Shin, Alexander Y.

Small proximal pole scaphoid nonunions are challenging to treat. We describe a technique for replacing the proximal pole fragment with an osteochondral autograft transplant harvested from the ipsilateral femoral trochlea. This is indicated in nonunions where the proximal pole fragment is smaller than the scaphoid isthmus; the scapholunate ligament complex is intact on the distal fragment, and in nonunions without dorsal intercalated segment instability and radiocarpal arthritis. The osteochondral autograft transplant is press-fitted into the distal scaphoid and does not require implants for osteointegration. This provides an advantage during revision surgery of previously fixed proximal scaphoid fractures that are not united with an implant in situ.

Background: Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome. The thread carpal tunnel release (TCTR) is an incision-less ultrasound-guided approach to divide the transverse carpal ligament. This retrospective case series aims to identify and assess the bleeding risks associated with continuing anticoagulation or antiplatelet therapy during TCTR. Methods: Retrospective chart review with follow-up questionnaires/surveys. One hundred and fourteen adult patients who were using antiplatelet or anticoagulation medication underwent 164 TCTR procedures during 2018 to 2023 at a single institution (tertiary care hospital) from June 29, 2018, and August 11, 2023. A chart review was performed to identify patients on antiplatelets or anticoagulants at the time of the procedure and to determine if there were any adverse events associated with continuing or holding their antiplatelet or anticoagulant therapy. Results: There were no significant complications associated with continuing or holding anticoagulation or antiplatelet therapy during TCTR. Conclusions: Continuing antiplatelet therapy during TCTR appears safe. The decision to continue antiplatelet or anticoagulation therapy should be made on a case-by-case basis.

Cases: Two patients with spontaneous loss of thumb interphalangeal joint extension were referred after history, electrodiagnostic, and/or magnetic resonance imaging (MRI) findings were felt to demonstrate a posterior interosseous nerve (PIN) palsy. Subsequent physical examination and additional directed studies suggested an alternative explanation: rupture of the extensor pollicis longus (EPL) tendon, subsequently confirmed at surgery. An extensor indicis proprius to EPL transfer restored thumb function. Conclusion: Electrodiagnostic and MRI changes consistent with diffuse PIN palsy may occur in the setting of EPL rupture. An accurate diagnosis of EPL dysfunction requires careful physical examination and confirmatory imaging. Further study of this previously unreported phenomenon is required.

Recent literature has emphasized the role of hand surgeons in screening patients with carpal tunnel syndrome (CTS) for amyloidosis by performing a carpal tunnel synovial biopsy during open carpal tunnel release (CTR). This has led to misconceptions about the diagnostic utility of synovial biopsy and the clinical evaluation of suspected amyloidosis. Controversy over carpal tunnel biopsy is exacerbated by minimally invasive advances in CTR procedures. This current perspective aims to determine the role of carpal tunnel synovial biopsy in amyloidosis and provide an update for hand surgeons regarding the nuances of amyloidosis. We conclude that carpal tunnel synovial biopsy should not be performed without CTS symptoms but only in patients meeting criteria for open CTR such as in those with severe symptoms which have failed nonoperative treatment and minimally invasive procedures are contraindicated. A screening approach for amyloidosis is proposed in patients presenting with CTS symptoms. Despite advances in the understanding, treatment, and diagnosis of amyloidosis, there remains a need for accurate, specific, and sensitive diagnostic tests.

Background: The treatment for Kienböck disease varies widely based on the status of the lunate. To date, there is no consensus regarding the optimal treatment for patients with coronal plane fractures of the lunate, or Lichtman Stage IIIC. Therefore, the purpose of this study was to assess whether coronal plane fractures of the lunate in Kienböck disease healed after surgical intervention, and to determine the outcomes after surgical fixation of the lunate compared with treatment with salvage procedures. Methods: A retrospective review of 36 patients with Lichtman IIIC Kienböck disease was conducted. Patients were classified into lunate reconstruction (vascularized bone graft [VBG] or non-VBG) or salvage procedures (proximal row carpectomy [PRC] or limited fusion). Preoperative and postoperative visual analog scale (VAS) pain, range of motion, grip strength, and Mayo Wrist Score (MWS) were analyzed. Radiographs and computed tomographic scans were reviewed for Lichtman stage, fracture location, union, modified carpal height ratio, Stahl index, and radioscaphoid angle. Results: Thirteen patients underwent lunate reconstruction, 13 underwent limited fusion, and 10 underwent PRC. The overall union rate was 45% after lunate reconstruction, with average time to union of 7 months. There were no differences in union rates between VBG and non-VBG. All 3 groups experienced improvement in their postoperative grip strength and MWS. There were no statistically significant differences in preoperative to postoperative changes in clinical outcome measures between the 3 cohorts; however, when we compared lunate reconstruction with all patients who underwent salvage procedures (limited carpal fusion and PRC), we noted the latter had improved functional outcomes ( P = .019). Four patients (31%) in the reconstruction cohort and 2 patients (8%) in the limited carpal fusion group required reoperation at latest follow-up. Conclusions: Union rate of coronal plane fractures in Kienböck disease remains variable. While the proportion of patients requiring reoperation was higher in the reconstruction group, all groups of patients experienced improvement in their clinical outcomes, without a significant difference between cohorts.

Background: This study aimed to validate the use of grayscale muscle ultrasound by measuring echo intensity to longitudinally evaluate functional muscle reinnervation in a rabbit peroneal nerve defect model. Methods: Eighteen New Zealand white rabbits underwent a 30-mm peroneal nerve reconstruction with autografts or decellularized allografts. Ultrasound measurements of tibialis anterior muscles were performed before surgery and at 4, 8, 12, 16, 20, and 24 weeks postoperatively and included cross-sectional muscle area, mean gray value (MGV), and mean gray value normalized for area (MGVA). At 24 weeks, functional motor recovery was evaluated with isometric tetanic force (ITF) and compound muscle action potential (CMAP). MGVA data were compared with ITF and CMAP measurements by calculating the Spearman correlation coefficient. Results: Muscle area (left/right [L/R] ratio) of autografts was superior to allografts at 4, 12, 16, 20, and 24 weeks (P < 0.03 for all comparisons). MGVs of the operated side were significantly higher for autografts at 4, 8, and 12 weeks and at 12, 16, 20, and 24 weeks for allografts (P < 0.01 for all comparisons), compared with their unoperated sides. Similar patterns were seen in both groups for MGVA (operated versus control side). MGVA (L/R) demonstrated a strong correlation with ITF (L/R) for autografts (ρ = −0.7) and allografts (ρ = −0.87), but inconsistent with CMAPs (L/R). Conclusions: Quantitative muscle ultrasound demonstrated a reliable, noninvasive tool for evaluating motor recovery in a rabbit peroneal nerve reconstruction model. Clinical translation could provide valuable insights into muscle health and structural changes following nerve reconstruction.

Case: A multicenter series of 3 patients with amyoplasia of the upper extremity were indicated for gracilis free functional muscle transfer (FFMT) to restore elbow flexion and found to have an absent gracilis. A final case is discussed detailing standardized evaluation with ultrasound to confirm gracilis before surgical intervention. Conclusion: In amyoplasia, the gracilis muscle may be absent or have fatty infiltration, making this donor muscle inadequate. Preoperative ultrasound to determine the presence of the gracilis is noninvasive and recommended in patients with amyoplasia of the upper extremity being considered for FFMT.

Restoration of elbow flexion is a priority in treating adult traumatic brachial plexus injuries. A tendon transfer is an ideal option for patients not candidates for reconstructive nerve surgery or free-functioning muscle transfer. For patients with a partial brachial plexus injury or a pan plexus injury with adequate recovered triceps function and loss of elbow flexion, a triceps-to-biceps tendon transfer is a nonmicrosurgical option to restore elbow flexion. The technique of triceps-to-biceps transfer in which the complete triceps tendon is transferred laterally, secured lateral to the radial tuberosity, and reinforced with suture to the biceps tendon is described.