Techniques in Hand and Upper Extremity Surgery最新文献

Metastatic bone disease of the radius is rare, but the functional loss of an upper extremity can profoundly impact patient quality of life and hinder independent living. When the mechanical stability of the radius is compromised, surgical intervention such as intramedullary (IM) nailing or plating may be considered in combination with radiation therapy (RT) to alleviate pain, control local tumor progression, and provide immediate stability to the bone. There are several limitations to traditional metallic IM nails, such as limited use in adults, complicated postoperative CT planning for RT, the obscuring of local tumor recurrence or progression, and metal scattering that affects RT dosing. Photodynamic nail IM stabilization is a novel, minimally invasive surgical technique that circumvents several of these shortcomings, in which a photocurable monomer is introduced through a balloon that can conform to the irregularities of an osteolytic metastatic lesion. We describe the photodynamic nail technique for the treatment of impending and/or pathologic fractures of the proximal radius.

In this article, a new modification technique is described to reconstruct large bone defects of the distal radius after en bloc giant cell tumor resection with a proximal vascularized fibula graft. We discuss anatomic landmarks during graft harvest as well as reconstructive considerations. We aim for a durable reconstruction with optimal mobility and, therefore, introduce a fibular-scaphoid-lunate fusion with a reconstruction of the distal fibula-ulnar joint with an "Adams-Berger-like" procedure with a palmaris longus tendon. The clinical results of 3 patients who underwent this procedure were included in this study and showed promising results in terms of wrist mobility, union, and overall patient satisfaction during follow-up.

The subcondylar fossa is the bony depression between the articulating surface of the proximal and middle phalanges of the fingers that allows for full flexion at the proximal interphalangeal joint. A bony block may form in the subcondylar fossa secondary to the malunion of a proximal phalangeal neck fracture. If there is a substantial loss of flexion, surgical correction could be indicated. Corrective osteotomy is technically challenging in the proximal interphalangeal joint area as the phalangeal head is small, creating fixation challenges and carrying the risk of avascular necrosis and joint contracture. Current literature describes multiple techniques with varying complexity and there is no consensus on the ideal operation to manage these fractures after malunion. The subcondylar fossa reconstruction first proposed by Simmons and colleagues is a simple and safe surgical technique that involves directly removing the bony block at the phalangeal neck. Despite its utility, it has not been described in pediatric patients since its original report of 3 patients in 1987. This study describes the subcondylar fossa reconstruction technique and presents the outcomes of its application in 4 pediatric patients.

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

Painful, end-stage elbow arthritis in young, active patients remains a challenging and unsolved problem. Lifetime weight-bearing restrictions make total elbow arthroplasty (TEA) an unrealistic and unsustainable option for most of these patients, and the alternatives for treating a failed TEA are limited and mostly unsatisfactory. Elbow interposition arthroplasty can provide good pain relief and reasonable restoration of motion while avoiding weight-bearing restrictions. However, resurfacing materials such as fascia, Achilles tendon, and skin are not durable and are likely torn or displaced. We propose using meniscus allograft as the interposition material, as it is strong, robust, and designed to resist high compressive and shearing loads. It can heal the native tissue, and the topological properties of an amphitheater-shaped meniscus wrapped in a semicircle anatomically simulates the native shape of the trochlea, conferring additional stability that abets concentric motion. We present a series of 5 patients who underwent meniscal allograft arthroplasty from 2021 to 2023 at a single institution. All patients had resurfacing with meniscus allographs with supplemental stabilization using a double internal joint stabilizer. All patients demonstrated improvement in pain and ulnohumeral range of motion. Our technique of meniscus allograft interposition arthroplasty demonstrates good short-term pain relief and functional improvement. Further follow-up is warranted to assess the longevity of the meniscus interposition. Level of Evidence: Level IV-treatment study.

Vascularized osteochondral flap reconstruction is an innovation with several potential benefits, but there are limited described autologous donor site options. This study explores the distal clavicle as a viable donor site for vascularized free osteochondral tissue transfer. Cadaveric dissection was performed in which a 39-year-old male with a comminuted fracture of the right distal humerus underwent open reduction and internal fixation. The patient later presented with avascular necrosis of the lateral column of the distal humerus and right trochlea and underwent reconstruction of the distal humerus with iliac crest bone graft and vascularized free osteochondral transfer of the distal clavicle. The distal clavicle was harvested with its periosteum and a small muscle cuff based on the acromial branch of the thoracoacromial system. The authors report a novel technique for distal clavicle osteochondral flap harvest and present a case in which the technique was used successfully in complex elbow reconstruction.

From an anatomic perspective, this paper delineates the proximal radial bone branches of the radial artery (RA). We also report the successful clinical use of a vascularized proximal radius bone graft (VPRBG), supplied by the RA, in a complex case involving a massive osseous elbow defect. In 10 latex-colored upper limbs from fresh human cadavers, RA branches were dissected under ×2.5 loupe magnification, noting all periosteal and osseous branches for the proximal radius. VPRBG length was measured. In the proximal forearm, the RA provides 10 (range: 7 to 14) periosteal and osseous branches to supply the area from the radial head to the proximal diaphysis. A 15 cm (11 to 17) vascularized bone graft can be harvested from the proximal radius, and RA dissection generates a 12 cm (9 to 15) pedicle with a wide arc of rotation, readily capable of reaching the distal part of the humerus. We used a 14 cm long VPRBG for elbow arthrodesis to fill a 12 cm defect, caused by a previous recalcitrant elbow infection in a 68-year-old man. The patient experienced no postoperative complications and successful consolidation was achieved 6 months postoperatively, with flap survival confirmed. After 2 years of follow-up, the contoured dorsal plate was removed, with no signs of infection. Final Disabilities of the Arm, Shoulder, and Hand and Mayo Wrist scores were 23 and 88, respectively. A VPRBG might be a safe and effective surgical option for massive osseous elbow defects, whenever elbow arthrodesis is planned, where it should be combined with a one-bone forearm technique.

Humerus de-rotational osteotomies are one of the commonly done salvage procedures in children with residual brachial plexus birth injuries. Conventionally, the degree of angular correction was measured clinically intraoperatively by the ability to reach the occiput and the belly or it can be measured by putting reference k-wires at the appropriate angles. However, accurate angular correction is essential to success, as under-correction may lead to parental dissatisfaction and over-correction may lead to loss of mid-line function. The 'Orthokids Precise De-rotation Jig' (Nebula Surgical, Rajkot, INDIA) allows the exact measurement of the rotational correction required, which will lead to improved clinical outcomes. This accurate measurement mitigates the risk of errors due to parallax or eyeballing. The jig is handy, radio-opaque, autoclavable, and can be used without extensive dissection than what is required for the plate fixation.

There are many approaches to the wrist both volar and dorsal, depending on the injury at hand. The design of the volar locking plate has created a rise in distal radius fractures being treated using a volar FCR approach and its modifications. It does, however, have limitations in visualization of the volar ulnar corner of the radius. In this paper, we will revisit the flexor carpi ulnaris approach and pose some considerations for its historical context, safety, efficacy, and surgical technique.

Incision of the dorsal side of the tendon sheath in release of De Quervain's tenosynovitis has traditionally been advocated to prevent the risk of volar tendon subluxation. We describe a novel technique of complete excision, rather than simple incision, of the first dorsal compartment tendon sheath. Over a 10-year period, 147 patients (154 wrists) underwent first dorsal compartment release using this technique of complete excision of the sheath. No postoperative immobilization is used. Patients were followed for a mean of 7.0 months. Records were assessed for any complications including reoperation, tendon subluxation, recurrence, wound complications, scar tenderness, and superficial radial sensory nerve paresthesias. There were no cases of recurrence, reoperation, or tendon subluxation after release with this technique. Postoperatively, 7 (4.5%) patients had scar tenderness and 5 (3.2%) of these patients also had superficial radial sensory nerve parasthesias, which all resolved at the time of final follow-up. Mean range of motion was 73±11 degrees of flexion and 69±10 degrees of extension. In contrast to simple incision, we propose that this technique provides a more complete release of the compartment without risk of symptomatic subluxation or bowstringing and provides a complete release of a separate extensor pollicis brevis subsheath or any concomitant retinacular cysts associated with the tendonitis. There is an immediate removal of the symptomatic swelling and visible, painful bump associated with the thickened retinaculum with this technique. Furthermore, no immobilization is required after surgery.