Citations

Abstract Background Some surgeons advocate for concomitant proximal row carpectomy (PRC) with total wrist arthrodesis (TWA), though there are limited data to support or oppose this view. Questions/Purposes Does concomitant PRC improve rates of union, revision, hardware loosening, hardware failure, and hardware removal in TWA? Patients and Methods A retrospective cohort study of patients who underwent TWA with and without concomitant PRC between January 2008 and December 2018 was undertaken. Patients were included if they underwent TWA using a dorsal spanning plate. Patients were excluded if they underwent partial wrist arthrodesis, revision TWA, or TWA with nondorsal spanning plate fixation. Results A total of 183 wrists in 180 patients were included in the study, 96 (52.5%) in the TWA only and 87 (47.5%) in the TWA + PRC groups. Median clinical and radiographic follow-up was 18.0 months (3.0–133.0 months) in the TWA + PRC group and 18.5 months (2.0–126.0 months) in the TWA only group (p = 0.907). No difference in nonunion (TWA + PRC: 13/87 [14.9%], TWA only: 18/96 [18.8%], odds ratio: 0.76, p = 0.494), revision (TWA + PRC: 5/87 [5.75%], TWA only: 8/96 [8.33%], hazard ratio [HR]: 0.73, p = 0.586), loosening (TWA + PRC: 4/87 [4.60%], TWA only: 6/96 [6.25%], HR: 0.74, p = 0.646), failure (TWA + PRC: 5/87 [5.75%], TWA only: 4/96 [4.17%], HR: 1.55, p = 0.530), and removal (TWA + PRC: 12/87 [13.8%], TWA only: 16/96 [16.7%], HR: 0.84, p = 0.634) were identified. Conclusion Concomitant PRC might not improve rates of union or diminish complications in patient undergoing TWA. The role of PRC and the rationale for its use in TWA need to be individualized and discussed with patients prior to surgery. Level of Evidence This is a Level IV, therapeutic study.

Purpose To develop a standardized method for tibial tunnel volumetric bone mineral density (BMD) analysis with quantitative computed tomography (qCT) using cadaveric specimens to provide validation of this technique on a healthy control population and to determine whether osteopenia occurs following an anterior cruciate ligament (ACL) injury. Methods: qCT was used to develop a volumetric BMD (mg/cm 3 ) measurement technique throughout the region of a standard tibial tunnel. This method was applied to 90 lower extremities, including 10 matched cadaveric knees, 10 matched healthy knees, 25 ACL‐injured knees, and 25 contralateral ACL‐uninjured knees. The mean total and segmental (proximal, middle, and distal) tibial tunnel BMD were analyzed. Results The mean entire tibial tunnel BMD measured 165.8 ± 30.5 mg/cm 3 (cadaver), 255.9 ± 28.2 mg/cm 3 (healthy control), 290.3 ± 36.4 mg/cm 3 (ACL‐injured), and 300.1 ± 35.1 (ACL‐uninjured). Segmental tibial tunnel BMD demonstrated distal one‐third segments as the greatest areas of BMD, followed by proximal one‐third, and middle one‐third for all cohorts with all pairwise comparisons ( P < .001). The mean BMD was significantly greater in the uninjured extremity compared with the injured extremity in the entire tunnel (290.3 vs 300.1; P < .001), proximal (271.2 vs 279.1; P = .002), middle (167.6 vs 179.6; P < .001), and distal segments (432.7 vs 441.7; P = .004) at an average of 8 weeks following ACL injury. Conclusions A standardized method to quantitatively measure the volumetric BMD within the region of a standard tibial tunnel for ACL reconstruction was successfully developed and validated. Significant osteopenia of the injured knee occurs following ACL injury when compared with the contralateral uninjured knee. This observation has potential clinical implications for ACL graft tibial fixation and healing. Level of Evidence Descriptive diagnostic study, Level III.

Abstract Background Placement and spacing of skin incisions are important for maintaining soft tissue perfusion and viability, particularly in the setting of local trauma. Question/Purpose The aim of this article is to determine if multiple skin incisions in the surgical management of distal radius fractures result in an increased risk of postoperative wound complications, particularly in the setting of high-energy mechanisms of injury with substantial initial displacement and associated soft-tissue insult that require multiple incisions for distal radius reconstruction. Patients and Methods A multicenter, retrospective chart review was performed for all adult patients who underwent open reduction, internal fixation of a closed distal radius fracture with multiple (≥2) hand, and wrist incisions with minimum follow-up of 6 weeks. Primary outcome measures included wound healing complications such as partial or complete skin necrosis, dehiscence, delayed healing, and superficial or deep infections. Results For 118 wrists, a total of 305 incisions were utilized, averaging 2.6 incisions per patient (range: 2–6) with the flexor carpi radialis and dorsal distal radius approaches occurring in 86 and 78% of cases, respectively. One patient was identified as having a pyogenic granuloma along an incision. However, two patients were identified as having wound concerns, including fracture blisters (n = 1) and wound margin epidermolysis (n = 1) along the incision. There were no cases of skin bridge necrosis, delayed healing, wound dehiscence, or infection. Conclusions There is no increased risk of wound healing complications with the use of multiple skin incisions (≥2) in the surgical management of distal radius fractures, afforded by the abundant and robust angiosomes around the wrist. Surgeons should have the confidence to utilize the necessary number of skin incisions to effectively reconstruct distal radius fractures.

A retrospective review of hospital employees at a single employer institution who underwent ultrasound guided thread carpal tunnel release (TCTR) or open carpal tunnel release (OCTR) between January 2018 and August 2020 was performed to ascertain differences in return-to-work status. Patient age, sex, occupation, handedness, severity of carpal tunnel syndrome, prior treatments and surgical outcomes were reviewed. A total of 18 patients underwent TCTR and 17 patients underwent OCTR. The TCTR group averaged 12 days to return to work without restrictions, as opposed to 33 days for the OCTR group. Resolution of symptoms was afforded in all patients without any complications regardless of surgical technique. While both TCTR and OCTR were effective, our data indicates that TCTR resulted in a shorter return to work. Level of evidence: III

Case: A 41-year-old woman sustained a distal radius fracture with concomitant median nerve transection. The wound was consistent with an inside-to-outside mechanism with noted metaphyseal bone loss at the level of the median nerve injury. The median nerve was not amenable to primary repair, and given concern for inability to define the zone of the injury, the patient underwent delayed reconstruction of the nerve. Conclusion: A review of the literature highlights the rare incidence of this combined injury that can be undetected or misdiagnosed as an acute carpal tunnel syndrome or stretch injury to the median nerve.

Background: The coronavirus disease 2019 (COVID-19) surge has enabled the widespread usage of telemedicine (TM) and presents a unique opportunity to determine the hand surgery patients’ perception of care using validated patient satisfaction scores. Methods: Electronic surveys were distributed to patients aged 18 years and older who underwent a video TM encounter with a single surgeon at an academic medical center during the initial COVID-19 surge (March 23 to October 22, 2020). The study-specific questions were derived from the Press Ganey (PG) Medical Practice TM Survey and compared with institutional PG Outpatient Medical Practice Survey data. Three cohorts were defined: pre-COVID face-to-face, post-COVID TM, and post-COVID face-to-face. Results: Thirty of 65 TM patients (46.2%) responded. No differences in sex, age, or visit type were identified between cohorts. The TM cohort was more likely to live greater than 300 miles from the institution. Median response for all cohorts for the PG care provider and overall experience responses were “very good,” and no differences were identified between cohorts. Patient satisfaction with their TM experience was high with median satisfaction scores for arranging and connecting to a TM visit, talking with the provider over a video connection, and having the provider understand the clinical problem were “very good.” Patients in the TM cohort reported no difference in preference for face-to-face or TM visits. Conclusions: Patients are satisfied with TM as a substitute for face-to-face visits suggesting that TM can possibly be used to deliver comparable patient experience for hand surgery encounters.

Background Little information exists to guide decision-making with regard to distal radius fractures in the setting of ipsilateral hemiparesis or hemiplegia. Methods Patients who sustained a distal radius fracture in the setting of ipsilateral hemiparesis or hemiplegia secondary to brain injury were evaluated. Investigated variables included perioperative pain, preinjury House functional classification score, length of immobilization, radiographic outcome measurements, and time to union. Results There were 15 patients with distal radius fractures with a mean age of 65.9 years. The mean clinical and radiographic follow-up was 2.8 and 2.9 years, respectively. Wrists were placed into the nonoperative group (NOG, n = 10) and operative group (OG, n = 5). Pain significantly decreased at final follow-up for both groups. Baseline House functional classification scores averaged 1.3 and 1.6 for the NOG and OG, respectively, and were maintained at final follow-up. Length of immobilization for the NOG was 46 days and OG was 37 days, P = .15. Radiographic outcomes at final follow-up in the NOG and OG, respectively, were a mean radial height of 9.3 versus. 11.6 mm, radial inclination of 18.3° versus 22.3°, 4.2° dorsal tilt versus 5.3° volar tilt, and tear drop angle of 45.6° versus 44.5°. There were no significant differences in these measurements. Time to radiographic union averaged 58 days for the NOG and 67 days for the OG, P = .42. There were no revision surgeries. Conclusions Based on this small case series, patients with distal radius fracture and ipsilateral hemiparesis or hemiplegia may have similar clinical, functional, and radiographic outcomes, regardless of nonoperative or operative treatment.

Learning Objectives: After reading this article and viewing the videos, the participant should be able to: 1. Recognize the following five wrist operations as consistent options for different wrist injuries: carpal tunnel release, medial femoral condyle bone flap for scaphoid nonunion associated with carpal collapse and avascular necrosis, scaphocapitate arthrodesis for Kienböck disease, percutaneous screw fixation of nondisplaced scaphoid fracture, and four-corner arthrodesis. 2. Know the state-of-the-art of these five procedures. 3. State the indications of each operation. 4. List the surgical steps of these five procedures. Summary: The wrist is a complex joint that concentrates different types of tissues (e.g., bone, cartilage, ligaments, nerves, vessels) and a broad different spectrum of diseases. Treatment of wrist injuries has improved during recent years, mainly because of improvement in strategy, techniques, microsurgical equipment, understanding anatomy and improvements in technology. In this article, we present the five operations (i.e., carpal tunnel release, medial femoral condyle bone flap for scaphoid nonunion associated with carpal collapse and avascular necrosis, scaphocapitate arthrodesis for Kienböck disease, percutaneous screw fixation of nondisplaced scaphoid fracture, and four-corner arthrodesis) that have consistently given good outcomes in patients suffering from different wrist injuries/maladies.

Background: Upper motor neuron (UMN) syndrome consists of muscle spasticity, weakness, and dyssynergy due to a brain or spinal cord injury. The purpose of this study is to describe the perioperative adverse events for adult patients undergoing single-event, multilevel upper extremity surgery (SEMLS) due to UMN syndrome. Methods: A retrospective case series was performed for 12 consecutive adult patients who underwent SEMLS to correct upper extremity dysfunction or deformity secondary to UMN syndrome. The evaluation consisted of primary outcome measures to identify readmission rates and classify adverse events that occurred within 30 days after surgery. Results: All 12 patients were functionally dependent with 50% (n = 6) men and 50% (n = 6) women at a mean age of 43.6 years (range: 21-73) with a mean of 5.92 (range: 0-16) comorbid diagnoses at the time of surgery. There were no intraoperative complications, hospital readmissions, or deaths among the 12 patients. Five patients experienced 5 minor postoperative complications that consisted of cast- or orthosis-related skin breakdown remote from the incision (n = 3), incidental surgical site hematoma that required no surveillance or intervention (n = 1), and contact dermatitis attributed to the surgical dressing that resolved with topical corticosteroids (n = 1). Conclusions: With an appropriate multidisciplinary approach, there is minimal risk for developing perioperative and 30-day postoperative adverse events for adults undergoing SEMLS to correct upper extremity deformities secondary to UMN syndrome. Level of Evidence: Level IV

Background: The scaphoid-trapezoid-trapezium (STT) articulation stabilizes the scaphoid and links the proximal and distal carpal rows. The purpose of the study was to determine whether trapezium excision in the treatment of trapeziometacarpal (TM) arthritis affects carpal stability. Methods: A retrospective chart and radiographic review was performed on all wrists that underwent trapeziectomy with suspensionplasty or ligament reconstruction, and tendon interposition for TM arthritis between 2004 and 2016. Radiographic outcome measures included the modified carpal height ratio (MCHR) and radioscaphoid (RS), radiolunate (RL), and scapholunate (SL) angles. Degenerative change at the TM and STT joints was classified according to the Eaton-Littler, and Knirk and Jupiter classification systems. Radiographic parameters were compared between preoperative and final follow-up time points. Results: A total of 122 wrists were included in the study with a mean follow-up of 3.5 years (range: 1.0-13.0 years). The mean RL (range: −2.2° ± 11.8° to −10.7° ± 16.5°) and RS angles (range: 52.6° ± 13.8° to 44.4° ± 17.8°) decreased significantly (<.001) without significant change in SL angle, indicating progressive lunate and scaphoid extension after trapeziectomy. The mean MCHR decreased significantly (range: 1.6 ± 0.1 to 1.5 ± 0.1) following trapeziectomy, indicating progressive carpal collapse. Progressive scaphoid-trapezoid arthrosis was observed following trapeziectomy. No other preoperative radiographic factors investigated were associated with significant differences in preoperative and postoperative values for radiographic outcome measures. Conclusions: Trapeziectomy can lead to loss of carpal height, coordinated extension of both the lunate and scaphoid, and progressive scaphotrapezoid arthrosis. As such, in wrists with dynamic or static carpal instability, trapeziectomy should be performed with caution due to the risk of carpal collapse with a nondissociative pattern of dorsal intercalated segment instability.