Emanuels, Andrew

Abstract The purpose of this study was to evaluate the incidence and outcomes of traumatic lunate fractures in a Level I trauma center over a 20-year period. Traumatic lunate fractures are rare, making it difficult to determine their frequency, outcomes, and patterns in clinical practice. A retrospective evaluation of 57 patients was conducted at a single institution from 2000 to 2022. Imaging studies, including radiographs, computed tomography, and magnetic resonance imaging, were reviewed to confirm traumatic etiology and fracture pattern. Fifty-seven lunate fractures met inclusion criteria: 11 were isolated and 46 had associated carpal fractures. Treatment included immobilization in 31 patients and surgery in 26. At a mean follow-up of 20.5 months (range, 2–186), average wrist flexion–extension range of motion was 90 degrees (range, 45–160), and grip strength averaged 26 kg (range, 6–48). Patient-reported outcomes were collected at a mean of 105 months (range, 12–226), with mean scores of 27 for the Disabilities of the Arm, Shoulder, and Hand, 19 for the Patient-Rated Wrist Evaluation, and 77 for the Mayo Wrist Score. Complications included 25 cases of posttraumatic arthritis, 2 cases each of avascular necrosis (AVN), nonunion, and complex regional pain syndrome, and 1 hardware infection. Posttraumatic arthritis was more frequently observed in patients with dorsal intercalated segment instability (DISI), age over 50 years, and displaced fractures. Lunate fractures occur in conjunction with greater arc injuries. Volar pole fractures were the most common fracture type observed. Predictors of long-term osteoarthritis included age over 50 years, DISI deformity, and displaced fractures at the time of diagnosis. Surgical fixation methods resulted in comparable outcomes. Two lunates progressed to AVN, both of which occurred following open operative fixation. Prognostic, Level IV

Summary: Umbilical piercings are popular among young individuals for aesthetic body enhancement. However, umbilical piercings can lead to complications such as infections, hypertrophic scarring, and epithelialized tracts that require surgical intervention. This case report presents a novel, minimally invasive technique using a lacrimal probe and iris scissors under local anesthesia to excise the epithelialized piercing tracts. A 23-year-old patient underwent the procedure, resulting in minimal scarring and high satisfaction at an 11-month follow-up. Compared with the existing methods, this approach ensures complete tract removal while preserving the natural umbilical contour. Given the limited literature, this technique offers an effective solution with excellent cosmetic outcomes.

Summary: Anatomy is a critical component of surgical training; however, traditional resources—such as Netter’s Surgical Anatomy , Gray’s Anatomy , and anatomy applications—often fall short in delivering surgically relevant, 3-dimensional (3D) perspectives of facial anatomy. Although cadaveric dissection remains a valuable teaching tool, its accessibility is limited by cost, ethical concerns, and the lack of structured curricula, making it less feasible for ongoing surgical education. To address these limitations, this article introduced a novel educational approach that integrates 3D photogrammetry and virtual reality technology into the surgical anatomy curriculum for craniofacial and aesthetic surgery. Six fresh cadaveric specimens were meticulously dissected by a plastic surgeon to illustrate the intricate layered anatomy of the face and neck. At each stage of the dissection, a photogrammetry technique was used to capture 360-degree images using 5 digital single-lens reflex cameras alongside a 3D handheld camera. This approach not only ensured high-quality imaging but also facilitated the creation of detailed, lifelike virtual 3D models, enhancing the understanding of facial and neck anatomy within a surgical context. Additionally, we present some technical refinements of the 3D volume renderings to capture precise anatomical details during our dissections. Preliminary results from the use of this technology in anatomy courses and workshops indicated trainee engagement, a clearer grasp of the spatial anatomical relationships, and greater confidence in applying this knowledge to hands-on surgical procedures.

Background: Kienböck disease most frequently affects 1 wrist and rarely occurs bilaterally. The purpose of this study is to describe the natural history and identify risk factors for development of bilateral Kienböck disease. Methods: After institutional review board approval, 350 patients with surgically managed Kienböck disease from 1976 to 2023 were identified. A retrospective review of the electronic medical record was used to collect demographic, clinical, and radiographic information. Two-tailed student t -test was used for continuous variable, and Fisher’s exact test was used for categorical variables with analysis of power. Results: Ten of 350 patients (2.9%) had bilateral disease. The mean age was 45 (range: 14-62) years, and 6 out of 10 patients were female. The mean follow-up time was 47 (range: 9-274) months. Three of the 10 patients were laborers. Antecedent trauma (n = 2), prior corticosteroid injection (n = 1), and concomitant autoimmune disease (n = 1) were rare events. There was no difference in Lichtman Stage comparing the dominant and nondominant hands, and 72.2% of wrists were ulnar negative. This was higher but not significantly different than the unilateral affected comparison cohort (60%). Sufficient power was demonstrated (0.99). Eighteen of 20 wrists were treated operatively. Two cases required operative revision due to progression of disease. Conclusions: The cause of bilateral versus unilateral Kienböck disease remains unclear. Bilateral disease was not associated with a higher incidence of autoimmune disease, systemic corticosteroid use, or exposure to heavy manual labor. However, thrombosis leading to avascular necrosis of the lunate may be influenced by hypercoagulable and inflammatory diseases. Surgeons should maintain a high index of suspicion for bilateral disease in patients with these comorbidities. Routine screening of the contralateral wrist is unjustified if the patient is asymptomatic.

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.

Summary: After a transnasal endoscopic resection of a high-grade adenoid cystic carcinoma that underwent adjuvant chemoradiation, there was delayed recurrence managed by en bloc resection through an open craniofacial approach. Subsequently, the patient developed a chronic nasocranial fistula with secondary infection and bone flap resorption. This resulted in infectious episodes with secondary scalp incisional dehiscence and hardware exposure which required multiple bone debridement procedures, hardware removal, prolonged IV antibiotics, and hyperbaric oxygen treatment. The nasocranial fistula and chronic frontal bone osteomyelitis persisted despite the previous interventions. The patient underwent a frontal bone removal and obliteration of the anterior cranial base fistula with a free vastus lateralis muscle flap. At 4 weeks postoperatively, the intranasal portion of the muscle flap had completely mucosalized. After a 6-week course of IV antibiotics, a secondary cranioplasty using a custom-made poly-ether-ether-ketone implant was performed. The patient remained disease- and infection-free for the duration of follow-up (17 months).