Scott F.M. Duncan

Biomechanics of the hand.

By understanding the biomechanical motions that allow the hand to function effectively and how patients used the hand before their injury, the surgeon can best determine which surgical method is most suited to prevent permanent loss of function and significant impairment. The objective of this article is to discuss the biomechanics of the hand and, particularly, to assess the range of biomechanical motions that account for most of the hand functions and to determine the value of each function and which specific surgical procedures best restore the optimum function of the hand.

Prevalence of Pulmonary Embolism After Total Elbow Arthroplasty

BACKGROUND Although numerous articles have addressed the risk of pulmonary embolism following total knee and total hip arthroplasty, we were unable to find comparable information for the risk following elbow arthroplasty. We therefore sought to determine the prevalence of pulmonary embolism after total elbow arthroplasty. METHODS We conducted a retrospective review of the medical records of consecutive patients who had undergone primary elbow arthroplasty (816 procedures) or revision total elbow arthroplasty (260 procedures) at our tertiary-care academic medical institution between June 1981 and June 2001. Our purpose was to identify all patients in whom a pulmonary embolism developed after the surgery. RESULTS Three patients had a pulmonary embolism and one died as a result of the complication during the twenty-year study period. Because of a low index of suspicion, the presenting symptoms of the pulmonary embolus were originally attributed to other causes of respiratory distress in two of the three patients. CONCLUSIONS These findings suggest that pulmonary embolism after total elbow arthroplasty is a rare but potentially fatal complication. Surgeons should consider this diagnosis when a patient exhibits respiratory distress after total elbow arthroplasty.

The volar approach to proximal interphalangeal joint arthroplasty.

Proximal interphalangeal joint arthroplasty has resulted in good outcomes in patients treated for osteoarthritis, posttraumatic arthritis, and rheumatoid arthritis. Most hand surgeons complete arthroplasties of the proximal interphalangeal joint through a dorsal approach. However, for the past 7 years, we have had positive results with a volar approach. We describe this technique, which avoids injury to the extensor tendon and allows for a more simplified approach to postoperative therapy compared with the therapy regimen required after the dorsal approach.

A MODIFIED TENSION BAND WIRING TECHNIQUE FOR TREATMENT OF THE BONY MALLET FINGER

PURPOSE To report the outcomes of mallet fractures treated with our modified tension band wiring technique. METHODS Eleven men and two women (mean age; 33 years) with mallet fractures in which happened more than five weeks before surgery, or with fracture fragments involving more than 2/3 or less than 1/3 of the distal phalanx articular surface or with previous surgical intervention, were subjected to this study. The fracture fragment was fixed with a modified tension band wiring technique using a stainless steel wire and an injection needle. RESULTS All patients achieved bone union in nine weeks in average. All patients had no pain except one with mild pain. No patient showed a gap or step-off greater than 1 mm. CONCLUSIONS Our tension band wiring technique can be used regardless of the size of the dorsal fracture fragment or the interval between injury and surgery.

Reverse Radial Forearm Fascial Flap With Radial Artery Preservation

The reverse radial forearm fascial (RRFF) flap is widely used in soft-tissue reconstruction of the hand. The traditional RRFF flap incorporates the radial artery from the forearm and is perfused by retrograde flow through the palmar arch. In patients with an abnormal Allen test because of an incomplete palmar arch, the traditional RRFF flap is contraindicated unless a vein graft is used to reconstruct the radial artery. A simpler alternative approach for hand reconstruction in such patients is a distally based RRFF flap based on radial artery perforators, which preserves the radial artery. We used RRFF flaps based on radial artery perforators in five patients who had palmar or dorsal soft-tissue loss. All five recovered full hand function, and only one had any complications (full-thickness skin graft loss at recipient site). The RRFF flap based on distal radial artery perforators is suitable for thin coverage of soft-tissue defects in hands with either a complete or an incomplete palmar arch.

Volar Capsulodesis of the Thumb Metacarpophalangeal Joint at the Time of Basal Joint Arthroplasty: A Surgical Technique Using Suture Anchors

PURPOSE To document the long-term results of our volar metacarpophalangeal (MCP) joint capsulodesis technique that is completed concomitantly with basal joint arthroplasty and involves a suture anchor placement, short-term pinning, and a rigid hand therapy protocol. METHODS We conducted a retrospective chart review to examine results over a 30-month period of our volar capsulodesis technique. Follow-up results were recorded 26 to 48 months after surgery. The treatment regimen included suture anchors, joint pinning for 6 weeks, and a strict hand therapy protocol. Indications for surgery were thumb MCP joint hyperextension deformity of at least 30° and radiographic evidence of stage 3 (or greater) basal joint arthritis. We examined preoperative and postoperative range of motion, pain, pinch strength, and complications. Average patient age was 63 years (range, 55-77 y). We treated 14 thumbs in 14 patients. RESULTS After capsulodesis, average range of motion for the MCP joint of the thumb was 4° extension and 46° flexion. The last follow-up indicated no cases of hyperextension contracture. Complications included one superficial pin track infection (treated with oral antibiotics) and one patients report of pain at the thumb MCP joint. CONCLUSIONS When completed as described, thumb MCP joint capsulodesis performed concurrently with trapeziometacarpal arthroplasty can be a straightforward procedure that produces positive results. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Latissimus dorsi tendon transfer for massive, irreparable posterosuperior rotator cuff tears: surgical technique.

Massive rotator cuff tears remain a complex and challenging problem for both the patient and the surgeon. Although significant advancements in surgical techniques as well as technology for arthroscopic and mini-open rotator cuff repairs have been made, many massive tears result in failed repair with continued progressive tendon retraction and degeneration. In cases when primary tendon to bone healing is impractical, latissimus dorsi tendon transfer provides promising and reproducible clinical results. Herein, we present a latissimus tendon transfer surgical technique, a procedure we have used as a salvage operation for failed arthroscopic/mini-open primary rotator cuff repair.

Recurrent Synovial Chondromatosis of the Distal Interphalangeal Joint: Case Report

A 59-year-old woman presented with recurrent synovial chondromatosis of the distal interphalangeal joint at the site of removal of what was thought to be a ganglion cyst in 2003 and the subsequent excision of a recurrent synovial chondromatosis in 2005. Although synovial chondromatosis is typically described as a benign, self-limiting process, recurrent disease and local erosion of the joint of this patient required wide excision with bone grafting and arthrodesis for definitive treatment.

Radius Neck–to–Humerus Trochlea Transposition for Elbow Reconstruction After Resection of the Proximal Ulna: Report of 2 Cases

The structural and functional deficit created after wide excision of the proximal ulna for malignant bone tumors presents a difficult reconstructive challenge. The purpose of our report was to retrospectively review the outcome of the radius neck-to-humerus trochlea transposition after wide resection of malignant forearm tumors in 2 patients. Good function was obtained using this surgical technique. This surgical option provides a durable biologic solution to a complex reconstructive problem.

Distal peripheral nerve blockade for patients undergoing hand surgery: a pilot study.

BackgroundData are limited regarding the use of peripheral nerve blockade at the level of the forearm, and most studies regard these procedures as rescue techniques for failed or incomplete blocks. The purpose of the study was to investigate patients undergoing hand surgery with distal peripheral nerve (forearm) blocks and compare them with patients having similar procedures under more proximal brachial plexus blockade. No investigations comparing distal nerve blockade to proximal approaches are currently reported in the literature.MethodsMedical records were retrospectively reviewed for patients who had undergone hand surgery with a peripheral nerve block between November 2012 and October 2013. The primary outcome was the ability to provide a primary anesthetic without the need for general anesthesia or local anesthetic supplementation by the surgical team. Secondary outcome measures included narcotic administration during the block and intraoperative procedures, block performance times, and the need for rescue analgesics in the post anesthesia care unit (PACU).ResultsNo statistical difference in conversion rates to general anesthesia was observed between the two groups. Total opiate administration for the block and surgical procedure was lower in the forearm block group. There was no difference in block performance times or need for rescue analgesics in the PACU.ConclusionsForearm blocks are viable alternatives to proximal blockade and are effective as a primary anesthetic technique in patients undergoing hand surgery. Compared to the more proximal approaches, these blocks have the benefits of not causing respiratory compromise, the ability to be performed bilaterally, and may be safer in anticoagulated patients.