paired design, bilateral Sprague-Dawley rat Achilles tendons (n = 105 rats) were transected and randomized to CS or SO repairs. Tendons were harvested at 4, 7, 10, 14, and 28 days and subjected to histologic and mechanical assessment. RESULTS Labeled cells were present at repair sites at all time points. The CS suture repairs displayed statistically greater strength compared to SO repairs at 7 days (12.6 ± 5.0 N vs 8.6 ± 3.7 N, respectively) and 10 days (21.2 ± 4.9 N vs 16.4 ± 4.8 N, respectively). There was no significant difference between the strength of CS suture repairs compared with SO repairs at 4 days (8.1 ± 5.1 N vs 6.6 ± 2.3 N, respectively), 14 days (22.8 ± 7.3 N vs 25.1 ± 9.7 N, respectively), and 28 days (40.9 ± 12.4 N vs 34.6 ± 15.0 N, respectively). CONCLUSIONS Bioactive CS sutures enhanced repair strength at 7 to 10 days. There was no significant effect at later stages. CLINICAL RELEVANCE The strength nadir of a tendon repair occurs in the first 2 weeks after surgery. Bioactive suture repair might provide a clinical advantage by jump-starting the repair process during this strength nadir. Improved early strength might, in turn allow earlier unprotected mobilization.

Suture Button Suspensionplasty After Arthroscopic Hemitrapeziectomy for Treatment of Thumb Carpometacarpal Arthritis

A myriad of techniques for reconstruction of the arthritic thumb carpometacarpal joint have been described. In the modern era, there has been a push, driven by both clinicians and patients, for more rapid rehabilitation after these procedures. A majority of the historically described techniques require pinning of the thumb ray for 4 weeks. Suture button placement between the thumb and index ray metacarpals has been shown in biomechanical studies to effectively resist subsidence of the thumb ray. We describe a novel technique of using a suture button for suspensionplasty of the thumb ray after arthroscopic partial trapeziectomy. This technique allows for early mobilization and may offer a potential improvement on current techniques. Early results of use of this technique are encouraging, but well-conducted follow-up studies are necessary.

Suture-Button Suspensionplasty for Thumb Carpometacarpal Arthritis: A Minimum 2-Year Follow-Up

PURPOSE To retrospectively review the results at a minimum of 2 years of suture-button plasty with partial or full trapeziectomy and suture-button suspensionplasty. METHODS We evaluated 21 patients who received suture-button suspensionplasty at least 2 years after surgery. We measured postoperative pinch strength, grip strength, range of motion, and metacarpal height. All patients also completed the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire. RESULTS At an average follow-up of 2.8 ± 0.7 years, the mean Quick Disabilities of the Arm, Shoulder, and Hand score was 10 ± 9. Pinch and grip strengths were 86% and 89% of the contralateral limb, respectively. Average first trapezial height was 74% of the contralateral trapezial height. There were no major complications. CONCLUSIONS The favorable results of the suture-button suspensionplasty procedure confirm its usefulness in treating thumb carpometacarpal arthritis with minimal risk of complications, ineffective fixation, or loss of function. Subjective and objective outcomes measures are similar to previously described techniques. The benefit of this technique results from the implanted nature of the suspensionplasty elements that require no time to heal, so rehabilitation is begun as early as 10 days postoperatively. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Suture button compared with K-wire fixation for maintenance of posttrapeziectomy space height in a cadaver model of lateral pinch.

PURPOSE Hematoma distraction arthroplasty has regained popularity as a treatment for thumb carpometacarpal arthritis with reports of satisfactory results. Our goal was to investigate the use of a suture button device to maintain the posttrapeziectomy space height of the thumb metacarpal. Our hypothesis is that a suture button that suspends the thumb metacarpal from the second metacarpal, when applied to the hematoma distraction arthroplasty technique, would provide subsidence resistance comparable to traditional K-wire fixation. METHODS Ten fresh frozen matched pairs of human cadaveric arms were used. After open trapeziectomy, suspension of the thumb metacarpal was performed with either a 1.4-mm (0.045-inch) K-wire advanced through the base of the thumb metacarpal into the second metacarpal shaft or a suture button device that suspended the thumb metacarpal from the second metacarpal shaft. Cyclic pinch was simulated by using a lateral pinch model previously described and validated. Lateral pinch is simulated by loading the extensor pollicis longus, adductor pollicis, abductor pollicis brevis, and flexor pollicis longus in a 1:5:6:10 ratio. Dynamic pinch is achieved with cyclic unloading of the abductor pollicis brevis, adductor pollicis, and flexor pollicis longus tendons. Measurements were made of the height of excised trapeziums, the distance from the metacarpal base to the scaphoid after trapeziectomy (trapeziectomy space height) at time zero, both loaded and unloaded, and at sequential loading cycles of 1,000, 2,000, 3,000, 4,000, 5,000, and 10,000 cycles. RESULTS Student t-test evaluation showed no significant differences between the groups in initial trapeziectomy space height (p = .10), postfixation trapeziectomy space height (p = .10), or loss of trapeziectomy space height between precycling and after 10,000 cycles (p = .80). CONCLUSIONS Suture button fixation maintains similar posttrapeziectomy space height and prevents subsidence of the thumb metacarpal when compared with K-wire fixation in this model. This technique may allow for earlier range of motion after the hematoma distraction arthroplasty.

The importance of pronator quadratus repair in the treatment of distal radius fractures with volar plating

BackgroundOpen reduction internal fixation (ORIF) of distal radius fractures via a volar approach involves surgical release of the overlying pronator quadratus (PQ) muscle. Complete repair of the PQ, defined as full and stable replacement of the periphery of the PQ back to its original anatomic location, is not always possible upon conclusion of the operation. Postoperative consequences of incomplete PQ repair with regards to range of motion (ROM), grip strength, and complications are not well documented. It was hypothesized that the completeness of PQ repair would yield no significant difference in the postoperative ROM, grip strength, and incidence of complications.MethodsA retrospective review was performed of 110 repairs of distal radius fractures with ORIF via placement of a volar locking plate. The following clinical data were extracted: complete or incomplete PQ repair, patient age, gender, follow-up ROM/grip strength, and incidence of postoperative complications.Results and conclusionsNo significant difference in ROM, grip strength, and postoperative complications was detected between the complete and incomplete PQ repair groups. Complications consisted of two incidences of malunion requiring revision surgery and one occurrence of complex regional pain syndrome. There were no tendon ruptures. No statistical difference in ROM/grip strength or incidence of postoperative complications was detected between the complete and incomplete PQ repair groups. Regardless of the level of injury sustained by the PQ, surgeons should make an effort to cover the distal aspect of the volar plate during closure following distal radius fracture ORIF. Coverage of the distal aspect of the plate with the PQ (at a minimum) provides adequate results in ROM and grip strength, as well as protection against flexor tendon injury.Level of evidenceTherapeutic Level III: Retrospective Comparative Study.

Bioactive Sutures for Tendon Repair: Assessment of a Method of Delivering Pluripotential Embryonic Cells

PURPOSE Pluripotential embryonic cells may be seeded onto sutures intended for tendon repair. These cells may be influenced to adhere to suture material using adhesion substrates, and furthermore, these cells may remain in culture attached to those sutures. These cell-impregnated sutures may be useful for promoting healing of tendon repairs. METHODS Ten-centimeter segments of 4-0 sutures (FiberWire) were coated overnight with 10 microg/mL fibronectin, 10 microg/mL poly-l-lysine, or phosphate-buffered saline. The sutures were placed in dishes and covered with a suspension of C3H10T1/2 cells at concentrations of 1 x 10(6), 2 x 10(6), or 4 x 10(6) cells for 24 hours. The sutures were then placed into low adhesion polypropylene tubes with Dulbeccos modified Eagles medium and 10% fetal bovine serum for 7 days. The presence of viable cells on these sutures was assessed by the colorimetric Alamar blue cell proliferation assay. Spectrophotometry was used to quantify the relative amount of cell proliferation across the experimental groups. The sutures were also visually inspected using phase-contrast light microscopy. RESULTS Our results show that at all seeding densities (1 x 10(6), 2 x 10(6), and 4 x 10(6) cells), the suture segments coated with poly-l-lysine and fibronectin showed a significant increase in C3H10T1/2 cell adhesion. Coating the suture with poly-l-lysine increased the adherent cell number to 17% of the initial seeding concentration compared with 2% for the control. Fibronectin coating increased the number of adherent viable cells present to 6.6%. CONCLUSIONS Pluripotential embryonic cells may be seeded onto sutures, adhere, and survive in culture. Coating sutures with poly-l-lysine and fibronectin offers significant improvement in retention of viable cells. This technique may be a useful adjunct for future tendon healing studies.

Incidence of Failure of Continuous Peripheral Nerve Catheters for Postoperative Analgesia in Upper Extremity Surgery

PURPOSE To explore the incidence of failure of continuous peripheral nerve blockade (CPNB) after upper extremity operations. METHODS Patient data regarding postoperative CPNB were retrospectively obtained from our institutions regional anesthesia database. Documented information on the first postoperative day included pain assessment ratings (numerical verbal pain scale, patient-reported breakthrough pain upon perceived return of sensation, appearance of the catheter site, complications, time of return of sensation, day of return of sensation, residual blockade, patient satisfaction with the block, and whether patient would receive the block again). RESULTS A total of 207 patients received CPNB for postoperative analgesia. The failure rate on the first postoperative day for infraclavicular (133 patients) and supraclavicular (58 patients) CPNB was 19% and 26%, respectively. Interscalene CPNB (16 patients) yielded 3 incidences of failure. No significant difference was found between supraclavicular and infraclavicular block techniques. In addition, no significant differences were found between the incidences of CPNB failures with potentially more painful surgeries involving bone compared with potentially less painful soft tissue procedures. CONCLUSIONS The CPNB technique used for hand surgery postoperative analgesia was associated with nontrivial failure rates. The potential of CPNB failure and resulting breakthrough pain upon recovery from the primary nerve block is important to help establish patient expectations. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.