Publications by authors named "Jerry I Huang"

50 Publications

A Morphometric Analysis of Hamate Autograft for Proximal Scaphoid Reconstruction.

J Wrist Surg 2021 Jun 14;10(3):268-271. Epub 2021 Apr 14.

Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington.

 Recently, authors have investigated using the proximal hamate as osteochondral autograft for proximal pole scaphoid reconstruction in the case of nonunion with avascular necrosis. The aim of our study was to analyze the morphology and anatomic fit of the proximal hamate compared with the proximal pole of the scaphoid using cadaveric specimens.  Ten cadaver specimens (five males and five females) were dissected. Scaphoid and proximal hamate bones were measured by two independent investigators using electronic calipers and radius of curvature gauges. After measurements were determined to have good correlation, the average value of the two observers' measurements were used for further analysis. Sagittal radius of curvature (ROC), coronal ROC, depth, width, and maximum graft length were compared.  The average depth of the scaphoid proximal pole was 12.3 mm (standard deviation [SD] = 1.12) compared with 11.3 mm (SD = 1.24) for the proximal hamate (  = 0.36). The average width was 7.8 mm (SD = 1.00) in the scaphoids compared with 8.6 (SD = 1.05) in the hamates (  = 0.09). There was also no significant difference in the sagittal ROC between hamates (9.1 mm, SD = 1.13) and scaphoids (9.5 mm, SD = 0.84;  = 0.36). All of these average measurements were within 1 mm. There was a significant difference between the coronal ROC of the hamate (23.4 mm) and scaphoid (21.1 mm) bones in our samples (  = 0.03). Females were on average smaller than their males, but there was no significant difference in fit based on sex alone.  The proximal pole of the hamate has similar morphology and size as the scaphoid, with similar depth, width, and sagittal ROC. It has potential as an osteochondral autograft for proximal pole scaphoid reconstruction.
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http://dx.doi.org/10.1055/s-0041-1726404DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8169172PMC
June 2021

Evaluation of Antegrade Intramedullary Compression Screw Fixation of Metacarpal Shaft Fractures in a Cadaver Model.

J Hand Surg Am 2021 May 7;46(5):428.e1-428.e7. Epub 2021 Jan 7.

Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA.

Purpose: Surgical options for displaced metacarpal shaft fractures include the use of Kirschner wires, plates and screws, and most recently, intramedullary headless compression screws (IMHCS), which have been reported using only retrograde insertion through the metacarpal head. We evaluated IMHCS fixation of metacarpal shaft fractures through an antegrade approach in a cadaver model.

Methods: We performed antegrade placement of IMHCS in 10 cadaver hands including all 5 digits (total of 50). Displaced transverse proximal metacarpal shaft fractures were created and reduced with a retrograde guidewire from the metacarpal head across the shaft fracture and exiting the metacarpal base. This was retrieved through a 6-mm dorsal wrist incision and overdrilled before the placement of a 4.1-mm-diameter IMHCS in the ring finger and a 4.7-mm screw in all other metacarpals. After IMHCS placement, carpometacarpal (CMC) joint violation was measured along with the optimal starting point for the guidewire on the metacarpal head relative to the dorsal cortex.

Results: In all 50 metacarpals, we achieved successful fracture reduction and fixation without violating the extensor mechanism at the wrist. Our retrograde guidewire entry point through the metacarpal head ranged from 4.2 to 4.7 mm volar to the dorsal cortex. The actual area of CMC joint violated by IMHCS placement was largest in the index CMC joint (4.9%), followed by the middle (3.7%), little (2.9%), ring (0.5%), and thumb joints (0.2%).

Conclusions: Placement of IMHCS through an antegrade approach from the CMC joint can be performed effectively for all transverse metacarpal fractures, including the thumb, using a limited incision. There is minimal violation of the articular surfaces of the trapezium, capitate, and hamate for the thumb, middle, ring, and little metacarpals.

Clinical Relevance: Antegrade IMHCS fixation successfully avoids the potential morbidity of creating a metacarpal head articular surface or extensor mechanism defect at the metacarpophalangeal joint seen with the retrograde approaches.
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http://dx.doi.org/10.1016/j.jhsa.2020.10.026DOI Listing
May 2021

An Anatomical Study of Metacarpal Morphology Utilizing CT Scans: Evaluating Parameters for Antegrade Intramedullary Compression Screw Fixation of Metacarpal Fractures.

J Hand Surg Am 2021 Feb 19;46(2):149.e1-149.e8. Epub 2020 Oct 19.

Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA.

Purpose: This study evaluated metacarpal morphology for antegrade placement of intramedullary headless compression screws (IMHCS) for metacarpal fracture fixation.

Methods: We analyzed 100 hand computed tomography scans to quantify cortical thickness, intramedullary diameter, and metacarpal lengths. In addition, dorsal or ulnar overhang of the metacarpals over their respective carpal bones was measured. We also predicted optimal entry points for guidewire placement at the metacarpal head.

Results: The ring finger metacarpal had the narrowest medullary canal width (coronal, 2.8 mm; sagittal, 3.5 mm). Not counting the thumb, the little finger metacarpal had the widest midshaft medullary width of 4.1 mm in the coronal plane and the middle metacarpal was widest in the sagittal plane with canal width of 3.9 mm. On average, there was maximal dorsal overhang at the base of the middle metacarpal (4.2 mm) and maximal ulnar overhang at the base of the small metacarpal (3.9 mm). The optimal entry point for guidewire placement over each metacarpal head was approximately 3.5 to 3.8 mm volar to the dorsal cortex.

Conclusions: Minimum IMHCS diameters of 3.5 mm for the ring and 4.0 mm for the index, middle and little fingers are necessary to achieve interference fit within the medullary canal. Minimum screw lengths of 38 mm would be needed to ensure 6 mm fixation past the midshaft of the metacarpals. Antegrade IMHCS for fixation of proximal metacarpal fractures may be most feasible with thumb, middle, and little finger metacarpals because there was larger dorsal or ulnar overhang to allow screw placement without violating the carpometacarpal joints.

Clinical Relevance: Our analysis provides a reference guide for intramedullary screw sizes for each metacarpal of the hand to achieve interference fit with fracture fixation. Furthermore, the dorsal and ulnar overhangs of the metacarpal bases suggest the practicality of antegrade IMHCS fixation.
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http://dx.doi.org/10.1016/j.jhsa.2020.08.007DOI Listing
February 2021

Risk factors associated with periprosthetic joint infection after total elbow arthroplasty.

Shoulder Elbow 2019 Apr 8;11(2):116-120. Epub 2017 Nov 8.

University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, WA, USA.

Background: For patients undergoing total elbow arthroplasty (TEA), the present study aimed to investigate: (i) what risk factors are associated with periprosthetic elbow infection; (ii) what is the incidence of infection after TEA; and (iii) what is the acuity with which these infections present?

Methods: The Statewide Planning and Research Cooperative System database was used to identify all patients who underwent TEA between 2003 and 2012 in New York State. Admissions for prosthetic joint infection (PJI) were identified using ICD-9 (International Classification of Diseases, Ninth Revision, Clinical Modification) diagnosis code 996.66. Multivariate analysis was used to determine risk factors that were independently prognostic for PJI.

Results: Significant risk factors for PJI included hypothyroidism [odds ratio (OR) = 2.04;  = 0.045], tobacco use disorder (OR = 3.39;  = 0.003) and rheumatoid arthritis (OR = 3.31;  < 0.001). Among the 1452 patients in the study period who underwent TEA, 3.7% ( = 54) were admitted postoperatively for PJI. There were 30 (56%) early infections, 17 (31%) delayed infections and seven (13%) late infections.

Conclusions: Pre-operative optimization of thyroid function, smoking cessation and management of rheumatoid disease may be considered in surgical candidates for TEA. The results of the present study add prognostic data to the literature that may be helpful with patient selection and risk profile analysis.

Level Of Evidence: Level III: prognostic study.
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http://dx.doi.org/10.1177/1758573217741318DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6434963PMC
April 2019

Changes in Provider Treatment Patterns for Dupuytren's Contracture: Analysis of Trends in Medicare Beneficiaries.

Plast Reconstr Surg Glob Open 2018 Oct 3;6(10):e1932. Epub 2018 Oct 3.

Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Wash.

Background: Collagenase Clostridium histolyticum (CCH) injection has been shown to be a safe and effective treatment option for Dupuytren's contracture. We hypothesize that the gaining popularity of CCH has resulted in a change in treatment patterns among providers, with increased utilization of CCH injections in the management of Dupuytren's contracture from 2012 to 2014.

Methods: The Medicare Provider Utilization and Payment Data Public Use Files were used to identify all surgeons who submitted claims for surgical fasciectomy, needle aponeurotomy (NA), and CCH injection. The data were analyzed for number of providers performing the procedures, number of procedures per provider, and location of practice.

Results: From 2012 to 2014, the number of providers performing more than 10 open fasciectomies decreased from 141 to 131. In the same time, the number of providers performing more than 10 NAs increased from 63 to 70 with mean procedures per provider decreasing from 35 to 21. In contrast, the number of providers performing more than 10 CCH injections increased from 72 to 112, with mean injections per provider going from 24 to 20. The total number of injections performed increased from 1,734 to 2,220 from 2012 to 2014. The largest increase in number of injections and number of providers performing injections occurred in the South.

Conclusions: The introduction of collagenase has changed treatment patterns with more providers treating Dupuytren's contractures with CCH injections and a statistically significant decline in the number of NA procedures per provider.
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http://dx.doi.org/10.1097/GOX.0000000000001932DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6250467PMC
October 2018

Variations in Hook of Hamate Morphology: A Cadaveric Analysis.

J Hand Surg Am 2019 Jul 2;44(7):611.e1-611.e5. Epub 2018 Oct 2.

University Hospitals Case Medical Center, Department of Orthopaedic Surgery, University Hospitals of Cleveland, Cleveland, OH; Yale Medicine Orthopaedics, New Haven, CT.

Purpose: The hook of the hamate is an anatomical structure that separates the ulnar border of the carpal tunnel from Guyon's canal and serves as a landmark for surgeons. The hook of the hamate is also subject to fracture from injury. We hypothesize that there are variations in the hook of the hamate in the general population.

Methods: One thousand pairs of hamates (2,000 hamates) from the Hamann-Todd Collection at the Cleveland Natural History Museum were analyzed. The height of the hook of the hamate and the total height of the hamate bone were measured using digital calipers. The hook height ratio was defined as the hook height divided by the total height of the hamate. Statistical analysis was performed using unpaired Student's t test to determine differences in sex and race.

Results: The mean hook height was 9.8 ± 1.4 mm (range, 2.5-15.9 mm), whereas the mean hook height ratio was 0.42 ± 0.04 (range, 0.15-0.56). There was a 3.1% (62/2,000) incidence of abnormally small hooks, which we classified as hypoplastic and aplastic. Of the hypoplastic hooks, 55% (24/44) were bilateral, whereas 44% (8/18) of the aplastic hooks were bilateral. The incidence of variation in size in the hook of the hamate was highest in white females (9.3%) and lowest in black males (1.4%).

Conclusions: Abnormalities in hook of hamate anatomy are common in the general population, especially in white females.

Clinical Relevance: Knowledge of anatomic variation in the hook of the hamate may provide additional insight into surgeons' palpation of bony anatomy, interpretation of imaging studies, and use of the hook as a landmark during surgery.
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http://dx.doi.org/10.1016/j.jhsa.2018.08.007DOI Listing
July 2019

The Quantitative Anatomy of the Dorsal Scapholunate Interosseous Ligament.

Hand (N Y) 2019 Jan 12;14(1):80-85. Epub 2018 Sep 12.

2 University of Washington, Seattle, USA.

Background: The anatomy of the scapholunate interosseous ligament (SLIL) has been described qualitatively in great detail, with recognition of the dorsal component's importance for carpal stability. The purpose of this study was to define the quantitative anatomy of the dorsal SLIL and to assess the use of high-frequency ultrasound to image the dorsal SLIL.

Methods: We used high-frequency ultrasound imaging to evaluate 40 wrists in 20 volunteers and recorded the radial-ulnar (length) and dorsal-volar (thickness) dimensions of the dorsal SLIL and the dimensions of the scapholunate interval. We assessed the use of high-frequency ultrasound by comparing the length and thickness of the dorsal SLIL on ultrasound evaluation and open dissection of 12 cadaveric wrists. Student's t test was used to assess the relationship between measurements obtained on cadaver ultrasound and open dissection.

Results: In the volunteer wrists, the mean dorsal SLIL length was 7.5 ± 1.4 mm and thickness was 1.8 ± 0.4 mm; the mean scapholunate interval was 5.0 mm dorsally and 2.5 mm centrally. In the cadaver wrists, there was no difference in dorsal SLIL length or thickness between ultrasound and open dissection.

Conclusions: The dorsal SLIL is approximately 7.5 mm long and 1.8 mm thick. These parameters may be useful in treatment of SLIL injuries to restore the native anatomy. High-frequency ultrasound is a useful imaging technique to assess the dorsal SLIL, although further study is needed to assess the use of high-frequency ultrasound in detection of SLIL pathology.
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http://dx.doi.org/10.1177/1558944718798846DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6346351PMC
January 2019

Complications of Semiconstrained Distal Radioulnar Joint Arthroplasty.

J Hand Surg Am 2018 06 22;43(6):566.e1-566.e9. Epub 2017 Dec 22.

Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA. Electronic address:

Purpose: The Aptis total distal radioulnar joint (DRUJ) prosthesis is a semiconstrained implant designed for treatment of DRUJ arthritis and instability. The purpose of this study was to analyze short-term complications of this device.

Methods: We performed a retrospective chart review of patients undergoing semiconstrained DRUJ arthroplasty from 2007 to 2015 at a single institution. Records were analyzed for complications and the need for subsequent surgical procedures.

Results: Two senior hand surgeons at one institution performed 52 semiconstrained DRUJ arthroplasties over 8 years. Nineteen complications necessitating operative management occurred in 15 patients (29%). A total of 26 procedures were undertaken to address these complications. Complications included 4 periprosthetic fractures, 3 infections, 2 instances of aseptic loosening, 2 implant component failures, 1 instance of screw loosening, 3 neuromas requiring neurectomy, 2 instances of finger stiffness necessitating extensor tenolysis, and 2 cases of heterotopic ossification at the DRUJ. Three of the 52 implants were revised (6%) and 2 were explanted (4%); 3 of these (6%) were caused by deep infection.

Conclusions: There is limited literature on outcomes of the semiconstrained DRUJ prosthesis. Prior studies reported low complication rates, with 0% to 5% revisions. In the current clinical series, 29% of patients required further surgery for complications, the most common reasons for which were periprosthetic fracture and infection.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2017.11.004DOI Listing
June 2018

Biomechanical Assessment of the Dorsal Spanning Bridge Plate in Distal Radius Fracture Fixation: Implications for Immediate Weight-Bearing.

Hand (N Y) 2018 05 7;13(3):336-340. Epub 2017 Apr 7.

2 Department of Orthopaedic Surgery, University of California, San Francisco, USA.

Background: The goal of this study was to compare the biomechanical stability of a 2.4-mm dorsal spanning bridge plate with a volar locking plate (VLP) in a distal radius fracture model, during simulated crutch weight-bearing.

Methods: Five paired cadaveric forearms were tested. A 1-cm dorsal wedge osteotomy was created to simulate an unstable distal radius fracture with dorsal comminution. Fractures were fixed with a VLP or a dorsal bridge plate (DBP). Specimens were mounted to a crutch handle, and optical motion-tracking sensors were attached to the proximal and distal segments. Specimens were loaded in compression at 1 mm/s on a servohydraulic test frame until failure, defined as 2 mm of gap site displacement.

Results: The VLP construct was significantly more stable to axial load in a crutch weight-bearing model compared with the DBP plate (VLP: 493 N vs DBP: 332 N). Stiffness was higher in the VLP constructs, but this was not statistically significant (VLP: 51.4 N/mm vs DBP: 32.4 N/mm). With the crutch weight-bearing model, DBP failed consistently with wrist flexion and plate bending, whereas VLP failed with axial compression at the fracture site and dorsal collapse.

Conclusions: Dorsal spanning bridge plating is effective as an internal spanning fixator in treating highly comminuted intra-articular distal radius fracture and prevents axial collapse at the radiocarpal joint. However, bridge plating may not offer advantages in early weight-bearing or transfer in polytrauma patients, with less axial stability in our crutch weight-bearing model compared with volar plating. A stiffer 3.5-mm DBP or use of a DBP construct without the central holes may be considered for distal radius fractures if the goal is early crutch weight-bearing through the injured extremity.
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http://dx.doi.org/10.1177/1558944717701235DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5987984PMC
May 2018

Classifications in Brief: The Eaton-Littler Classification of Thumb Carpometacarpal Joint Arthrosis.

Clin Orthop Relat Res 2016 Dec 4;474(12):2729-2733. Epub 2016 May 4.

Department of Orthopaedics and Sports Medicine, University of Washington, 1959 N.E. Pacific St., Box 356500, Seattle, WA, 98195-6500, USA.

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http://dx.doi.org/10.1007/s11999-016-4864-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5085928PMC
December 2016

Classifications in Brief: The Wassel Classification for Radial Polydactyly.

Clin Orthop Relat Res 2017 06 9;475(6):1740-1746. Epub 2016 Sep 9.

Department of Orthopaedics and Sports Medicine, University of Washington, 4245 Roosevelt Way NE, Box 354740, Seattle, WA, 98105, USA.

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http://dx.doi.org/10.1007/s11999-016-5068-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5406327PMC
June 2017

Prosthetic Design in Total Wrist Arthroplasty.

Orthop Clin North Am 2016 Jan;47(1):207-18

UW Combined Hand Fellowship, Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, 4245 Roosevelt Way Northeast, Box 354740, Seattle, WA 98105, USA. Electronic address:

Total wrist arthroplasty (TWA) provides a motion-preserving alternative to total wrist arthrodesis for low-demand patients with debilitating pancarpal arthritis. The earlier generation total wrist implants had high complication and failure rates. Advances in prosthetic design have contributed to improved clinical outcomes and implant survivorship. The current fourth-generation implants allow for expansion of indications for TWA. Careful patient selection remains critical; patients with high-demand lifestyles and poor bone stock may not be candidates. Long-term studies on implant survival and patient outcomes are critical for the current generation total wrist implants in assessing their long-term value compared with total wrist arthrodesis.
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http://dx.doi.org/10.1016/j.ocl.2015.08.018DOI Listing
January 2016

Surgical Treatment of Distal Biceps Ruptures.

Orthop Clin North Am 2016 Jan;47(1):189-205

Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA 98105, USA. Electronic address:

Distal biceps ruptures occur from eccentric loading of a flexed elbow. Patients treated nonoperatively have substantial loss of strength in elbow flexion and forearm supination. Surgical approaches include 1-incision and 2-incision techniques. Advances in surgical technology have facilitated the popularity of single-incision techniques through a small anterior incision. Recently, there is increased focus on the detailed anatomy of the distal biceps insertion and the importance of anatomic repair in restoring forearm supination strength. Excellent outcomes are expected with early repair of the distal biceps, with restoration of strength and endurance to near-normal levels with minimal to no loss of motion.
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http://dx.doi.org/10.1016/j.ocl.2015.08.025DOI Listing
January 2016

A novel computational method for evaluating osteochondral autografts in distal radius reconstruction.

Hand (N Y) 2015 Sep;10(3):492-6

Department of Orthopaedics and Sports Medicine, University of Washington, 4245 Roosevelt Way NE, 2nd Floor, Box 354740, Seattle, WA 98105 USA.

Background: We describe a novel computational method for assessing the fit of an osteochondral graft. We applied our software to five normal wrist computed tomography (CT) scans to determine the fit of the scaphoid to the lunate fossa of the distal radius.

Methods: CT scans of five wrists were digitally rendered. The capitate facet of the scaphoid was fit to the lunate fossa of the distal radius using custom software based on the iterative closest point (ICP) algorithm. This approach iteratively determines the optimal position of a model surface to minimize the sum of squares of distances from all points on a target surface. The fit of the two surfaces was reported by calculating the mean residual distance (MRD) between each point on one surface and its nearest neighbor on the other.

Results: The MRD for the five subjects was found to be 0.25 mm, with 82.8-98.3 % of the articular surfaces within 0.5 mm of each other.

Conclusions: We have developed a software algorithm for comparing two articular surfaces to test fit for a proposed joint reconstruction. The software is versatile and may be applied to any bony surface to identify new graft donor sites. The fit assessment renders a richer, three-dimensional understanding of the fit of the graft as compared to traditional two-dimensional assessments.

Level Of Evidence: Decision analysis, Level V.
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http://dx.doi.org/10.1007/s11552-014-9654-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4551626PMC
September 2015

Limited intercarpal fusion as a salvage procedure for advanced Kienbock disease.

Hand (N Y) 2015 Sep;10(3):472-6

Department of Orthopaedics & Sports Medicine, University of Washington Medical Center, 4245 Roosevelt Way NE, Box 354740, Seattle, WA 98105 USA.

Background: With progressive lunate collapse, salvage procedures in advanced Kienbock disease attempt to provide pain relief and maintain motion. Scaphocapitate arthrodesis may provide a durable option with comparable outcomes to proximal row carpectomy in the well-selected patient.

Methods: We performed a retrospective chart review of all consecutive patients with Lichtman stage IIIA or IIIB Kienbock's disease who underwent either scaphocapitate or scaphotrapeziotrapezoid-capitate arthrodesis from January 2004 to December 2013.

Results: Twelve patients were included with a mean age of 41.6 years. Ten patients underwent scaphocapitate arthrodesis, while two patients underwent scaphotrapezio-trapezoid-capitate arthrodesis with an average clinical follow-up of 13.1 months. All patients achieved fusion. The average postoperative flexion-extension arc was 53° (range 20-110°). The average ulnar deviation was 9° (range 5-15°), and the average radial deviation was 13° (range 5-25°). Postoperative pain scores were significantly improved, having changed from an average of 6.6 preoperatively to 2.8 on a 10-point scale (W = 18, P < 0.05).

Conclusions: Despite a mean flexion-extension arc that is reduced from that of a normal individual, the postoperative range of motion following a midcarpal arthrodesis was not significantly different than that reported in a recent systematic review of proximal row carpectomy (73.5° compared with 53°, respectively) (P = 0.05). Additionally, given the significant postoperative reduction in associated pain symptoms at the time of follow-up, scaphocapitate arthrodesis should be considered as a treatment option for wrist salvage in the patient with advanced Kienbock's disease.
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http://dx.doi.org/10.1007/s11552-014-9705-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4551650PMC
September 2015

Chronic Scapholunate Ligament Injuries: Treatment with Supplemental Fixation.

Hand Clin 2015 Aug;31(3):457-65

Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, 1959 NE Pacific Street, Seattle, WA 98195, USA. Electronic address:

Treatment of chronic scapholunate ligament injuries can be challenging. Traditional reconstructive techniques, including varied capsulodeses and tenodeses often yield inconsistent results with loss of reduction and radiographic deterioration. As a result, supplemental hardware fixation has become more popular and may allow more robust stabilization of the scapholunate reconstruction. However, these procedures have complications and few data regarding outcomes are currently available. This article evaluates the role of supplemental fixation in the management of chronic scapholunate instability.
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http://dx.doi.org/10.1016/j.hcl.2015.04.003DOI Listing
August 2015

Functional Outcomes Following Bridge Plate Fixation for Distal Radius Fractures.

J Hand Surg Am 2015 Aug 2;40(8):1554-62. Epub 2015 Jul 2.

Department of Orthopaedics, University of Washington, Seattle, WA.

Purpose: To determine the functional outcomes of patients treated with dorsal spanning distraction bridge plate fixation for distal radius fractures.

Methods: All adult patients at our institution who underwent treatment of a unilateral distal radius fracture using a dorsal bridge plate from 2008 to 2012 were identified retrospectively. Patients were enrolled in clinical follow-up to assess function. Wrist range of motion, grip strength, and extension torque were measured systematically and compared with the contralateral, uninjured wrist. Patients also completed Quick-Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation outcomes questionnaires.

Results: Eighteen of 100 eligible patients, with a minimum of 1 year from the time of implant removal, were available for follow-up (mean, 2.7 y). All fracture patterns were comminuted and intra-articular (AO 23.C3). There were significant decreases in wrist flexion (43° vs 58°), extension (46° vs 56°), and ulnar deviation (23° vs 29°) compared with the contralateral uninjured wrist. Grip strength was 86% and extension torque was 78% of the contralateral wrist. Comparison of dominant and nondominant wrist injuries identified nearly complete recovery of grip (95%) and extension (96%) strength of dominant-sided wrist injuries, compared with grip (79%) and extension (65%) strength in those with an injured nondominant wrist. Mean Quick-Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation scores were 16 and 14, respectively. There were 2 cases of postoperative surgical site pain and no cases of infection, tendonitis, or tendon rupture.

Conclusions: Distraction bridge plate fixation for distal radius fractures is safe with minimal complications. Functional outcomes are similar to those published for other treatment methods.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2015.05.008DOI Listing
August 2015

Assessment and Treatment of Extensor Carpi Ulnaris Tendon Pathology: A Critical Analysis Review.

JBJS Rev 2015 Jun;3(6)

1Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, 4245 Roosevelt Way N.E., Box 354740, Seattle, WA 98105.

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http://dx.doi.org/10.2106/JBJS.RVW.N.00070DOI Listing
June 2015

In Brief: Kanavel's Signs and Pyogenic Flexor Tenosynovitis.

Clin Orthop Relat Res 2016 Jan 29;474(1):280-4. Epub 2015 May 29.

Department of Orthopaedics and Sports Medicine, University of Washington, 1959 NE Pacific Street, Box 356500, Seattle, WA, 98195-6500, USA.

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http://dx.doi.org/10.1007/s11999-015-4367-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4686527PMC
January 2016

Proximal Interphalangeal Joint Arthroplasty: A Critical Analysis Review.

JBJS Rev 2015 May;3(5)

1Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, 4245 Roosevelt Way N.E., Box 354740, Seattle, WA 98105 2Division of Plastic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215.

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http://dx.doi.org/10.2106/JBJS.RVW.N.00063DOI Listing
May 2015

Danger zones for flexor tendons in volar plating of distal radius fractures.

J Hand Surg Am 2015 Jun 2;40(6):1102-5. Epub 2015 Apr 2.

Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA.

Purpose: To define a danger zone for volar plates using magnetic resonance imaging by analyzing the position of the flexor tendons at risk around the watershed line.

Methods: We analyzed 40 wrist magnetic resonance images. The location of the flexor pollicus longus (FPL) and index flexor digitorum profundus (FDPi) tendons was recorded at 3 and 6 mm proximal to the watershed line of the distal radius. We measured the distance between the volar margin of the distal radius and the FPL and FDPi tendons, and the coronal position of the tendons.

Results: At a point 3 mm proximal to the watershed line, FPL and FDPi were located on average 2.6 and 2.2 mm anterior to the volar margin of the distal radius. This distance increased to 4.7 and 5.3 mm at a point 6 mm proximal to the watershed line. The FPL and FDPi were located at 57% and 42% of the total width of the distal radius from the sigmoid notch at 3 mm from the watershed, and at 66% and 46% at 6 mm from the watershed.

Conclusions: Surgeons should be aware of the close proximity of the flexor tendons to the volar cortex of the distal radius proximal to the watershed line and their radial to ulnar position. Three millimeters proximal to the watershed line, plate placement more than 2 mm anterior to the volar cortex or the use of plates thicker than 2 mm poses a high risk for directly contacting flexor tendons.

Clinical Relevance: This article may prove to be helpful in avoiding flexor tendon injury during volar plate fixation.
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http://dx.doi.org/10.1016/j.jhsa.2015.02.026DOI Listing
June 2015

Biomechanical evaluation of metacarpal fracture fixation: application of a 90° internal fixation model.

Hand (N Y) 2015 Mar;10(1):94-9

Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA USA.

Purpose: Complications in metacarpal fracture treatment increase in proportion to the severity of the initial injury and the invasiveness of the surgical fixation technique. This manuscript evaluates the feasibility of minimizing internal fixation construct size and soft tissue dissection, while preserving the advantages of stable internal fixation in a biomechanical model. We hypothesized that comparable construct stability could be achieved with mini-plates in an orthogonal (90/90) configuration compared with a standard dorsal plating technique.

Methods: This hypothesis was evaluated in a transverse metacarpal fracture model. Twelve metacarpals were subject to either placement of a 2.0-mm six-hole dorsal plate or two 1.5-mm four-hole mini-plates in a 90/90 configuration. These constructs were tested to failure in a three-point bending apparatus, attaining failure force, displacement, and stiffness.

Results: Mean failure force was 353.5 ± 121.1 N for the dorsal plating construct and 358.8 ± 77.1 N for the orthogonal construct. Mean failure displacement was 3.3 ± 1.2 mm for the dorsal plating construct and 4.1 ± 0.9 mm for the orthogonal construct. Mean stiffness was 161.3 ± 50.0 N/mm for the dorsal plating construct and 122.1 ± 46.6 N/mm for the orthogonal construct. Mean failure moment was 3.09 ± 1.06 Nm for the dorsal plating construct and 3.14 ± 0.67 Nm for the orthogonal construct. The dorsal plating group failed via screw pullout, whereas the orthogonal failed either by screw pullout or breakage of the plate.

Conclusions: When subject to apex dorsal bending, the orthogonal construct and the standard dorsal plate construct behaved comparably. These data suggest that despite its shorter length, lower profile, and less substantial screws, the orthogonal construct provides sufficient rigidity.

Clinical Relevance: This study represents a "proof of concept" regarding the applicability of orthogonal plating in the metacarpal and provides the foundation for minimizing construct size and profile.
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http://dx.doi.org/10.1007/s11552-014-9673-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4349836PMC
March 2015

Predicting a safe screw length for volar plate fixation of distal radius fractures: lunate depth as a marker for distal radius depth.

J Hand Surg Am 2015 May 3;40(5):940-4. Epub 2015 Mar 3.

Department of Orthopaedic Surgery, University of Washington, Seattle, WA.

Purpose: We hypothesized that the lunate depth as measured on plain lateral radiographs can be used to predict distal radius depth radially and ulnarly and serve as a useful reference for intraoperative screw placement in volar plate fixation of distal radius fractures.

Methods: Plain radiographs and magnetic resonance imaging (MRI) of the wrists of 30 patients were reviewed. The lunate depth and the maximal depth of the distal radius were determined from plain lateral radiographs. Depth of the distal radius, measured in quartiles, was determined from axial MRI images, and the lunate depth was obtained from sagittal MRI images. The depth of the distal radius in each quartile was then calculated related to the lunate depth.

Results: The mean depth of the lunate on plain radiographs and MRI was 17.5 mm and 17.4 mm, respectively. The depth of the distal radius from ulnar to radial was 18.4 mm, 20.2 mm, 19.4 mm, and 15.1 mm for the 1st through 4th quartiles, respectively. The depth of the distal radius is the least radially (4th quartile), with a mean 87% of the lunate depth, and greatest in the 2nd quartile, with a mean 116% of the lunate depth.

Conclusions: The depth of the lunate as measured on plain radiographs can be used as a marker for drilling and placement of safe screw lengths during volar plate fixation of distal radius fractures. We recommend that surgeons use the lunate depth as an estimate for the length of their longest screw when fixing distal radius fractures with volar plate techniques to avoid extensor tendon irritation and rupture.

Type Of Study/level Of Evidence: Therapeutic III.
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http://dx.doi.org/10.1016/j.jhsa.2015.01.008DOI Listing
May 2015

Morphology of the extensor carpi ulnaris groove and tendon.

J Hand Surg Am 2014 Dec 11;39(12):2412-6. Epub 2014 Oct 11.

Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Orthopaedics & Sports Medicine, University of Washington Medical Center, Seattle, WA. Electronic address:

Purpose: Injury to the extensor carpi ulnaris (ECU) fascial supports on the distal ulna can result in ulnar-sided wrist pain, particularly when the tendon subluxates medially out of the fibroosseous groove with forearm rotation. To better understand the potential risk factors for injury and the indications for modifying the ECU groove, we have evaluated and quantified the morphology of the ECU groove and tendon.

Methods: Axial plane magnetic resonance imaging of the wrist obtained for triangular fibrocartilage complex and intercarpal pathology in 60 patients were reviewed. Mean and standard error of the mean were calculated and unpaired Student t tests performed to compare groove width and depth, radius of curvature of the groove, carrying angle, and tendon-to-groove ratio.

Results: There were 23 females (38%), and the mean patient age was 40 years (range, 17-71 y). The average ECU groove depth and standard error of the mean was 1.4 mm ± 0.1 mm. The radius of curvature for the ulnar ECU groove was found to be 7.0 mm ± 0.4 mm with a carrying angle of 143° ± 2°. In neutral forearm rotation, the average ratio of the width of the ECU tendon to groove was 0.7 ± 0.02. The data approximated a normal distribution. There were no statistically significant differences in these measurements between the triangular fibrocartilage complex and the intercarpal pathology subgroups.

Conclusions: Variability in the relationship of the ECU groove and tendon may combine to represent risk factors for tendinosis or tendon subluxation. There may be a more normal distribution of ECU groove morphology than previously recognized.

Clinical Relevance: ECU injuries may require clinical imaging of the tendon and subsheath, in addition to potential surgical reconstruction and ulnar groove deepening. This report establishes the normative morphology and depth of the ECU groove and provides a comparative baseline when considering treatment modalities.
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http://dx.doi.org/10.1016/j.jhsa.2014.09.009DOI Listing
December 2014

Prospective randomized controlled trial comparing 1- versus 7-day manipulation following collagenase injection for dupuytren contracture.

J Hand Surg Am 2014 Oct 4;39(10):1933-1941.e1. Epub 2014 Sep 4.

Department of Orthopaedic Surgery and Sports Medicine, University of Washington, Seattle, WA.

Purpose: To compare the efficacy, tolerance, and safety of manual manipulation at day 7 to day 1 following collagenase Clostridium histolyticum (CCH) injection for Dupuytren contracture.

Methods: Eligible patients were randomized to manipulation at day 1 versus day 7 following CCH injection. Preinjection, premanipulation, postmanipulation, and 30-day follow-up metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint contractures were measured. Pain scores were recorded at each time point. Data were stratified per cohort based on primary joint treated (MCP vs PIP). Means were compared using paired and unpaired t-tests.

Results: Forty-three patients with 46 digits were eligible and were randomized to 1-day (22 digits) and 7-day (24 digits) manipulation. For MCP joints, there were no significant differences in flexion contractures between 1- and 7-day cohorts for initial (47° vs 46°), postmanipulation (0° vs 2°), or 30-day follow-up (1° vs 2°) measurements. Premanipulation, the residual contracture was significantly lower in the 7-day group (23° vs 40°). For PIP joints, there were no significant differences between 1- and 7-day cohorts for initial (63° vs 62°), premanipulation (56° vs 52°), postmanipulation (13° vs 15°), or 30-day (14° vs 16°) measurements. There were no significant differences in pain or skin tears between the 2 groups. No flexor tendon ruptures were observed.

Conclusions: The effectiveness of CCH in achieving correction of Dupuytren contractures was preserved when manipulation was performed on day 7, with no differences in correction, pain, or skin tears. These data suggest that manipulation can be scheduled at the convenience of the patient and surgeon within the first 7 days after injection.

Type Of Study/level Of Evidence: Therapeutic I.
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http://dx.doi.org/10.1016/j.jhsa.2014.07.010DOI Listing
October 2014

Acute Distal Radioulnar Joint Instability in Adults: A Critical Analysis Review.

JBJS Rev 2014 Jul;2(7)

1Department of Orthopaedics and Sports Medicine, University of Washington, 4245 Roosevelt Way N.E., Box 354740, Seattle, WA 98105 2Duke University, School of Medicine, 201 Trent Drive, Durham, NC 27710.

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http://dx.doi.org/10.2106/JBJS.RVW.M.00110DOI Listing
July 2014

A Scaphoid Osteochondral Autograft for Reconstruction of the Lunate Fossa of the Distal Part of the Radius After a Complex Open Fracture: A Case Report.

JBJS Case Connect 2014 Jun;4(2):e52-e4

Department of Orthopaedics and Sports Medicine, University of Washington, 4245 Roosevelt Way NE, 2nd Floor, Box 354740, Seattle, WA 98105. E-mail address for J.I. Huang:

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http://dx.doi.org/10.2106/JBJS.CC.M.00251DOI Listing
June 2014

Extensor carpi ulnaris subluxation.

J Hand Surg Am 2014 Jul 3;39(7):1400-2. Epub 2014 May 3.

Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA. Electronic address:

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http://dx.doi.org/10.1016/j.jhsa.2014.03.037DOI Listing
July 2014

Radiographic evaluation of the modified Brunelli technique versus a scapholunotriquetral transosseous tenodesis technique for scapholunate dissociation.

J Hand Surg Am 2014 Jun 26;39(6):1041-9. Epub 2014 Apr 26.

Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA. Electronic address:

Purpose: To compare reduction of the scapholunate articulation using a transosseous tenodesis through the scaphoid, lunate, and triquetrum (SLT) with the modified Brunelli technique (MBT) in a cadaver model, as measured by scapholunate (SL) angle and diastasis on radiographs.

Methods: Twelve fresh-frozen cadaveric wrists were radiographically examined in a neutral posture, ulnar deviation, and clenched fist position. The SL angle and diastasis were recorded in each position with the SL ligament intact, after sectioning the ligament and secondary restraints, and after reconstruction by either the MBT (6 wrists) or SLT technique (6 wrists). Wrists were cycled through their maximum flexion and extension arc 100 times to simulate wrist motion after ligament sectioning and reconstruction.

Results: After sectioning and cycling, all wrists demonstrated radiographic evidence of SL diastasis. After ligament reconstruction and cycling, there was no statistically significant difference in diastasis in the MBT reconstructions compared with the SLT reconstructions (3.0 vs 2.4 mm). The SLT group demonstrated better maintenance of the restored SL angle than the MBT reconstructions.

Conclusions: In this cadaveric model, both MBT and SLT reconstructions restored anatomic parameters in the SL joint, with correction of SL diastasis and SL angle. Future studies to assess the clinical outcomes of SLT tenodesis in patients with chronic SL disruptions are important.

Clinical Relevance: The SLT tenodesis, with a central biologic tether along the SL axis and dorsal reinforcement, may prove clinically useful.
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http://dx.doi.org/10.1016/j.jhsa.2014.03.005DOI Listing
June 2014

Fungal nail infections.

J Hand Surg Am 2014 May;39(5):985-8

Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA. Electronic address:

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http://dx.doi.org/10.1016/j.jhsa.2013.11.017DOI Listing
May 2014
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