Shin, Alexander Y

This study describes a novel technique for the preoperative surgical planning for an osteoarticular medial femoral condyle (MFC) graft to replace the proximal pole of a scaphoid. In cases of proximal pole scaphoid nonunion or in Preiser disease, fragmentation of the articular surface can occur, leading to significant pain and disability. Osteoarticular MFC bone grafting can be used to treat these injuries by providing a vascularized osteoarticular surface. Using 3-dimensional imaging and printing we are able to precisely model the injured scaphoid, and also accurately plan the harvest of MFC osteoarticular graft. This technique allows for accurate preoperative planning of a complex 3-dimensional bone, and has improved our execution of the plan intraoperatively.

PurposeOur objective was to determine the prevalence and quality of restored external rotation (ER) in adult brachial plexus injury (BPI) patients who underwent spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer, and to identify patient and injury factors that may influence results.MethodsFifty‐one adult traumatic BPI patients who underwent SAN to SSN transfer between 2000 and 2013, all treated less than 1 year after injury with >1 year follow‐up. The primary outcome measured was shoulder ER. The outcomes we utilized included “clinically useful ER” (motion ≥ −35° with ≥MRC 2 strength), modified British Medical Research Council (MRC) grading, and electromyographic (EMG) reinnervation.ResultsEMG evidence of re‐innervation was found in 85% of patients. Surgery resulted in improved ER in 41% (21/51) of shoulders at an average of 28 months follow‐up. Of these, only 31% (17/51) had clinically useful ER. The average ER active range of motion was 12° from full internal rotation (Range: −60° to 90°) and MRC grade 2.2 (2–4). The only predictor of ER improvement was an isolated upper trunk (C5‐C6) injury. Improved ER was clinically evident in 76%, 37% and 26% of upper trunk (UT), C5‐C6‐C7 and panplexus injuries, respectively (P < 0.03).ConclusionsAlthough 85% had EMG signs of recovery, the SAN to SSN transfer failed to provide useful recovery of ER through reinnervation of the infraspinatus muscle in injuries involving more levels than a C5‐C6 root/upper trunk pattern. In patients with greater than C5‐6 level injuries alternatives to SAN to SSN transfer should be considered to restore shoulder ER. © 2016 Wiley Periodicals, Inc. Microsurgery 37:365–370, 2017.

Background: The purpose of this study is to evaluate long-term outcomes of ligamentous repair rather than reconstruction for chronic thumb ulnar collateral ligament (UCL) injuries. Methods: Patients at least 15-years status-post repair of a chronic (greater than 6 weeks) UCL tear were contacted for clinical evaluation, radiographs, and postoperative outcome questionnaires, including the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, visual analog scale (VAS) pain scale, and study-specific questions. Twelve of 21 (57%) living patients were available for long-term, greater than 15-year follow-up (average 24.5 years, range 16.9-35.6). Results: Eighty-eight percent of patients had some degree of osteoarthritis. Increased age at the time of injury and higher DASH scores were correlated with increased grades of the thumb metacarpophalangeal osteoarthritis. Delay to treatment and VAS pain scores had no correlation with radiographic findings. Conclusions: Repair of a chronic UCL injury with available local tissue appears to be a reasonable alternative to ligament reconstruction, resulting in durable long-term outcomes despite the majority of patients progressing to osteoarthritis.

Background: The purpose of this study is to compare the outcome of the conical fully threaded headless screw to that of a smooth shaft headless screw in a series of scaphoid nonunions requiring screw fixation to determine if screw design had an influence on union rates.Methods: We retrospectively reviewed 104 cases of surgically treated scaphoid nonunions. After eliminating cases with our exclusion criteria, the study cohort had 40 cases for analysis. A comparison and analysis of union rates was undertaken between the fully threaded Acutrak 2 mini screw and the smooth shaft Herbert screw.Results: Overall union rate for screw fixation was 88%. The fully threaded conical screw fixation had a significantly lower union rate of 50% compared to 97% for the smooth shaft screws.Conclusions: Our data revealed that the fully threaded conical screws were associated with significantly lower union rate compared to the smooth shaft Herbert type screws.

Purpose Carpal tunnel syndrome is a common entrapment neuropathy. When conservative management fails to relieve symptoms, carpal tunnel surgery is indicated. The surgical exposure for this procedure is commonly based on variable anatomic landmarks. The purpose of this study was to describe a fixed, easily referenced anatomical landmark for the distal extension of the transverse carpal ligament, the “Cup of Diogenes.” Materials and Methods Topographical landmarks including Kaplan cardinal line, palmaris tendon, and distal palmer crease were marked on six fresh frozen cadaveric wrist and hand specimens. The apex of the Cup of Diogenes is determined to be the confluence of the thenar and hypothenar musculature of the palm. Wrists were dissected and the distance between these landmarks and the superficial palmar arch, median nerve, transverse carpal ligament, and ulnar nerve were measured. Results In all specimens, the ulnar nerve was ulnar to this the apex of the Cup of Diogenes, while the median nerve was radial. The apex was proximal in all specimens to the superficial palmar arch. The apex marked the distal extent of the transverse carpal ligament in all specimens. Discussion Based on our results, we feel the apex of the Cup of Diogenes is a consistent, fixed anatomical marker for the distal extent of the transverse carpal ligament, marking a safe zone in the palm for surgical planning of incisions. Level of Evidence Level V - Therapeutic

Processed nerve allografts have become an alternative to repair segmental nerve defects, with results comparable with autografts regarding sensory recovery; however, they have failed to reproduce comparable motor recovery. The purpose of this study was to determine how revascularizaton of processed nerve allograft would affect motor recovery. Eighty‐eight rats were divided in four groups of 22 animals each. A unilateral 10‐mm sciatic nerve defect was repaired with allograft (group I), allograft wrapped with silicone conduit (group II), allograft augmented with vascular endothelial growth factor (group III), or autograft (group IV). Eight animals from each group were sacrificed at 3 days, and the remaining animals at 16 weeks. Revascularization was evaluated by measuring the graft capillary density at 3 days and 16 weeks. Measurements of ankle contracture, compound muscle action potential, tibialis anterior muscle weight and force, and nerve histomorphometry were performed at 16 weeks. All results were normalized to the contralateral side. The results of capillary density at 3 days were 0.99% ± 1.3% for group I, 0.33% ± 0.6% for group II, 0.05% ± 0.1% for group III, and 75.6% ± 45.7% for group IV. At 16 weeks, the results were 69.9% ± 22.4% for group I, 37.0% ± 16.6% for group II, 84.6% ± 46.6% for group III, and 108.3% ± 46.8% for group IV. The results of muscle force were 47.5% ± 14.4% for group I, 21.7% ± 13.5% for group II, 47.1% ± 7.9% for group III, and 54.4% ± 10.6% for group IV. The use of vascular endothelial growth factor in the fashion used in this study improved neither the nerve allograft short‐term revascularization nor the functional motor recovery after 16 weeks. Blocking allograft vascularization from surrounding tissues was detrimental for motor recovery. The processed nerve allografts used in this study showed similar functional motor recovery compared with that of the autograft. © 2014 Wiley Periodicals, Inc. Microsurgery 36:134–143, 2016.

OBJECT Transfer of the triceps motor branch has been used for treatment of isolated axillary nerve palsy in the adult population. However, there are no published data on the effectiveness of this procedure in the pediatric population with traumatic injuries. The authors reviewed demographics and outcomes in their series of pediatric patients who underwent this procedure. METHODS Six patients ranging in age from 10 to 17 years underwent triceps motor branch transfer for the treatment of isolated axillary nerve injuries between 4 and 8 months after the inciting injury. Deltoid muscle strength was evaluated using the modified British Medical Research Council (MRC) grading system. Shoulder abduction at last follow-up was measured. RESULTS The mean duration of follow-up was 38 months. The average postoperative MRC grading of deltoid muscle strength was 3.6 ± 1.3. The median MRC grade was 4. One patient who did not achieve an MRC grade of 3 suffered multiple injuries from high-velocity trauma. Unlike in the adult population, age, body mass index of the patient, and delay from injury to surgery were not significant factors affecting the outcome of the procedure. CONCLUSIONS In the pediatric population with traumatic injuries, isolated axillary nerve injury treated with triceps motor branch transfer can result in good outcomes.