Warren C. Hammert

Impact of Smad3 loss of function on scarring and adhesion formation during tendon healing.

Studies were performed evaluating the role of Smad3, a transcription factor mediating canonical TGF‐β signaling, on scarring and adhesion formation using an established flexor digitorum longus (FDL) tendon repair model. In unoperated animals the metatarsophalangeal (MTP) range of motion (ROM) was similar in Smad3−/− and wild‐type (WT) mice while the basal tensile strength of Smad3−/− tendons was significantly (39%) lower than in WT controls. At 14 and 21 days following repair Smad3−/− MTP ROM reached approximately 50% of the basal level and was twice that observed in WT tendon repairs, consistent with reduced adhesion formation. Smad3−/− and WT maximal tensile repair strength on post‐operative day 14 was similar. However, Smad3−/− tendon repairs maximal tensile strength on day 21 was 42% lower than observed in matched WT mice, mimicking the relative decrease in strength observed in Smad3−/− FDL tendons under basal conditions. Histology showed reduced “healing callus” in Smad3−/− tendons while quantitative PCR, in situ hybridization, and immunohistochemistry showed decreased col3a1 and col1a1 and increased MMP9 gene and protein expression in repaired Smad3−/− tendons. Thus, Smad3−/− mice have reduced collagen and increased MMP9 gene and protein expression and decreased scarring following tendon FDL tendon repair.

Non-surgical treatment of lateral epicondylitis: a systematic review of randomized controlled trials.

BackgroundNon-surgical approaches to treatment of lateral epicondylitis are numerous. The aim of this systematic review is to examine randomized, controlled trials of these treatments.MethodsNumerous databases were systematically searched from earliest records to February 2013. Search terms included “lateral epicondylitis,” “lateral elbow pain,” “tennis elbow,” “lateral epicondylalgia,” and “elbow tendinopathy” combined with “randomized controlled trial.” Two reviewers examined the literature for eligibility via article abstract and full text.ResultsFifty-eight articles met eligibility criteria: (1) a target population of patients with symptoms of lateral epicondylitis; (2) evaluation of treatment of lateral epicondylitis with the following non-surgical techniques: corticosteroid injection, injection technique, iontophoresis, botulinum toxin A injection, prolotherapy, platelet-rich plasma or autologous blood injection, bracing, physical therapy, shockwave therapy, or laser therapy; and (3) a randomized controlled trial design. Lateral epicondylitis is a condition that is usually self-limited. There may be a short-term pain relief advantage found with the application of corticosteroids, but no demonstrable long-term pain relief. Injection of botulinum toxin A and prolotherapy are superior to placebo but not to corticosteroids, and botulinum toxin A is likely to produce concomitant extensor weakness. Platelet-rich plasma or autologous blood injections have been found to be both more and less effective than corticosteroid injections. Non-invasive treatment methods such as bracing, physical therapy, and extracorporeal shockwave therapy do not appear to provide definitive benefit regarding pain relief. Some studies of low-level laser therapy show superiority to placebo whereas others do not.ConclusionsThere are multiple randomized controlled trials for non-surgical management of lateral epicondylitis, but the existing literature does not provide conclusive evidence that there is one preferred method of non-surgical treatment for this condition. Lateral epicondylitis is a condition that is usually self-limited, resolving over a 12- to 18-month period without treatment.Level of EvidenceTherapeutic Level II. See Instructions to Authors for a complete description of level of evidence.

An outcome study for ulnar neuropathy at the elbow: A multicenter study by the surgery for ulnar nerve (SUN) study group

BACKGROUND Many instruments have been developed to measure upper extremity disability, but few have been applied to ulnar neuropathy at the elbow (UNE). OBJECTIVE We measured patient outcomes following ulnar nerve decompression to (1) identify the most appropriate outcomes tools for UNE and (2) to describe outcomes following ulnar nerve decompression. METHODS Thirty-nine patients from 5 centers were followed prospectively after nerve decompression. Outcomes were measured preoperatively and at 6 weeks, 3 months, 6 months, and 12 months postoperatively. Each patient completed the Michigan Hand Questionnaire (MHQ), Carpal Tunnel Questionnaire (CTQ), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires. Grip, key-pinch strength, Semmes-Weinstein monofilament, and 2-point discrimination were measured. Construct validity was calculated by using Spearman correlation coefficients between questionnaire scores and physical and sensory measures. Responsiveness was assessed by standardized response means. RESULTS Key-pinch (P = .008) and Semmes-Weinstein monofilament testing of the ulnar ring (P < .001) and small finger (radial: P = .004; ulnar: P < .001) improved following decompression. Two-point discrimination improved significantly across the radial (P = .009) and ulnar (P = .007) small finger. Improved symptoms and function were noted by the CTQ (preoperative CTQ symptom score 2.73 vs 1.90 postoperatively, P < .001), DASH (P < .001), and MHQ: function (P < .001), activities of daily living (P = .003), work (P = .006), pain (P < .001), and satisfaction (P < .001). All surveys demonstrated strong construct validity, defined by correlation with functional outcomes, but MHQ and CTQ symptom instruments demonstrated the highest responsiveness. CONCLUSION Patient-reported outcomes improve following ulnar nerve decompression, including pain, function, and satisfaction. The MHQ and CTQ are more responsive than the DASH for isolated UNE treated with decompression.

Current concepts in the evaluation and treatment of mallet finger injury.

Summary: The mallet finger is a frequently encountered fingertip injury that leads to extensor lag of the distal phalanx. Classification systems stratify these injuries as ranging from soft-tissue disruption of the extensor mechanism alone to those that have articular involvement and volar subluxation. The management of mallet finger injuries varies based on injury pattern and surgeon preference. These treatment options include splinting regimens, closed reduction and percutaneous pinning, and open reduction and internal fixation. Although the final goal of treatment is to establish a congruent joint, the efficacy of each treatment modality has been shown to vary.

High-pressure injection injuries in the hand: current treatment concepts.

Background: High-pressure injection injury to the hand and upper extremity is a rare but very serious clinical entity. The objective of this article was to review the current available literature and highlight important topics. Methods: A PubMed literature search was undertaken with the terms “high pressure injection injuries,” “injection injuries,” “finger injection injuries,” and other related terms. Articles were reviewed with specific attention to clinical presentation, treatment, outcome, and prognostic variables. Results: Most of the available literature included case studies, case series, retrospective cohorts, and literature reviews. The most common presentation of a high-pressure injection injury is a puncture wound on the nondominant index finger of a working class man in his mid thirties. Important factors at presentation include the time of injury and type and pressure of material injected. Initial treatment should include tetanus prophylaxis, broad-spectrum antibiotics, and urgent consultation with a hand surgeon. Injections with air, gas, or small amounts of veterinary vaccines can usually be managed with observation and serial examinations if there is not concern for compartment syndrome. Injections with other liquid materials typically require emergent surgical débridement, with the best outcomes occurring when treated within 6 hours. A wide surgical irrigation and débridement of necrotic tissues should be performed under general or regional anesthesia. Organic and caustic materials are associated with a higher amputation rate, and decreasing the time from injury to surgery improves the prognosis. Conclusions: High-pressure injection injuries to the hand can result in permanent impairment. Proper diagnosis and urgent treatment are essential for a good outcome.

Lessons learned reconstructing complex scalp defects using free flaps and a cranioplasty in one stage

Background: The purpose of this study was to review our experience in single-stage reconstruction of skull and scalp defects, aiming to highlight pitfalls in our management. Methods: We performed a retrospective chart review of all patients who had a single-stage cranioplasty and free-tissue transfer at our institution over the last 10 years. Thirteen patients (9 men and 4 women) with an average age of 66.5 years (range, 34-83 years) were identified. Etiology of the defects included malignancy (n = 7), osteoradionecrosis (n = 3), and infection (n = 3). The size of the bony defect averaged 103.1 cm2 (range, 12-300 cm2). Cranioplasty procedures included reconstruction by methylmethacrylate and titanium mesh (n = 10), methylmethacrylate only (n = 1), or mesh only (n = 2). Free flaps used were anterolateral thigh (n = 10), latissimus dorsi (n = 2), or a rectus flap (n = 1). Results: Five patients (38%) developed at least 1 complication. These included 2 anastomotic problems that were successfully salvaged, 5 cases of wound dehiscence, and 1 mortality due to a respiratory event. Four patients developed a recurrence, and 2 patients required flap contouring at a second stage. Two patients had further reconstruction using 1 (1 patient) or 2 (1 patient) additional free flaps. Conclusions: Given the complexity of these procedures, the high recurrence rate, and the likelihood of complications, methylmethacrylate is contraindicated in 1-stage cranioplasty and soft-tissue reconstruction in high-risk patients. For unfavorable local conditions (eg previous infection, radiotherapy), the surgeon can either postpone the cranioplasty until the soft-tissue reconstruction has healed, or use a nonanatomical titanium mesh alone. The soft-tissue flap should be harvested of larger dimensions than anticipated.

Current trends in the management of proximal interphalangeal joint injuries of the hand.

Summary: Injuries to the proximal interphalangeal joint are commonly encountered by the hand surgeon. Proper diagnosis and treatment are vital for optimal outcomes. Proper treatment of these injuries requires a working knowledge of the anatomy of the joint and an appreciation for principles for reduction, stabilization, and early rehabilitation to provide the best outcomes possible. Injuries can include fractures of the head of the proximal phalanx, dislocations, fracture dislocations, and fractures of the base of the middle phalanx. Similar to other aspects of plastic surgery, there is little high-level evidence guiding treatment and thus most treatment is based on level III or IV evidence. The goal for treatment of any injury around the proximal interphalangeal joint is to establish a congruent joint and allow for early motion. Stiffness and posttraumatic arthritis are common following these injuries. Salvage procedures are limited to arthrodesis and arthroplasty, neither of which can restore the normal function of the hand.

Trend of recovery after simple decompression for treatment of ulnar neuropathy at the elbow.

Background: Although numerous studies have investigated long-term outcomes after surgical treatment of ulnar neuropathy at the elbow with simple decompression, no study has evaluated the trend of postoperative recovery. The authors assessed timing of recovery after simple decompression for ulnar neuropathy at the elbow. Methods: The five-center Surgery of the Ulnar Nerve Study Group prospectively recruited 58 consecutive subjects with ulnar neuropathy at the elbow and treated them with simple decompression. Patients were evaluated preoperatively and at 6 weeks, 3 months, 6 months, and 1 year postoperatively. Patient-rated outcomes questionnaires included the Michigan Hand Questionnaire; the Disabilities of the Arm, Shoulder and Hand questionnaire; and the Carpal Tunnel Questionnaire. Functional tests used were grip strength, key pinch strength, two-point discrimination, and Semmes-Weinstein monofilament testing. Postoperative improvement was assessed at each time point to establish the trend of recovery in reaching a plateau. Results: Significant patient-reported symptomatic and functional recovery occurred over the first 6 weeks postoperatively as represented by improvements in questionnaire scores. Symptomatic recovery occurred earlier than functional recovery as measured by sensory and strength testing and the work domain of the Michigan Hand Questionnaire. Improvement in patient-reported outcomes continued and reached a plateau at 3 months, whereas measured strength and sensory recovery continued over 12 months. Conclusion: The greatest clinical improvement after simple decompression for ulnar neuropathy at the elbow, according to questionnaire scores, occurs in the first 6 weeks postoperatively and reaches a plateau by 3 months. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

AAOS appropriate use criteria: Treatment of distal radius fractures

Distal radius fractures (DRFs) are common injuries, with an incidence of 643,000 per year in the United States, and therefore have a substantial impact on healthcare expenditures. There are a variety of treatment options, particularly in the adult patient. These injuries can occur as a result of a lowenergy injury, such as a fall from a standing height in an elderly patient, or a high-energy injury, such as a motorcycle accident in a younger patient. There is an increasing trend toward surgical treatment of these injuries, even in the elderly population, despite the fact that, traditionally, it has been felt that these patients would do well even when the fracture heals in a malunited position. Ideally, treatment decisions should be based on high-quality literature, such as studies of level I or II evidence. Unfortunately, there are few randomized clinical trials for treatment of DRF and, thus, decisions are often made based on retrospective case series and clinical experience. The American Academy of Orthopaedic Surgeons (AAOS) approved these appropriate use criteria (AUC) for the treatment of DRFs in an effort to assist the clinician in caring for these injuries and also, in part, because of the lack of high-level evidence supporting the recommendations in the AAOS Clinical Practice Guideline, The Treatment of Distal Radius Fractures: Guideline and Evidence Report. The purpose of the following case studies is to present two clinical scenarios and treatment options. Although each surgeon may have a preferred method for treating a specific injury, many treatment alternatives would be considered appropriate for a given injury. The indications and classification (ie, AO/OTA fracture patterns, American Society of Anesthesiologists [ASA] classification, treatment options) for management of these injuries are discussed in the DRF AUC summary.

Comparison of an All-Inside Suture Technique With Traditional Pull-Out Suture and Suture Anchor Repair Techniques for Flexor Digitorum Profundus Attachment to Bone

PURPOSE One goal in repairing zone 1 flexor digitorum profundus (FDP) injuries is to create a tendon-bone construct strong enough to allow early rehabilitation while minimizing morbidity. This study compares an all-inside suture repair technique biomechanically with pull-out suture and double-suture anchor repairs. METHODS Repairs were performed on 30 cadaver fingers. In all-inside suture repairs (n = 8), the FDP tendon was attached to bone with two 3-0 Ethibond sutures and tied over the dorsal aspect of distal phalanx. Pull-out suture repairs (n = 8) were performed with 2-0 Prolene suture and tied over a dorsal button. There were 2 suture anchor repair groups: Arthrex Micro Corkscrew anchors preloaded with 2-0 FiberWire suture (n = 7) and Depuy Micro Mitek anchors preloaded with 3-0 Orthocord suture (n = 7). Repair constructs were tested using a servohydraulic materials testing system and loaded until the repair lost 75% of its strength. RESULTS There were no statistically significant differences in tensile stiffness, ultimate load, or work to failure between the repairs. Failure mode was suture stretch and gap formation greater than 2 mm at the repair site for all pull-out suture repairs and for 7 of 8 all-inside suture repairs. Two of the Arthrex Micro Corkscrew repairs and 5 of the Depuy Micro Mitek repairs failed by anchor pull-out. CONCLUSIONS This cadaveric biomechanical study showed no difference in tensile stiffness, ultimate load, and work to failures between an all-inside suture repair technique for zone 1 FDP repairs and previously described pull-out suture and suture anchor repair techniques. The all-inside suture technique also has the advantages of avoiding an external button and the cost of anchors. Therefore, it should be considered as an alternative to other techniques. CLINICAL RELEVANCE This study introduces a new FDP reattachment technique that avoids some of the shortcomings of current techniques.