bluuebunny/crossref_metadata_2025 huggingface dataset:
Adeno-Associated Virus-2–Mediated VEGF Gene Transfer to the Tendon Improves the Healing Strength of the Digital Flexor Tendons
Authors: Wu Ya Fang , Zhou You Lang , Chen Jing , Xing Shu Guo , Sun Yu Cheng , Tang Jin Bo
Published: September 2016

Purpose: A major challenge in repairing injured digital flexor tendon is the weak intrinsic healing capacity of tendon, which is responsible for rerupture of repaired tendon after primary repair. In an experimental model of transection and surgical repair of the digital flexor tendon in chicken toes, we aim to test the effectiveness of introducing the vascular endothelial growth factor (VEGF) gene through an adeno-associated virus (AAV) vector to enhance tendon healing strength. Materials and Methods: One hundred and eighteen flexor digitorum profundus (FDP) tendons in the long chicken toes were completely transected the in zone 2 and surgically repaired using 2-strand modified Kessler method. These toes were divided into two groups: 58 FDP tendons (group 1) were injected with 2 × 109 particles of AAV2-VEGF per tendon and 62 tendons (group 2) after injection with saline. The toes were immobilized in semiflexed position for the first 3 weeks and then released for free toe motion. At postoperative 1, 2, 3, 4, 6, and 8 weeks, the ultimate strengths of the healing tendons were tested in an Instron tensile testing machine. At weeks 4, 6, and 8, the work of digital flexion (WOF) was also recorded and adhesions around the repair site scored. We also supplemented a group (20 toes) in which only empty AAV2 vector was injected to the tendon, and tendon strength and adhesions were recorded at weeks 2 and 4. Results: Delivery of AAV2-VEGF significantly increased ultimate strength of the healing tendons at postoperative weeks 3, 4, 6, and 8 ( P < .05 or P < .01). At week 4, the tendon strength was 12.4 ± 8.6 N after AAV2-VEGF injection, but 5.7 ± 1.1 N after saline injection. At week 6, the strength was 46.4 ± 19.2 N after AAV2-VEGF injection, but 27.1 ± 8.9 N after saline injection. At week 6 and 8, the adhesion scores and WOF of the toes after AAV2-VEGF injected were not increased. We found no significant increases in the strength of the tendon after injection of sham vector compared with that in saline control group. Conclusions: The results of this study show the therapeutic efficacy of AAV2-VEGF for improvement of tendon healing strength without aggravating adhesion formation after surgical tendon repair. AAV2-VEGF therapy appears to be a promising method of biological modulation of healing of the digital flexor tendons.
Effect of Local Interferon-α, Interferon-β, and 5-Fleurouracil on Repair Strength and Prevention of Peritendinous Adhesion Following Flexor Tendon Surgery in Rabbits
Authors: Fatemi Mohammad Javad , Shirani Shahram , Baghaei Mehrdad , Lebaschi Amir Hossein , Gharegozlu Mohammad , Pedram Mirsepehr , Saberi Mohsen , Araghi Shirin , Bagheri Tooran
Published: September 2016

Background: Peritendinous adhesion is the most common complication following tendon surgery, particularly in zone 2 of the hand. Prevention of inflammation around tendon that develops following trauma and surgery can decrease tendon adhesion formation. This study evaluates the effect of some anti-inflammatory cytokines and 5-fleurouracil in prevention of peritendinous adhesion formation. Methods: Sixteen rabbits were allocated equally into 4 groups. Tendons of index and ring fingers in zone 2 of the right hind paw were cut in all animals and then repaired. In groups 1 and 2, interferon (IFN)-α and 5-fluorouracil (5-FU) were administered locally to repair sites of index and ring fingers, respectively. In groups 3 and 4, normal saline and IFN-β were locally applied to repair sites of index and ring fingers, respectively. Three weeks later, tensiometric and histopathologic evaluations were performed. Results: The force required for removing the tendon from the sheath was not different between the groups ( P, .130), but the time that was required for removal was significantly shorter in 5-FU group ( P, .049). The strength of repair was not different between the groups in terms of force and time needed for rupture ( P, .11 and .67, respectively). In histopathologic examination, normal architecture of tendon and peritendon environment was less disturbed in IFN groups, especially in IFN-β specimens. Conclusions: Local application of 5-FU significantly reduced peritendinous adhesion. Local IFN-α and β had no significant effect on prevention of peritendinous adhesion formation. Strength of the repair was not affected by these cytokines and 5-FU.
Failure of Surgical Treatment in the De Quervain Tenosynovitis
Authors: Urbán Ferenc , Bábás Gèza , Czinke Zoltán , Rimaszèki Zsolt , Bajdik Beáta
Published: September 2016

Background: The De Quervain tenosynovitis is a rather common “easy to treat” syndrome. The majority of patients are successfully treated with conservative treatment. If the symptoms persist, the surgical release of the first dorsal compartment of the wrist usually definitively solves the problems. Sometimes, we observe patients whose problems are not solved by the surgical treatment. Aim: Our aim was to analyze the failed surgically treated cases selecting those patients whose symptoms did not disappear after a surgical treatment and find out the reason for the failure. Patients and Methods: We analyzed the last 9 years looking for those patients who returned with the persistence or the reappearance of the same symptoms like before the operation. We analyzed the intraoperative findings of the first operation, the clinical examination, and the applied treatment. In case of second operation, we analyzed the results of this. Results: In the period of 2007-2015, we found a total of 42 patients with unsuccessful operations for the De Quervain tenosynovitis. Careful clinical examination demonstrated in 7 cases the presence of a Wartenberg syndrome. All these patients underwent a successful operation for this. In 4 cases, trapezo-metacarpal osteoarthritis caused the problems. They received conservative treatment with infiltration and splinting. Ten cases presented hyper sensibility of the operated area. Six cases were treated successfully by physiotherapy. Four cases underwent reoperation. In 3 cases, the lesion, and in 1 case, the compression of the superficial branch of the radial nerve was found. Nineteen patients of the remaining 21 accepted a second operation. In all these cases, we found an unreleased tendon in an additional compartment. Conclusion: We can conclude that the failure of an operation in the De Quervain tenosynovitis is due to anatomical variations, the involvement of the radial superficial nerve, and the ignoration of another syndrome in the proximity.
Engineering Tendon With a Novel Composite Scaffold and Repairing Monkey Tendon Defect
Authors: Jiang Yongkang , Chen Bo , Liu Wei , Wang Bin
Published: September 2016

Objective: The use of biodegradable materials as scaffold is essential for tendon engineering to repair tendon defects. However, poor mechanical property of in vitro engineered tendon is a major challenge for clinical application. This study aims to develop a composite scaffold by combining different types of polymer fibers with knitted technique and to test the long-term result of the engineered tendon using this new designed composite scaffold for repairing the monkey tendon defect. Materials and Methods: Four groups of knitted scaffolds were first prepared with different ratio of polyglycolide acid (PGA) to polylactic acid (PLA): (1) 100% PGA; (2) PGA/PLA, 4:2; (3) PGA/PLA, 2:4; and (4) 100% PLA, respectively. The hydrolysis and biocompatibility of these scaffolds were tested. Then by using these scaffolds, the in vitro engineered tendon with human dermal fibroblasts and in vivo monkey tendon defect repair were investigated. Results: The hydrolysis assay showed that group 1 scaffold degraded fastest with a significant mass loss and tensile strength decrease. Increase of PLA content led to a decrease of the mass loss rate and resulted in an enhancement of tensile strength. The PGA/PLA, 4:2, scaffold maintained about 40% (62.9 ± 5.5 N) of its initial tensile strength after 4 weeks of hydrolysis and about 31% (48.9 ± 2.9 N) after 20 weeks, indicating a proper strength for implantation. The cell-scaffold biocompatibility assay revealed good cell survival and extracelular matrix (ECM) production in groups 1 and 2. At the same time, the in vitro tendon engineering with human dermal fibroblasts showed that only groups 1 and 2 formed tendon-like tissues while not in the other two groups. At 8 weeks, the failure load of engineered tendon in group 2 reached to 55.3 ± 5.2 N, a sufficient strength for in vivo implantation. Furthermore, in in vivo monkey tendon defect repairing model using the PGA/PLA, 4:2 scaffold, the repaired flexor digitorum profundus (FDP) and Achilles tendon exhibited shiny-white color and cord-like shape with a relatively smooth surface and without obvious material residue 2 years postrepair. A relatively mature tissue structure and the D-band periodicity were clearly developed. There was no significant difference in maximal load between the engineered Achilles tendon (233.7 ± 33.3 N) and the normal Achilles tendon (249.4 ± 35.2 N; P > .05). The repaired finger exhibited normal passive flexion and extension motion and participated in grasping. Conclusions: This study designed a novel degradable composite scaffold for tendon engineering, which could withstand the mechanical stretch instantly after in vivo implantation. The PGA/PLA, 4:2 composite scaffold was considered the most ideal scaffold. The long-term results for repairing the defects of flexor digitorum superficialis (FDS) and Achilles tendon in a Rhesus monkey model were encouraging, which may give insight into future clinical translation of tendon engineering.
Therapeutic Results of Nonunion of the Scaphoid Including Intractable Cases
Authors: Takase Katsumi , Yamamoto Kengo
Published: September 2016

Purpose: The nonunion of the scaphoid is caused by various mistreatment of the scaphoid fracture, including long-term untreated or inadequately treated cases. We report our findings and discussions on postoperative outcomes and selection of surgical procedures in 47 cases including 13 cases of refractory scaphoid nonunion that required multiple operations. Materials and Methods: Those 47 cases included 44 males and 3 females with an age range of 15 to 65 at the time of operation (mean age: 27.8). Focal curettage and bone graft for the nonunion site were applied in 40 cases excluding 7 with scaphoid nonunion advanced collapse (SNAC) wrist. As the methods of bone graft, Russe procedure was applied in 4 cases and Herbert procedure was applied in the other 36 cases. As the internal fracture fixation materials, K-wires were used in 6 cases, Herbert screw in 8 cases, Bold screw in 5 cases, Whipple screw in 3 cases, and Acutrak mini screw in 18 cases. Meanwhile, the proximal part of the scaphoid was resected with tendon ball graft, 4-corner fusion, or modified Graner procedure was applied in the 7 cases with SNAC wrist. Postoperative follow-up periods were 2 to 10 years (mean: 4 years 7 months). Results: Bone union was observed in 28 out of 40 cases. The remaining 12 cases included the following: 5 cases which went untreated for at least 15 years, 3 with the application of Herbert-Whipple screw, 2 with the application of Bold screw, 1 with the inadequate insertion of Acutrak mini screw, and 1 with repeat nonunion caused by broken Acutrak screws. Revision surgery was conducted for the all cases: 1 with Russe procedure, 1 with Herbert procedure, and other 10 with vascularized bone graft procedure (2 with Zaidemberg procedure and 8 with the second metacarpal bone graft). As a result, bone union was observed in 10 cases. As the final treatment outcome, the ratio of grip strength of an operated hand to that of nonaffected hand was 50% to 114% (mean: 89%) and flexion-extension arc was 60° to 180° (mean: 121°). Conclusions: We had a satisfactory outcome for our treatment of the scaphoid nonunion. However, it should be noted that pedicle vascularized bone graft procedure needed to be applied to long-term untreated or repeat nonunion cases.
Subchondral Cyst Involving the Ulnar Aspect of the Lunate
Authors: Lee Jae-Sung
Published: September 2016

Introduction: The etiology of subchondral cyst formation is not well known; however, there are several articles which address that it can be occurred by recurrent minor trauma which results in cartilage injury and consequently makes joint fluid to enter the bone marrow spaces of the subchondral bone to form a cyst. The purpose of this study was to find out the relationship between lunate cyst with ulnocarpal impaction which could give repeated mechanical stress to lunate. Methods: From March 2012 to January 2014, total of 387 patients’ 3D upper extremity computed tomography (CT) images at Chung-Ang University Hospital that includes wrist images were reviewed. Among these patients, 10 patients had been diagnosed of ulnocarpal impaction syndrome (group 1). Nine patients had been treated with ulnar shortening and 1 patient had injection to ulnar fovea. In the rest of 377 patients, none of the patients had specific ulnar side pain of their wrist (group 2). Among these images, 35 patients (9.26%) had lunate cysts positioned near distal ulna which can be suggested as ulnolunate impaction. They were assessed for difference, correlation, and logistic regression to evaluate if there is true relationship between lunate cyst and the degree of ulnar positive variance or age. Results: In total, 241 patients had ulnar positive variance on their wrist and 41 patients (17%) had lunate cyst. The prevalence of lunate cyst was significantly higher in group 1 (6 patients [60%] vs. 35 patients [9.26%], P < .001, respectively). However, there was no difference of the size of lunate cyst in groups 1 and 2 ( P = .242). The size of lunate cyst had no correlation to ulnar positive variance or patient’s age as well ( P = .857, P = .349, respectively). Logistic regression analysis demonstrated that the presence of lunate cyst was associated with the patient’s age (odds ratio = 1.045, P < .001) and also the association between the presence of lunate cyst and the degree of ulnar positive variance was found (odds ratio = 1.186, P = .022). Patients with lunate cyst had more positive ulnar variance ( P = .020). However, only 15% of patients with lunate cyst had symptomatic ulnocarpal impaction syndrome. In addition, in the patients with lunate cyst, there was no difference of cyst size whether the patients had the symptomatic ulnocarpal impaction syndrome or not ( P = .262). Conclusion: In our study, the lunate cyst was associated with patient’s age and ulnar positive variance. However, we could not find significant effect of symptomatic ulnocarpal impaction on the formation of subchondral cyst in lunate.
Retrograde Percutaneous Scaphoid Type II Nonunion Screw Fixation in Schernberg Zones 2 to 4
Authors: Taleb Chihab
Published: September 2016

Background: Regardless of the treatment used, 25% to 45% of scaphoid fractures do not heal. Open approach surgery compromises vascularization and destabilizes ligamentous attachments. The aim of this retrospective study was to assess the value of retrograde percutaneous screw fixation of Alnot stage IIA and B scaphoid nonunion considering Schernberg zone 2 to 4. Material and Method: This series included 38 patients with a mean age of 31 years old. Following the Alnot classification, there were 16 stage IIA nonunions (12 in zone 3 and 4 in zone 2 according to the Schernberg classification) and 22 stage IIB nonunions (9 in zone 3 and 13 in zone 2). The mean delay time between the initial trauma and the surgical treatment was 10 months. Percutaneous retrograde fixation was performed with a cannulated 2.7 mm compression screw. Results: At 25 months follow-up, 31 nonunions had healed (81.6%), among which 14 were stage IIA (87.5%) and 17 stage IIB (77.3%) at an average 6.3 months. Average pain was 1.6. The average Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) was 17.3/100. Compared with the opposite side, the average range of motion was 84.8% in flexion, 84.7% in extension, 98.9% in pronation, 96.5% in supination, 96.8% in ulnar inclination, and 86.4% in radial inclination, with an average 80.4% grip strength. Seven patients did not heal after screw fixation among which 4 healed after further electromagnetic stimulation and 3 after vascularized bone graft. Discussion: According to our results, stage IIA nonunions can heal with a simple retrograde percutaneous screw fixation. Concerning stage IIB, same procedure could be enough; however, we recommend the addition of a cancellous bone graft under arthroscopy. According to the authors, open surgery procedures are preferred when percutaneous procedure failed.
Arthroscopic Treatment of Scaphoid Nonunion Without Bone Graft and Distal Radius Core Decompression
Authors: Caloia Martín F. , Caloia Hugo F. , Scotti Diego González , Fernández Diego L.
Published: September 2016

Introduction: The scaphoid bone is the most commonly broken carpal bone and an untoward characteristic of this bone is its unpredictable union. The management of scaphoid nonunion still remains controversial with a reported failure rate up to 40% and absence of a “gold standard” of treatment. Based on the new concepts of the potential osteogenic capacity of the nonunion cells with the ability to heal, the encouraging results generated by increasing vascularization within the metaphyseal radius, and ulna decompression used in the treatment of Kienböck disease as well as the advantages of minimal surgical trauma using percutaneous and arthroscopic techniques, we propose to treat scaphoid nonunions with (a) arthroscopic-assisted reduction and internal fixation (AASSIF) and adding (b) metaphyseal core decompression of the distal radius (MCDDR) in advanced stages, without bone graft. Material and Methods: We evaluated retrospectively 48 patients with scaphoid nonunions treated prospectively by (AASSIF) with (MCDDR) in 48 cases. The average age was 30.63 years. The right side was affected in 31 patients, and 79.7% corresponded to the dominant extremity. The mean time from injury to surgery was 22.93 months. The nonunions were grouped according to the Slade-Dodds classification. Results: Scaphoid union was obtained in 44 patients, 4 patients failed to obtain healing. One patient decided to not be operated again, because of the lack of symptoms. Three required a new surgical procedure 9 months later. In 2 patients, the failures were by improper placement of the screw, although these patients had no symptoms. In cystic and/or magnitude bone nonunion defects with large zones of necrosis, defect filling was observed, even in those cases in which the loss of bone stock exceeded 10 mm. The biological effect of the metaphyseal decompression characterized by an increased hyperemia over the radial column was demonstrated with SPECT studies. The visual analogue scale showed an average of 1.04 (0-2) postoperative pain. The average postoperative range of function was 65.3° extension (range, 46° to 88°), 69.2° flexion (range, 55° to 88°), 10.7° radial deviation (range, 5° to 20°), and 26° ulnar deviation (range, 20° to 37°). The average Mayo score was 95 ± 6. Conclusion: We recommend arthroscopic-assisted internal fixation without bone grafting and core decompression of the distal radius for young or middle-aged nonsmoking patients with scaphoid nonunions including cystic and deformed types, typical of advanced stages. The method is not recommended for nonunions with significant sclerosis or in those with a very small proximal fragment in which solid screw fixation would be questionable.
Stabilization of Scaphoid Fractures by 1 or 2 Headless Bone Screws
Authors: Quadlbauer S. , Pezzei Ch. , Porta J. , Hausner T. , Leixnering M.
Published: September 2016

Objective/Hypothesis: Scaphoid fractures are a rare and account only 2% to 3% of all fractures and 10% of all hand fractures. But they make up to 60% of all carpal fractures. In all, 70% to 80% of the blood supply of the scaphoid occur through terminal vessels of the radial artery. Due to its special anatomy and blood supply, Herbert and Fisher introduced in 1984, for the first time, the headless bone screw. Since then many studies were published with the aim to improve stability. So new screw designs were developed both biomechanically and clinically. Displaced scaphoid fractures are treated typically with headless bone screws, but a treatment with 1 screw will not lead to absolute stability. Due to the complex and multidirectional movements of the scaphoid, 1 screw is, specially against rotational forces, insufficient. Therefore, some authors started to use temporary antirotation k wires. Main aim of this study was to compare radiological outcomes between scaphoid fractured stabilized by 1 and 2 headless bone screws. So the null hypothesis was that there is no difference in healing rate between scaphoid fractures treated by 1 and 2 headless bone screws. Secondary aim of this study was to compare functional results between the groups. Materials and Methods: All B2 scaphoid fractures from January 2009 till February 2015 had been included in this study and analyzed retrospectively. Inclusion criteria were (1) stabilization by 1 or 2 headless bone screws, (2) B2 fracture of the scaphoid according to the classification of Herbert and Krimmer, and (3) existing preoperative computed tomography (CT) scan. Exclusion criteria included (1) additional injuries of the wrist and (2) prior existing wrist injuries. For statistical purposes, age, gender, cause of accident, and range of motion had been analyzed. As well, the last x-rays and CT scans were analyzed in respect of fracture healing, arthrosis, and complications. Results: Forty-five patients met inclusion criteria. Thirty-two had been stabilized by 1 and 13 by 2 headless bone screws. Mean interval between injury and surgery was 4 weeks and mean follow-up interval 7 months. At last follow-up, 12/13 (92%) healed in the group treated by 2 headless bone screws and 22/32 (69%) in the group stabilized by 1 screw. No differences in respect of range of motion were accounted. Conclusion: Stabilization of B2 scaphoid fractures by 2 headless bone screws lead to better healing rates than a stabilization by 1 screw with equally functional outcome.
Gadolinium-Enhanced Magnetic Resonance Imaging Evaluating Lunate Vascularity in Lichtman Stage IIIB Kienböck Disease
Authors: Xu Gong , Min Jiang Zheng , Jin Lu Lai
Published: September 2016

Purpose: In the treatment of stage IIIB Kienböck disease, the ailing lunate preservation or resection is at the discretion of the surgeon’s preference with no clearly defined indications. The aim of this study was to identify whether gadolinium-enhanced magnetic resonance (MR) imaging is useful in the assessment of lunate vascularity in stage IIIB Kienböck disease, thereby providing an indication for lunate preservation or excision procedures. Methods: From February 2014 to September 2015, 7 patients of 46 years on average were diagnosed as stage IIIB Kienböck disease. According to Goldfarb’s modification of Lichtman’s classification, stage IIIB was established based on radioscaphoid (RS) angle of 60°. All patients underwent preoperative MR imaging with gadolinium enhancement and lunate excision arthroplasty during the vascularized capitate transposition. Histopathological examination of the excised lunate was performed to observe whether there existed vascular structures in the ailing bone. The enhanced area on the postcontrast MR imaging was compared with nonnecrotic area within the lunate specimen with regard to the shape and size. Results: In 6 patients, the precontrast T1-weighted imaging without fat saturation demonstrated hypointense signal within the lunate, whereas the postcontrast T1-weighted imaging with fat saturation demonstrated heterogeneous hyperintense signal within the lunate. The corresponding histopathological examination confirmed existence of vascular structures within the lunate. In 1 patient, both the precontrast and postcontrast T1-weighted imaging without fat saturation showed hypointense signal within the lunate, and the corresponding histopathologic examination confirmed complete osteonecrosis without vascular structures. The correlation of the area percentages between enhanced zone and nonnecrotic zone was significant ( r = .897). Conclusions: The present study revealed that the presence or absence of vascularity within stage IIIB lunate could be distinguished preoperatively by enhanced MR imaging.
Comparative Study of Ulnar-Shortening Osteotomy, Arthroscopy Wafer Procedure, and Distal Metaphyseal Ulnar-Shortening Osteotomy for Ulnar Impaction Syndrome
Authors: Yin Hua-Wei , Chen Yu-Tong , Xu Jing , Shen Yun-Dong , Xu Jian-Guang , Gu Yu-Dong , Xu Wen-Dong
Published: September 2016

Purpose: To investigate the results of ulnar-shortening osteotomy, arthroscopy wafer procedure, and distal metaphyseal ulnar-shortening osteotomy for the treatment of ulnar impaction syndrome. Methods: In all, 33 cases of ulnar impaction syndrome, which were treated with ulna orthopedic surgery in our hospital from June 2011 to May 2014, were studied retrospectively. They were divided into 3 groups: group A, including 10 cases who underwent ulnar-shortening osteotomy; group B, including 19 cases who underwent arthroscopy wafer procedure; group C, including 4 cases who underwent distal metaphyseal ulnar-shortening osteotomy. Wrist functions of these cases were evaluated before the surgery and after the surgery every 3 months. The evaluations included visual analogue scale, range of motion, grip strength, and the modified Mayo wrist scores. Results: The mean follow-up period was 25 months (SD, ±14). In group A, 9 cases underwent pain relief, 1 better. In group B, 13 relief, 5 better, and 1 no improvement. In group C, 1 relief, 2 better, and 1 no improvement. Conclusions: Ulnar diaphyseal shortening osteotomy, arthroscopy wafer procedure, and distal metaphyseal ulnar-shortening osteotomy are effective surgical options of ulnar impaction syndrome. Ulnar-shortening osteotomy is reliable procedure in pain relief. The shape of the distal radioulnar joint in the midcoronal plane should be considered in the decision-making stage.
Unstable PIP Fracture-Dislocations
Authors: Riano Felix , Suarez Fabio , Garcia Aida , Naquira Luis F.
Published: September 2016

Purpose: Multiple techniques exist as part of the armamentarium for the management of Proximal Interphalangeal (PIP) joint fracture-dislocations. Of these, unstable lesions with hard reduction are the most complicated to handle. This study aims to compare the biomechanical results obtained with volar plate arthroplasty (VPA) and the hemihamate arthroplasty (HHA). Materials and Methods: We used 20 fingers from 8 cadaveric hands. We created a 50% defect on the base of the middle phalanges to simulate an unstable fracture-dislocation. The 2 techniques were assigned randomly to the different fingers (10 for each technique). A biomechanical harness was used to carry all PIP joints from extension to complete flexion. The amount of dorsal translation of the subluxation was recorded digitally at full extension. We recorded the angle at which subluxation occurred for each specimen. Results: The average of dorsal displacement of the middle phalanx did not show statistical significant difference (0.02 mm for the HHA and 0.01 mm for the VPA). All the fingers with VPA coursed with flexion contracture as opposed to the HHA. Conclusions: The VPA and the HHA are current techniques used for the management of unstable PIP fracture-dislocations. The 2 procedures manage to maintain reduction throughout the range of flexo-extension. Surgeons must choose between a little more invasive technique with double incision, hamate block bone graft with potential discomfort in the donor area and screw fixation on the recipient middle phalanx not leading to flexion contracture (HHA); versus a single surgical approach technique -dorsal or ventral- which provides stability but may course with certain flexion contracture.
Arthroscopic Repair of Triangular Fibrocartilage Complex
Authors: Riano Felix , Chargot Michelle
Published: September 2016

Purpose: To compare the biomechanical strength of the foveal repair (distal ulnar tunnel technique) and the traditional outside-in repair to the capsule in Type IB Triangular Fibrocartilage Complex (TFCC) tears. Materials and Methods: The distal ulna and the TFCC of 8 matched pair cadaveric wrists were dissected. We created a type IB tear in each specimen. In 8 wrists, the tear was repaired with the conventional outside-in technique to the capsule with two 2-0 fiberwire vertical mattress stitches. In the other 8 wrists, the tears were repaired by drilling a 3 mm tunnel at the distal ulna from the lateral cortex to the fovea. The 2-0 fiberwire sutures pierced through the superficial and deep portions of the TFCC, and were recovered out through the tunnel on the lateral cortex. The TFCC was pulled back down to the fovea. The final fixation in this group was obtained by securing the sutures to the cortex with a small anchor coupled with a 3 × 8 mm interference screw in the tunnel after dialing proper suture tension. The strength of the repair was assessed with a materials testing machine (MTM). The repairs were subjected to load until a 2-mm gap was created on the site of the repair, and subsequently increased the load to produce failure. Failure mechanism was obtained for each repair. Results: The foveal repair was statistically stronger (18 + 4 N) than the capsular outside (2.5 + 1 N; P < .05) for the 2-mm gap formation and load to failure (82 + 2 N and 51 + 5 N, respectively; P < .05). Loosening of the sutures was the mechanism of failure for both repairs. Conclusions: The arthroscopic distal ulnar tunnel technique was stronger than the capsular outside-in biomechanically. Type IB TFCC tears compromising both the superficial and deep portion commonly course with distal radioulnar joint (DRUJ) instability. A capsular repair may not be enough under these circumstances. The arthroscopic distal ulnar tunnel is a very reproducible technique, which allows repair of the superficial and distal portions of the TFCC back to the bone (original anatomical point) preventing DRUJ instability.
The Impact of Transferred Vascularized Toe Joint Length on Motion Arc of Reconstructed Finger Proximal Interphalangeal Joint
Authors: Hsu Chung-Chen , Loh Charles , Moran Steven L. , Lin Yu-Te
Published: September 2016

Objective: Vascularized toe joint transfer for finger proximal interphalangeal joint (PIPJ) reconstruction is a well-described technique in the literature. However, the reconstructed PIPJ is known to have issues with suboptimal range of motion and extension lag. One of the reasons for this problem is the length of the intercalated bony segment. There is a lack of evidence and consensus regarding the optimal length of the intercalated segment. This study hence was performed to determine the impact of the intercalated segment length on the subsequent passive arc of motion (AOM) and extension lag of the reconstructed PIPJ. Materials and Methods: We harvested the intercalated joint graft (the toe PIPJ along with its associated extensor tendons) from the lesser toes and transferred it to the finger of cadavers. A predetermined constant PIPJ defect size of 2 cm was created on the finger. By insetting 3 different lengths of the intercalated segment to the finger PIPJ, we investigated the effect of shortened (1.5 cm), exact (2.0 cm), or lengthened (2.5 cm) intercalated segment lengths on the AOM and extension lag of the reconstructed PIPJ. Results: The average AOM of finger PIPJ was 81.0° ± 19.1° and that of the toe PIPJ was 53.6° ± 16.1°. In the group with longer intercalated segment, the average AOM was 29.9° ± 10.5° with an extension lag of 32° ± 11.7°. In the group with equal intercalated segment length, the average AOM was 49.1° ± 11.5° with an extension lag of 15.4° ± 10.6°. In the group with shorter intercalated segment, the average AOM was 70.9° ± 12.6° with an extension lag of 8.4° ± 8.9°. Conclusions: From our study, shortening the intercalated segment may provide the most reduction in the extension lag of the reconstructed PIPJ. Future studies could involve further refinement of the amount of length to be shortened. This would probably lie between 0 to 5 mm.
Salvage Procedures for Advanced Carpal Collapse
Authors: Celigoj Vanja , Deglmann Claus , Lukas Bernhard
Published: September 2016

Objective: Salvage procedures for advanced carpal collapse (scapholunate advanced collapse [SLAC], scaphoid nonunion advanced collapse [SNAC]) include mainly four-corner fusion (4-CF) and the proximal row carpectomy (PRC). To facilitate the decision-making procedure between the two operations, we initiated a follow-up study of our salvage procedures. Methods: Between 2008 and 2015, we performed 248 salvage procedures in our Hand Surgical Department. In all, 172 4-CFs and 76 PRCs were carried out, of which we were—so far (study is still going on)—able to follow up retrospectively n = 67 of the 4-CF group (mean follow-up 33 months) and n = 27 of the PRC group (mean follow-up 34 months). We evaluated the pain score (visual analogue scale [VAS] 1-10) in rest and on exertion. Disabilities of the Arm, Shoulder and Hand (DASH) scores were routinely recorded preoperatively, at 6 months and on follow-up exam. Grip strength (Jamar) and range of motion (ROM) were examined on the operated and on the opposite hand. Results: The 4-CF group showed a mean DASH score of 18.9 (preoperative 44.3), and the PRC group 26.5 (preoperative 46.9). Pain was reduced for the 4-CF group to 0.90 VAS (during rest: R) and 3.29 VAS (on exertion: E)—2.87 (R) and 7.5 (E), preoperatively. The PRC group claimed a pain score of 1.36 VAS (R) and 3.96 VAS (E)—1 (R) and 7.0 (E), preoperatively. Jamar Grip was 82.7% compared with the nontreated hand in the 4-CF group and 84.4% in the PRC group. The active ROM for wrist extension and flexion showed in the 4-CF group 87.2° and in the PRC group 97.9° preoperatively, worsened 6 months after the operation in both groups (54.9°, respectively, 58°) and was measured in the follow-up 68.7° in patients with 4-CF and 77.2° in patients with PRC. In addition, 75% would choose the same treatment again and were satisfied in both groups. Conclusions: In our patients, 4-CF and PRC proved to be reliable procedures for advanced carpal collapse. Although there is no significant difference in the outcome, we tend to suggest 4-CF to younger patients due to the anatomic reconstruction and the tendency of a (not significant) better DASH and a lower pain score on exertion. Because of the possibility of osteoarthritis of the lunate fossa, we tend to promote the PRC procedure to patients with less demand or higher age, if not yet progressed to a third stage carpal collapse.
Sauve-Kapandji Procedure in Patients With Advanced Distal Radioulnar Joint Arthritis
Authors: Chung Yang-Guk , Lee Yong-Suk , Shin Seung-Han , Kim Dong-Hyun
Published: September 2016

Purpose: We evaluated the clinical and radiographic outcome of the Sauve-Kapandji procedure for the treatment of advanced distal radioulnar joint arthritis. Materials and Methods: Between January 2001 and July 2013, 26 patients, 31 wrists were treated for advanced distal radioulnar joint arthritis with Sauve-Kapandji procedure. Twenty-two patients (27 wrists) had rheumatoid arthritis and the remaining 4 patients (4 wrists) had osteoarthritis. The average age of patients was 50 years (range, 25-74 years). Twenty-one patients were women and 5 were men. Patients were evaluated in terms of wrist pain, bony union, instability of the ulnar proximal stump, ulnar stump pain, range of motion, and other complications. Pain was evaluated using a visual analogue scale (VAS). Radiographic evaluation included calculation of the carpal translation index to assess the extent of ulnar translation of the carpus. The average follow-up period after surgeries was 36.8 months (range, 6-152 months). Results: Pain was resolved in 24 patients with 29 wrists, but mild pain was remained in 2 patients (2 wrists). The average VAS score improved from 4 ± 1.88 preoperatively to 0.71 ± 0.9 at the last follow-up ( P = .001). Bone unions in distal radioulnar joint were obtained in all 26 patients, 31 wrists at mean 10.7 (range, 6-28) weeks after operation. The supination/pronation range of motion was changed from 55/50° preoperatively to 79/71° at postoperative 6 months follow-up ( P = .31). The mean carpal translation index did not change after the operation. Conclusion: The Sauve-Kapandji procedure is a reliable method of relieving pain, preserving range of motion (supination/pronation) and preventing ulnar translation of the carpus in managements of the severely destroyed distal radioulnar joints.
Radiologic Assessment of Scaphoid Dorsal Translation in Patients With Scapholunate Instability
Authors: Villa Jordan , Saltzman Eliana , Mintz Douglas , Wolfe Scott , Lee Steve
Published: September 2016

Objective/Hypothesis: The objective of this study is to radiographically assess scaphoid dorsal translation in patients with scapholunate instability. We hypothesized that (1) there is a significant difference in scaphoid dorsal translation in lateral plain radiographs in patients with scapholunate instability when compared with controls, (2) magnetic resonance imaging (MRI) will correlate with radiographic dorsal scaphoid translation measurements in patients with scapholunate instability. Materials and Methods: This was a retrospective case-controlled study of 24 patients with scapholunate ligament (SLIL) injury. Five carpal alignment indices were assessed on radiographs: scapholunate gap in clenched pencil view, scapholunate angle, radiolunate angle, scaphoradial angle, and scaphoid dorsal translation. Scaphoid dorsal translation was defined as the distance (mm) between the centers of the best fit circles for (1) the scaphoid proximal articular surface and (2) the scaphoid fossa, using the external palmar cortex of the radius as the orientation axis. Two examiners measured these radiographic indices, and interobserver reliabilities were determined and expressed as intraclass correlation coefficient (ICC). For convergent validity testing, the correlation between the radiograph dorsal translation and dorsal translation in MRI was assessed. Independent sample t test was used to compare the alignment indices between cases and controls. Results: Significant differences were found between the cohorts in the following measurements: scapholunate angle ( P = .001), scaphoradial angle ( P = .04), and scaphoid dorsal translation (mm) ( P ≤ .001). However, no difference was found between groups for the radiolunate angle measurement ( P = .665). Interobserver reliability for scaphoid dorsal translation in radiographs and MRI was excellent with ICCs of .82 and .92, respectively (95% confidence interval [CI], 0.565-0.925, and 0.111-0.914, respectively). The correlation between radiographs and MRI scaphoid dorsal translation was moderate for reader 1 with ICCs of .505 (95% CI, 0.021-0.161) and excellent for reader 2 with ICCs of .908 (95% CI, 0.135-0.968). Conclusions: This study introduces a new radiographic parameter, scaphoid dorsal translation, in patients with diagnoses of scapholunate instability. This parameter is, theoretically, the most correlative to symptoms as it shows whether the joint is statically subluxated. Radiographic scaphoid dorsal translation is correlated with MRI findings and might represent a lower cost option for early detection of the radioscaphoid joint eccentric wear seen in some stages of scapholunate instability.
Mid-term Outcomes in Perilunate Dislocations
Authors: Breyer Juan Manuel , Vergara Pamela , Perez Alfonso , Sotelo Paula , Prado Nicolas
Published: September 2016

Introduction: Perilunate dislocations and fracture-dislocations are often related to fair or poor results. The goal of this study is to analyze radiographic and functional outcomes of surgically treated patients with perilunate injuries. Methods: We assessed a retrospective series of 37 patients (36 male), mean age 36 (range, 17-71), with a mean follow-up of 4 years (range, 1-10.1). All were subject to worker’s compensation. All patients had dorsal perilunate dislocations; there were 13 cases of perilunate dislocation and 24 cases of perilunate fracture-dislocations. Seventeen patients had a scaphoid fracture and 7 presented other fractures (radial styloid, triquetrum, etc.). All patients had surgical treatment with k wire carpus stabilization, open ligamentous repair (24 cases), scaphoid fixation (9 k wire, 8 headless screws), and other bone fixation when indicated. The Mayo wrist score (MWS) was used for functional evaluation. Radiographic examination was focused in osteoarthritis and instability, according to Herzberg classification. We defined poor results patients with at least one of the following: MWS < 60 points, advanced osteoarthritis, scapholunate instability (SL gap > 5 mm or SL angle > 70°), scaphoid nonunion, or major surgery: proximal row carpectomy (PRC), wrist arthrodesis, or nonunion surgery. Results: Patients had a mean flexion of 44.8° (SD 15.2) and mean extension of 46.8° (SD 16.7). Two cases had severe stiffness (less than 30° arc of motion). Mean grip strength was 66% of contralateral (SD 19.2). According to MWS, 1 patient had excellent results, 7 good (19%), 18 fair (49%), and 11 patients poor results (30%). According to our definition of poor results, 24 of 37 (65%) patients had an unsatisfactory outcome. Radiographic evaluation showed 10% of advanced osteoarthritis and 45% of instability signs. Six patients were classified as Herzberg A (normal alignment without osteoarthritis) and 11 patients as A1 (normal alignment with osteoarthritis). One patient showed instability without osteoarthritis (B) and 11 patients showed instability with osteoarthritis (B1). Seven patients had x-rays modified by the treatment (C). Five patients with trans-scaphoid fracture dislocation had nonunion, 4 of them went to bone graft and only 2 of these get union. One scaphoid nonunion went directly to PRC. There were 3 total wrist arthrodesis (2 due to arthritis and 1 due to instability) and 4 PRC, 3 in context of failed nonunion treatment and 1 in a severe and complex instability. Discussion: Perilunate dislocations and fracture-dislocations are complex injuries with a high rate of unsatisfactory outcomes. Our series showed poor clinical outcomes in 65% which correlate with the poor and fair results in the MWS. We observed a high rate of nonunion in trans-scaphoid dislocations, carpal instability, and articular degenerative changes. These factors would be independent of patient functional performance.
Shortening Osteotomy for Ulnar Impaction Syndrome
Authors: Lόpez José Joaquín Díaz , Alonso Ma. Francisca Vázquez , Pérez Jesús Javier Briseño
Published: September 2016

Objective: To assess the outcomes of patients with ulnar impaction syndrome, undergoing ulnar shortening osteotomy. Material and Methods: Descriptive, longitudinal, and ambispective study. In all, 26 patients were assessed, in which an ulnar shortening osteotomy was performed during 4 years, with Mayo and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scales, force measurement, range of motion, and pain. Patients who underwent shortening osteotomy because of ulnar impaction syndrome were included. Frequency and descriptive statistics and Wilcoxon rank sum test for a single sample was performed. It was considered as statistically significant, a value P < .05. Introduction: The ulnar impaction syndrome is a positive ulnar variance, which causes an impingement of the triangular fibrocartilage complex between the ulnar head and lunate in one side and the pyramid on the other side. It is characterized by a pressure increase in a longitudinal direction. Ulnar shortening osteotomy is an alternative management that seeks decompression of the triangular fibrocartilage complex, by an extra-articular ulnar shortening at its distal third, to decrease pain and increase the range of motion. Results: Mean age of patients was 39 years. The predominant sex was male in 67%. In 65% of the cases, the affected hand was the right. The follow-up of the patients was in average 41 months, the patient with a longer observation time was 63 months and the shortest time 13 months. The improvement in pain was evident, from an average of 8 preoperative to 1 postoperative, with mild in most patients with disabling residual pain in only 1 case. Improvement was observed in the range of motion in all patients, with improvement in flexion, extension, radial, and ulnar deviation ( P < .05). The Mayo scale reported on average a score of 82. The QuickDASH scale postoperative indicated an average score of 16. With these results, we found that 85% of patients studied had no disabilities, 11% had mild disability, 4% moderate disability, and none presented severe disabilities. The complications were 1 case of nonunion (3.8%), complex regional pain syndrome (3.8%), and did not show any case of infection. In 7 cases (27%), removal of osteosynthesis material was required by pain and swelling at the surgical site. Conclusions: Ulnar shortening osteotomy tight the remaining ligaments and the interosseous membrane, setting the articular surface in a biomechanical advantage. It is an extra-articular simple technique, with a low cost and does not require special implants, which has a tendency to decrease pain and improve functional disability of the limb.
Static Progressive Orthoses
Authors: Schwartz Deborah A.
Published: September 2016

Purpose: The purpose of this research is to increase understanding of the current levels of evidence supporting the use of static progressive orthoses, and to provide clarity on appropriate diagnoses, outcome measures, and duration of use for this intervention. Rationale: Static progressive orthoses are an intervention commonly provided for clients with stiffness and/or limited range of motion (ROM) of upper extremity joints, due to trauma or injury. This type of orthosis incorporates nonelastic components to apply force to the stiff joint or tissue, holding it at end-range position to improve passive motion. There are only a limited number of studies on the use of static progressive orthoses for the upper extremity with a small number of clients enrolled. Design: A literature search of the current evidence supporting static progressive orthoses for treatment of stiff upper extremity joints was performed to identify information regarding common diagnoses of clients treated with this type of orthotic intervention, outcomes achieved, wearing schedules, and duration of orthotic use. Participants: This research examined the current levels of evidence supporting the use of static progressive orthoses for clients with limitations in ROM of the upper extremity following surgery or trauma (orthopedic pathologies). Analytic Methods: The current evidence supporting the use of static progressive orthoses is found in 11 studies on the elbow, 2 studies on the forearm, 3 studies on the wrist, 2 studies on stiff fingers, and 2 systematic reviews. The data provided in these 20 studies on client diagnoses, type of orthotic design, outcome measures, and duration of use are analyzed and described. Conclusions: Clients benefit from the use of static progressive orthoses by demonstrating increased ROM, increased function and grip strength, and decreased pain. The current evidence includes 20 studies that present information on appropriate client diagnoses, outcome measures, protocols of use, and average duration of wear.