Moran, Steven L.

Introduction: This study investigated the association between capitate morphology and the success rates of non-vascularized bone graft (NVBG) and vascularized bone graft (VBG) operations for scaphoid nonunion. Methods: We retrospectively analysed 213 patients with established scaphoid non-union who underwent either non-vascularized bone graft ( n = 75) or vascularized bone graft ( n = 138). We analysed risk factors, including demographics, medical history, implant type, previous surgery, bone graft donor site and capitate morphology for their association with treatment outcome. We also assessed the relationship between capitate and scaphoid morphology in the uninjured wrists of 31 patients. Results: The overall success rate was 81% for NVBG and 86% for VBG, with no significant difference. For NVBG, Type II capitate, age 40 or older and tobacco use were significant risk factors for failure. For VBG, only previous surgery was a significant risk factor. In uninjured wrists, a Type II capitate was associated with a significantly thinner scaphoid waist and a lower waist index than a Type I capitate. Conclusion: Our study introduces a new radiographic classification of capitate morphology and establishes its significant association with scaphoid morphology. Beyond traditional factors, capitate morphology can help to assess scaphoid morphology and potentially infer vascularity, aiding the selection of the most appropriate bone graft type for treating scaphoid non-union. Level of evidence: III

Background: Myxofibrosarcomas are notoriously highly infiltrative soft-tissue sarcomas, making negative surgical margins difficult to obtain. Recently, vacuum-assisted closure (VAC) is used to delay wound closure until a negative margin has been achieved; however, this can delay care and increase costs. Our institution has historically performed single-stage resections with intraoperative frozen margin analysis and reconstruction in these patients. The purpose of this study is to report the outcomes of this technique. Methods: We reviewed 112 patients (62 males, mean age 70 ± 14 years) with superficial myxofibrosarcoma. Eighty-eight patients received preoperative radiation. All patients underwent surgical resection with intraoperative frozen margin analysis, and the planned reconstruction was performed in a single anesthetic. Results: The 10-year local recurrence-free survival was 90%; positive intraoperative frozen section (HR 7.44, p = 0.004) and final permanent margins (HR 8.53, p = 0.007) were associated with local recurrence. Intraoperative margins were negative in 103 (92%) of patients, 1 of which was positive on final permanent section. There were nine cases of microscopically positive margins, of which seven underwent immediate re-excision to a negative margin. The accuracy of frozen margin assessment for myxofibrosarcoma was between 92.92 and 98.23%. All patients underwent reconstruction at the time of resection, with 19% needing an additional procedure, most commonly due to a wound complication (12%). Conclusions: Multidisciplinary single-stage excision with intraoperative frozen margin assessment and soft-tissue reconstruction yields low rates of local recurrence in patients with superficial myxofibrosarcoma.

AbstractThumb carpometacarpal (CMC) arthritis is a common and sometimes debilitating condition with a variety of surgical treatments. Pyrocarbon thumb CMC hemiarthroplasty is one option, which has demonstrated promise; however, no long-term outcomes have been reported.We performed a retrospective institutional review of 106 primary thumb CMC pyrocarbon hemiarthroplasties with a minimum of 1 year, median 6.1-year follow-up. We analyzed rates of pain relief, reoperation, and implant failure as well as biomechanical, radiographic, and patient-reported outcomes.Pain was significantly decreased after surgery. Radial and palmar abduction were modestly improved postoperatively (increased from 40–50 degrees). Implants showed high rates of radiographic osteolysis (53%) and subsidence (44%). Two-, 5-, and 10-year rates of reoperation (18, 21, 21%) and implant removal (15, 19, and 19%), respectively.Pyrocarbon thumb CMC hemiarthroplasty provides high rates of pain relief and preservation of pinch and grip strength. Patients had modest improvement in radial and palmar abduction; however, hemiarthroplasty was associated with moderate rates of reoperation and implant revision.Therapy Level IV.

Abstract To present our clinical experience with a volar scapholunate (SL) ligament reconstruction using a strip of the long radiolunate ligament. This was a single-institution observational study (2004–2022) of SL ligament injuries with evidence of a torn volar component on arthroscopy that received volar capsulodesis with/without a dorsal repair. The postoperative range of motion (ROM), grip strength, complications, and secondary surgery (e.g., four-corner fusion or total wrist fusion), and radiographic changes were reported. Disabilities of arm, shoulder, and hand/patient-rated wrist evaluation (DASH/PRWE) scores were prospectively collected. Patients were stratified by static versus dynamic/predynamic SL diastasis and by isolated volar versus volar and dorsal ligament injury. Twenty-eight patients (15 females and 13 males) with a mean age of 35.1 years (± 15.7) met the inclusion criteria. The follow-up was 86.3 months (± 53.4; minimum 11 months). Most (26/28) patients were right-handed. The majority (20/28) of the patients presented ≥ 6 weeks postinjury. Few (4/28) used tobacco. Most (20/28) patients had dynamic/predynamic injuries. Postoperatively, the mean pronation/supination was 83 degrees/83 degrees, flexion/extension was 56 degrees/61 degrees, ulnar deviation was 30 degrees, and radial deviation (RD) was 19 degrees (n = 13). The mean grip strength was 78.8% (± 30.4) of the contralateral normal side (n = 14). Except for increased RD in patients with dynamic/predynamic injuries (p = 0.02), there were no other ROM differences. SL widening (>3 mm) postoperatively was observed in 33.3% (2/6) of static versus none of the dynamic/predynamic injuries (p = 0.165). There were only two postoperative complications, both surgical site infections. Two patients had persistent pain and required secondary surgery at a median of 48 months. At 86.9 months, patients reported a mean DASH of 16.4 (± 17.8) and a PRWE of 24.6 (± 23.6), and 78.9% (15/19) returned to prior work. We report long-term functional outcomes after a volar capsulodesis for volar SL injuries. This appears to be a safe procedure with an acceptable complication rate and low disability after 7 years. Most (approximately 79%) patients returned to their previous employment. A larger comparative study will be required to prove superiority to other types of repairs. Level IV, Case series.

Background: The authors present a novel microsurgical model to investigate ischemia-reperfusion (I/R) injury in composite tissue (muscle/skin) using a musculocutaneous flap. I/R was induced in a rodent biceps femoris musculocutaneous flap through collateral ligation and arteriovenous clamping. The authors hypothesized that I/R flaps would show greater tissue damage compared with sham. Methods: Male rats were randomized into I/R ( n = 10) and sham ( n = 9) groups. The I/R group underwent flap elevation, collateral ligation, 3 hours of arteriovenous clamping, followed by reperfusion. The sham group had flap elevation only. Perfusion was monitored using laser-speckle imaging, and flap discoloration was assessed with blinded skin ischemia necrosis scores. Serum and the composite tissue (skin/muscle) were analyzed for injury on postoperative days (PODs) 1 or 3. Results: Clamping reduced perfusion ( P = 0.00), whereas unclamping increased perfusion ( P <0.00). Over time, flaps exposed to I/R were more ischemic (estimate, 0.39; P = 0.02). At POD1, the injury group had higher serum creatine kinase ( P = 0.04) and potassium ( P = 0.00) than the sham group. The injury group had more muscle apoptosis (34.7% versus 5.2%; P = 0.03), myonecrosis (30.3% versus 14.1%; P = 0.04), and inflammation (13.7% versus 4.9%; P = 0.02) than the sham group; myonecrosis and inflammation persisted into POD3. Skin apoptosis and inflammation were similar. Conclusions: This model reliably reproduces I/R injury with a 3-hour ischemic period followed by early reperfusion. Animals subjected to the authors’ technique showed greater tissue damage than the sham group, with muscle being more vulnerable than skin. Serum showed peak muscle injury at 24 hours, and histologic analysis showed myonecrosis and inflammation through 72 hours. This suggests that less than 24 hours’ reperfusion (eg, critical window) may serve as the optimal time for possible intervention. Clinical Relevance Statement: I/R injury is a complex phenomenon affecting vascular composite tissues. The mitochondrial superoxide dismutase may be more specific for I/R injury. There may be a critical window within which to mitigate injury (<24 hours after reperfusion). The authors’ model helps investigate muscle/skin I/R injury.

Background: In Kienböck disease with carpal collapse scaphocapitate fusion (SCF) and proximal row carpectomy (PRC), are mainstays of surgical treatment. This study analyzed objective and patient-reported outcomes after SCF or PRC in laborers versus nonlaborers. Methods: A retrospective cohort study of patients who underwent surgery for Kienböck disease within a single health system from 1976 to 2023 was conducted. Postoperative Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Rated Wrist Evaluation (PRWE) scores were surveyed from the available population. Labor status, grip, ROM, and return to the operating room were collected and radiographs were analyzed. Results: Sixty-four patients underwent PRC, and 78 underwent SCF. Patients with PRC were significantly older than patients with SCF. Mean follow-up was 29 months (SD, 53 months). There was no significant difference in postoperative ROM or relative grip strength between the cohort groups. Laborers who underwent SCF demonstrated the least disability on DASH scores. There was no significant difference in postoperative DASH scores in PRC when comparing laborers versus nonlaborers. In contrast, the DASH and PRWE scores of patients who underwent SCF postoperatively varied between laborers and nonlaborers (mean ± SD, 11.1 ± 13.9 versus 30.5 ± 24.8, P = 0.005; and 17.5 ± 19.4 versus 42.3 ± 31.4, P = 0.024). Patients who underwent SCF had a greater rate of revision surgery compared with the PRC group (22 of 78 versus 6 of 64; P = 0.026). Wrist fusion rates were 19% for SCF compared with 1.6% for PRC ( P = 0.0007). Conclusions: SCF and PRC demonstrated no difference in postoperative ROM and grip based on labor status. Laborers with SCF had the least postoperative disability on DASH; however, SCF was associated with the need for additional surgical intervention and conversion to total wrist arthrodesis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutc, III.

Summary: Computer vision has emerged as a useful technology that may prove capable of facilitating remote clinical examinations in hand surgery. This study’s primary aim is to evaluate the efficacy of computer vision for assessing peripheral motor function and range of motion of the hand for future clinic and telemedicine purposes. Five healthy volunteer subjects (10 hands total) were filmed performing three static hand examinations (“peace sign,” “hitchhiker thumb,” and “OK sign”) as well as apposition. Videos were processed using the proprietary H.AI.ND program based on the MediaPipe API (Google, v0.9.2.1), generating temporal and spatial data for joint angle analysis. The median joint angles determined for each test were compared with their manually derived counterparts to assess accuracy and reliability. The measurements were compared at a population level using Wilcoxon signed rank tests and at the individual video level using interclass correlation analyses. The artificial intelligence–generated angle outputs demonstrated a high level of reliability when compared with manually determined measurements for the 3 clinical positions included in this study. Assessment of compound appositional movement also demonstrated high reliability with time-dependent multijoint evaluation. Goniometric analysis through computer vision applications may provide an easy and reliable alternative for hand evaluation in the normal population for both static and dynamic function. Further study is warranted to evaluate this program’s potential role for diagnostic assessment in the diseased population before and after surgical investigation.

ABSTRACT Long segment losses exceeding 10 cm in the sciatic nerve are challenging in both the reconstructive techniques and optimizing sensory and motor function recovery. This case report and literature review describes our experience of using a pedicled vascularized common peroneal nerve graft to repair a 14‐cm sciatic nerve defect, involving L4 , L5 , and S1 nerve roots. Additionally, we conducted a literature review of various types of nerve autografts for large sciatic nerve defects, summarizing their characteristics and outcomes to aid clinicians in decision‐making and expected results in different scenarios. The patient, a 23‐year‐old female diagnosed with neurofibromatosis type I, underwent R0 tumor resection of the proximal left sciatic nerve due to a malignant peripheral nerve sheath tumor. She received an ipsilateral pedicled vascularized common peroneal nerve graft. The reconstruction included the L4 , L5 , and S1 nerve roots beyond the greater sciatic foramen into the inner pelvis. The patient's postoperative course was uneventful. At the 26‐month follow‐up, she showed MRC grade 4/5 strength in hamstrings with 90°knee flexion and a steady gait pattern. At the 32‐month follow‐up, she could ambulate very well with an ankle‐foot orthosis. The outcomes support the use of a pedicled vascularized common peroneal nerve graft in a single‐staged surgery to restore motor function for large sciatic nerve defects. Our literature review revealed that in cases where sural nerves are insufficient or injured for sciatic nerve reconstruction, the common peroneal nerve is a viable alternative to help patients regain functional independence.

ABSTRACTBackgroundGlenohumeral arthrodesis is a demanding surgical procedure. However, it is an option for reconstruction an oncologic resection, especially for patients in whom the axillary nerve is compromised.MethodsWe reviewed 26 (12 male:14 female) glenohumeral arthrodeses (14 primary:12 revision) following an oncologic resection. The most common method of reconstruction was a free vascularized fibula autograft with a bulk allograft (n = 18). The median follow‐up was 22 years (IQR 19 years).ResultsMedian Musculoskeletal Tumor Society Scores and Toronto Extremity Salvage Scores at final follow‐up were 86% and 80%. MSTS scores were similar in patients receiving arthrodesis for primary versus secondary reconstruction. Fifteen (58%) patients had postoperative complications requiring reoperation. Most reoperations occurred with‐in the first 5 years postoperative, with two procedures occurring after 10‐years. Three patients were diagnosed with metastatic disease, one of which also had a local recurrence.ConclusionGlenohumeral arthrodesis provides satisfactory long‐term outcomes for primary and secondary management of shoulder girdle tumors. While early complication rates were high, long‐term complications were rare.

Abstract Rhabdomyolysis following revascularization of the ischemic upper extremity can lead to life- & limb- threatening sequelae. In the context of replantations and vascularized composite allografting, a reconstructive procedure usually reserved for upper limb amputees, prolonged tissue ischemia is detrimental to extremity functional recovery. Currently, validated survival small animal models of extremity reperfusion injury that permit longitudinal assessment of limb function are lacking. To date, studies that evaluated reperfusion injury-induced neuromuscular impairment rely on terminal ex vivo procedures and do not provide clinically translatable measurements. Furthermore, it is unclear if upper extremity musculature exhibits a different ischemic threshold compared to the lower limb given the relatively rare incidence of upper limb ischemia. Here, we present a reliable rat model of extremity post-reperfusion syndrome (PRS) that comprehensively recapitulates the biochemical hallmarks of rhabdomyolysis secondary to upper extremity reperfusion injury and allows for monitoring in vivo upper limb function using clinically relevant electrodiagnostic and kinematic metrics. In addition to inducing severe metabolic derangements, our forelimb PRS provided insights on gross motor and electrophysiological alterations upper extremity reperfusion injury. We identify gait coordination parameters such as stride frequency and forelimb-hindlimb coordination index and electrophysiological metrics including compound muscle action potential amplitude as objective, non-invasive outcome measures for limb function assessment in small animal models of extremity PRS. This comprehensive, validated functional model can serve as an invaluable tool to evaluate therapeutics or preconditioning regimens to attenuate PRS and mitigate resulting neuromuscular dysfunction.