Techniques in hand & upper extremity surgery

Publications in this journal

• Article: PyroCarbon Implant Hemiarthroplasty for Trapeziometacarpal Arthritis.

  Joseph F Woodward, Justin B Heller, Neil F Jones
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  ABSTRACT: The trapeziometacarpal joint is commonly affected by degenerative arthritis, presenting with pain, stiffness, and swelling at the base of the thumb. When conservative treatment fails, surgical intervention may be warranted based on clinical and radiologic staging as well as patient demand. The concept of replacing the trapeziometacarpal joint remains attractive because of the decreased pain and stiffness, prevention of thumb shortening, and earlier recovery of strength seen with implant arthroplasty. A technique of using a cementless PyroCarbon hemiarthroplasty implant that allows excellent range of motion and decreased postoperative stiffness and pain is presented, with a focus on dorsal capsular reconstruction to prevent subluxation of the implant.
  Techniques in hand & upper extremity surgery 03/2013; 17(1):7-12.
• Article: A novel arthroscopic technique utilizing bone morphogenetic protein in the treatment of kienböck disease.

  Rebecca A Rajfer, Jonathan R Danoff, Joshua A Metzl, Melvin P Rosenwasser
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  ABSTRACT: Kienböck disease, first described in 1910, is osteonecrosis of the carpal lunate and has been associated with ulnar minus variance. Numerous joint leveling procedures have been developed for patients with ulnar-negative variance to decrease forces transmitted across the lunate. The basis of operative treatment is the presence or absence of advanced osteoarthritis associated with fragmentation of the carpal lunate and capitate descent. Bone morphogenetic proteins (BMPs) have been utilized successfully as adjunctive treatment in fracture healing and recently in the surgical treatment of a patient with Lichtman stage IIIA Kienböck disease. Arthroscopy is an available tool in assessing cartilage injury and coupled with the use of BMP may be of benefit in patients with ulnar-neutral or ulnar-negative wrists who have not progressed to severe arthritis and capitate descent. We report a novel arthroscopic technique in which a stage IIIA and IIIB carpal lunate osteonecrosis is treated by curettage and grafting with an admixture of autologous radial cancellous bone marrow graft and BMP-2.
  Techniques in hand & upper extremity surgery 03/2013; 17(1):2-6.
• Article: Cable-augmented, Quad Ligament Tenodesis Scapholunate Reconstruction: Rationale, Surgical Technique, and Preliminary Results.

  Gregory I Bain, Adam C Watts, James McLean, Yu C Lee, Kevin Eng
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  ABSTRACT: Eight patients underwent scapholunate reconstruction using tensionable suture anchors. Adapted from a modified Brunelli technique, the anchors provide a fixed cable that reduces the scapholunate diastasis and maintains reduction during the healing phase. The flexor carpi radialis tendon graft is advanced through the scaphoid and stabilizes the volar scaphotrapezial ligament, dorsal scapholunate ligament, dorsal intercarpal ligament, and dorsal radiocarpal ligament. The ligament-sparing approach is closed using an ulnar advancement capsulodesis that further reinforces the dorsal intercarpal and dorsal radiocarpal ligament. Good clinical results were obtained. Measured on a visual analog scale (0 to 10), the average pain score improved from 5.8 to 2.1, average patient satisfaction was 7.6, average extension was 56 degrees (91% of contralateral side), flexion was 44 degrees (70% of contralateral side), and grip was strength 41 kg (95% of contralateral side). Radiographic parameters were less favorable. The average scapholunate angle was 71 degrees, radiolunate angle 16 degrees, and scapholunate interval 3.0 mm. The cable-augmented, quad ligament scapholunate ligament reconstruction offers theoretical advantages over previously published techniques, but long-term follow-up is required.
  Techniques in hand & upper extremity surgery 03/2013; 17(1):13-9.
• Article: Alternate technique in managing adhesions after zone 3 extensor tendon repair: a case report.

  Sudhagar Gangatharam, Monique Leblanc
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  ABSTRACT: Extensor tendon injuries are given less importance than the flexor tendon injuries; however, the extensor mechanism is more complicated than flexor tendon system, and regaining satisfactory function is a challenge. It has been reported that loss of digital flexion would affect grasp and power grip imposing greater functional loss than digital extensor lag. Zone 3 extensor tendon management is complex because of excessive scar formation limiting composite digital flexion and extension. The adhesions are more common if the tendon is immobilized for long period. The purpose of this care report is to describe the alternate technique in managing adhesion after prolong immobilization in zone 3 extensor tendon injuries.
  Techniques in hand & upper extremity surgery 03/2013; 17(1):46-8.
• Article: Anterolateral Surgical Approach to the Malunited Distal Radius Fracture for Corrective Osteotomy and Bone-graft Harvest.

  Philip Mathew, Marc Garcia-Elias
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  ABSTRACT: The most common complication after distal radius fractures is union with deformity. When symptomatic, distal radial malunions may require operative intervention. Numerous approaches to the distal radius have been described. Most volar approaches involve sectioning the brachioradialis and opening the first extensor compartment to permit adequate exposure. When bone graft is required, this may necessitate a separate incision and further add to the morbidity. We present an alternative anterolateral surgical approach to the distal radius, which allows for excellent exposure, and minimal trauma to the tendons while permitting harvest of local bone graft through the same incision.
  Techniques in hand & upper extremity surgery 03/2013; 17(1):28-34.
• Article: A novel external fixator of the hand: a practice pearl.

  Hamid Namazi, Kamran Mozaffarian
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  ABSTRACT: External fixation of comminuted hand fractures, especially those associated with soft-tissue injuries, is a good option and avoids several complications resulting from open surgery. Therefore, many versions of mini external fixators have been developed, including commercially fabricated implants and hand-made implants. However, these devices are costly or associated with serious complications. Through this study we have introduced a cost-effective and easy-to-apply mini external fixator.
  Techniques in hand & upper extremity surgery 03/2013; 17(1):57-9.
• Article: Subscapularis slide correction of the shoulder internal rotation contracture after brachial plexus birth injury: technique and outcomes.

  Igor Immerman, Herbert Valencia, Patricia Ditaranto, Edward M Delsole, Sergio Glait, Andrew E Price, John A I Grossman
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  ABSTRACT: Internal rotation contracture is the most common shoulder deformity in patients with brachial plexus birth injury. The purpose of this investigation is to describe the indications, technique, and results of the subscapularis slide procedure. The technique involves the release of the subscapularis muscle origin off the scapula, with preservation of anterior shoulder structures. A standard postoperative protocol is used in all patients and includes a modified shoulder spica with the shoulder held in 60 degrees of external rotation and 30 degrees of abduction, aggressive occupational and physical therapy, and subsequent shoulder manipulation under anesthesia with botulinum toxin injections as needed. Seventy-one patients at 2 institutions treated with subscapularis slide between 1997 and 2010, with minimum follow-up of 39.2 months, were identified. Patients were divided into 5 groups based on the index procedure performed: subscapularis slide alone (group 1); subscapularis slide with a simultaneous microsurgical reconstruction (group 2); primary microsurgical brachial plexus reconstruction followed later by a subscapularis slide (group 3); primary microsurgical brachial plexus reconstruction followed later by a subscapularis slide combined with tendon transfers for shoulder external rotation (group 4); and subscapularis slide with simultaneous tendon transfers, with no prior brachial plexus surgery (group 5). Full passive external rotation equivalent to the contralateral side was achieved in the operating room in all cases. No cases resulted in anterior instability or internal rotation deficit. Internal rotation contracture of the shoulder after brachial plexus birth injury can be effectively managed with the technique of subscapularis slide.
  Techniques in hand & upper extremity surgery 03/2013; 17(1):52-6.
• Article: A novel method of using mini external fixator for maintaining web space after the release of contracture and syndactyly.

  Jagannath B Kamath, Harsh Vardhan, Deepak M Naik, Ankush Bansal, Mayur Rai, Anup Kumar
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  ABSTRACT: Syndactyly and postburn contracture of the digits are the common cases seen in a hand clinic. Their management can be roughly divided into 3 stages. In stage 1, syndactyly/postburn contracture of the digits are surgically released; in stage 2, surgical wound care is provided; and in stage 3, the patient undergoes physiotherapy (rehabilitation). The most common method of immobilizing the digit after the release is by plaster of Paris splints. Its demerit includes loss of correction, painful postoperative dressing, and suboptimal graft uptake due to improper immobilization and maceration. We describe a simple and effective method of mitigating the above-mentioned drawbacks using a mini external fixator, after the release of the contracted fingers. The use of this fixator also helps during the surgery (stage 1) as resurfacing of the raw areas becomes quick because 2 surgeons can perform this simultaneously. The web can be further opened up using the fixator to facilitate the suturing of the FTG/flap, after which it can be brought back to its normal position. As the dimension of the raw area created is fully defined it becomes easier to suture the flap/graft with appropriate tension and tie-over dressing. The postoperative dressings become easier and pain free. The maceration of the skin graft and skin margin is reduced as the compressive dressing can be applied to individual fingers rather than a collective dressing. It is advantageous even in stage 3 as it allows the surgeon to customize the splint for each finger.
  Techniques in hand & upper extremity surgery 03/2013; 17(1):37-40.
• Article: Treatment of Middle-Third Clavicle Fractures Using Anterior Plating With a Dynamic Compression Plate (DCP).

  Padmanabhan Subramanian, Meera Joshi, Sophie Shilston, Donald Wallace, Oliver J Pearce
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  ABSTRACT: Significantly displaced midshaft clavicle fractures can be managed operatively to restore anatomy and allow early mobilization. Several techniques have described using precontoured anatomically designed plates placed on the superior surface of the bone or reconstruction plates contoured by the surgeon placed either superiorly or anteriorly. We describe the use of the dynamic compression plate placed anteriorly on the clavicle in treating these fractures and discuss the relative advantages of this technique. We have a case series of 8 patients over a 2-year period, who were followed up and all went on to successful fracture union.
  Techniques in hand & upper extremity surgery 03/2013; 17(1):35-6.
• Article: Simplified and strong: abductor pollicus longus suspension arthroplasty with biotenodesis screw fixation in the base of the index metacarpal.

  Terrill P Julien, Brandon E Earp, Philip E Blazar
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  ABSTRACT: Surgical treatment of thumb basal joint arthritis is aimed at pain relief, restoration of pinch strength, and stability. We describe a variation of the abductor pollicus longus (APL) suspension arthroplasty originally described by Thompson, which maximizes strength of repair and is technically simple to perform. The technique consists of a trapeziectomy followed by resection of a slip of the APL and secure docking of the tendon into the base of the index metacarpal base. Stability is enhanced with a 3.0 mm biotenodesis screw. From March 2009 to September 2011, 50 patients were treated at our institution. Early results showed consistent pain relief, functional improvement, and minimal complications. The data support APL suspension arthroplasty with tenodesis screw fixation as a safe and effective treatment for CMC arthritis.
  Techniques in hand & upper extremity surgery 03/2013; 17(1):49-51.
• Article: Endoscopic Carpal Tunnel Release: A New Single-portal Device.

  Maarten R Fechner, Marijn Hameeteman, René R W J van der Hulst, Bas B G M Franssen
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  ABSTRACT: Carpal tunnel syndrome is a common peripheral nerve disease, often requiring surgical intervention. After the first description of endoscopic carpal tunnel release 20 years ago, several endoscopic techniques have been described. The endoscopic procedure seems to have a better outcome in terms of time to return to work. A feared complication of endoscopic carpal tunnel release is injury to the median nerve or branches of the median nerve. We developed a new guiding cannula with raised borders, which will prevent accidental injury to the median nerve. A single-portal anterograde technique, to release the transverse carpal ligament, is described with the use of this new guiding device.
  Techniques in hand & upper extremity surgery 03/2013; 17(1):25-7.
• Article: Simultaneous reconstruction of extensor mechanism in the free transfer of vascularized proximal interphalangeal joint.

  Yu-Te Lin, Dennis S Kao, Derrick C Wan, Shwu-Huei Lien, Chih-Hung Lin, Fu-Chan Wei
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  ABSTRACT: From a recent systemic review, vascularized toe proximal interphalangeal joint (PIPJ) transfer achieved an average arc of motion (AOM) of merely 37 degrees for finger PIPJ reconstruction. Despite the technical refinement over the past 3 decades, the resulting active motion of the reconstructed joint remains unpredictable and often fraught with extension lag. The technique for vascularized toe PIPJ transfer at our institute has evolved over the years to its current state, with simultaneous extensor mechanism reconstruction being a major component. During the transfer, the quality of extensor tendons on the recipient finger and donor toe are carefully evaluated. If the central slip of finger extensor is destroyed but the quality of lateral bands is adequate, centralization of lateral bands overlying the transferred PIPJ is performed. If there is acceptable central slip remnant at the proximal phalanx level, modified Stack procedure is performed for central slip reconstruction while leaving the lateral bands in continuity. If both lateral bands are poor, modified Stack procedure is performed unless the central tendon of the toe is strong enough to extend the PIPJ. From November 2008 to October 2010, 7 joints were transferred with this modified technique. The average follow-up was 18.2 months. The average active AOM of the transferred PIPJ was 56.4 degrees. The average extension lag of the toe PIPJ was 10.7 and 16.4 degrees before and after the transfer, respectively. Simultaneous reconstruction of extensor mechanism decreases the extension lag without sacrificing AOM of the transferred PIPJ.
  Techniques in hand & upper extremity surgery 03/2013; 17(1):20-4.
• Article: Changing of the guard.

  Alexander Y Shin
  Techniques in hand & upper extremity surgery 03/2013; 17(1):1.
• Article: Hamate hook nonunion treated with a hook plate: case report and surgical technique.

  Chihab Taleb, Joel Murachowsky, Gustavo M Ruggiero
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  ABSTRACT: Despite of its rarity, hamate hook nonunion can cause several complications like tendon rupture or loss of grip strength. Admitted treatments in the literature are excision of the bone fragment or its open reduction and internal fixation. We report a clinical case of a high-level baseball player with hamate hook nonunion treated with an original technique of fixation using a hook plate.
  Techniques in hand & upper extremity surgery 12/2012; 16(4):194-7.
• Article: Arthrodesis of the thumb metacarpophalangeal joint with plate fixation.

  Sudhir B Rao
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  ABSTRACT: This is a surgical technique for arthrodesis of the thumb metacarpophalangeal joint using a low-profile plate. Using the principles of tension band fixation and interfragmentary compression, a high rate of fusion is achieved with a low incidence of complications. The technique is versatile allowing fixation at any desired position. It can be used in porotic bone and avoids the need for postoperative immobilization.
  Techniques in hand & upper extremity surgery 12/2012; 16(4):215-7.
• Article: The Simple Wire Interosseous Fixation Technique (SWIFT) for Reattachment of FDP Avulsions With a Large Bony Fragment.

  Daniel B Markeson, Maleeha Mughal, Padmanabhan Subramanian, Srinivasan Iyer
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  ABSTRACT: Avulsion injuries of the flexor digitorum profundus tendon can be with or without a bony fragment. Types 3, 4, and 5 injuries often have a sizeable bony fragment. In the past, they have been repaired with either a screw, plate, or pull-out wire with a dorsal button, often in combination with a K wire to immobilize the distal interphalangeal joint. We illustrate with 2 cases a simple technique for secure repair of the flexor digitorum profundus avulsions with a bony fragment. In contrast to previously described techniques, our technique involves minimal dissection, has a significantly reduced risk of fracture to the bony fragment, is completely internalized thereby reducing the risk of postoperative infection and allows immediate mobilization.
  Techniques in hand & upper extremity surgery 12/2012; 16(4):220-4.
• Article: Two-team simultaneous open surgical treatment in bilateral shoulder fracture dislocation.

  Christian Allende, Damian Bustos, Pablo Bruno, Horacio Galera
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  ABSTRACT: Different surgical options have been described for the treatment of bilateral shoulder fracture dislocations. We report 2 cases of bilateral shoulder fracture dislocation treated simultaneously by 2 surgical teams. One case had bilateral hemiarthroplasty performed, and the second case had 1 hemiarthroplasty and McLaughlin procedure on the other shoulder. A device to allow holding the patient in a bend chair position, with both shoulders hanging outside the operative table, allowing their free movement, was designed. At 1-year follow-up, neither of the patients had complications and both are pleased with their early result. Simultaneous treatment of both the shoulders by 2 different surgical teams in bilateral shoulder fracture dislocations that need surgical treatment has the advantages of reduced overall hospitalization time, reduced anesthetic risk, faster return to work, and reduced overall cost of care. The decision for simultaneous bilateral shoulder surgery must be made in concert with the patient, medical consultant, and anesthesiologist.Level of Evidence: Level IV-case series.
  Techniques in hand & upper extremity surgery 12/2012; 16(4):210-4.
• Article: Minimally invasive partial fasciectomy for dupuytren contractures.

  Scott E Gelman, Robert Schlenker, Sidney M Jacoby, Eon K Shin, Randall W Culp
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  ABSTRACT: Treatment options for the Dupuytren contractures vary from percutaneous needle aponeurotomy, open fasciotomy or fasciectomy, dermofasciectomy, and more recently, injectable collagenase. Although utilization of injectable collagenase avoids a formal surgical procedure, not all patients are eligible and some patients do not feel comfortable with an enzyme injection or the associated risks, which may include hematoma, wound dehiscence, or tendon rupture. This study describes the technique and early results of partial fasciectomy through a mini-incision approach as an additional treatment option for Dupuytren contractures. We found that this procedure results in contracture correction with a low rate of complications and thus provides the surgeon with an alternative treatment option to offer patients.
  Techniques in hand & upper extremity surgery 12/2012; 16(4):184-6.
• Article: Salvage reconstruction of failed interposition arthroplasty at the base of the thumb.

  Richard M Braun, Mark Rechnic, Kalpit N Shah
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  ABSTRACT: We present an operative procedure designed to revise a failed arthroplasty at the base of the thumb. This report describes a reliable operation that corrects residual instability and malignment which results in thumbs that are weak and painful despite a previous procedure. The operation has also been used as a primary procedure for arthritis of the trapeziometacarpal joint where instability and subluxation was a major component of the problem requiring joint reconstruction. The unique features of this procedure include a reinforced double-thickness tendon graft, a unique tendon anchor, and a fascia lata allograft spacer. Significant functional improvement is anticipated when joint reconstruction provides increased proximal stability. Pinch and grip measurements improve. Pain scores also diminish after the operation. Hand function and patient satisfaction can be substantially improved with revision arthroplasty when the initial operation has failed to provide a thumb that is mobile, stable, and pain free. The technical features of the procedure address reduction of malignment, restoring of anatomic balance, and secure fixation of the proximal apex of the thumb metacarpal which restores thumb reduction position and digital balance.
  Techniques in hand & upper extremity surgery 12/2012; 16(4):230-5.