Publications by authors named "Kenneth R Means"

55 Publications

All-Suture Anchor Repair of the Flexor Digitorum Profundus Insertion: A Biomechanical Comparison of 2 Suturing Techniques.

J Hand Surg Am 2022 Jun 28. Epub 2022 Jun 28.

The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD. Electronic address:

Purpose: We compared 2 suturing techniques for reattachment of the flexor digitorum profundus (FDP) via all-suture anchor.

Methods: We used fresh, matched-pair, cadaveric hands. We disarticulated the fingers at the proximal interphalangeal joints, preserving the proximal FDP. We released the FDPs at their distal insertion and placed an all-suture, 1.0-mm anchor at the center of each FDP footprint. Each anchor's sutures were used to reattach each FDP using 1 of 2 techniques: group H (n = 14) via horizontal mattress; group H + K (n = 12) via horizontal mattress with knots thrown and, with each suture tail, 3 proximal, running-locking, Krackow-type passes on the radial and ulnar FDP sides with the suture ends tied together. We excluded 2 specimens from the H + K group because of improper anchor placement. All other fingers in both groups were individually mounted in an MTS machine for FDP loading in the following sequence for 500 cycles each: (1) to 15 N to simulate passive motion forces; (2) to 19 N for short-arc active motion forces; and (3) to 28 N for full active motion forces. Specimens that had not failed during cyclic testing were then loaded to failure. We measured FDP-to-bone gapping via a digital transducer. We defined failure as >3-mm gapping.

Results: The H + K group had significantly less gapping during cyclic loading up to 19 N and significantly higher load to failure. The H + K group failed exclusively at the anchor-bone level; the H group failed mostly by suture-tendon pullout.

Conclusions: The H + K group performed significantly better regarding cyclic and load-to-failure testing after FDP reattachment.

Clinical Relevance: The H + K technique combines the benefits of horizontal-mattress tendon-to-bone apposition and Krackow-tendon locking. It converts the point of failure to the bone level rather than the suture-tendon level.
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http://dx.doi.org/10.1016/j.jhsa.2022.05.003DOI Listing
June 2022

Total Joint Arthroplasty of a Proximal Interphalangeal Joint with Proximal Metal Surface Replacement and Distal Hemi-Hamate Autograft: A Long-Term Follow-Up.

J Hand Surg Glob Online 2022 May 3;4(3):189-193. Epub 2022 Mar 3.

The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.

A 28-year-old female recreational athlete presented with middle finger proximal interphalangeal joint pain, stiffness, and ulnar deviation deformity 2 years after internal fixation of a middle phalanx base fracture-dislocation. Radiographs revealed posttraumatic changes on both sides of the proximal interphalangeal joint. Having failed nonsurgical measures, she elected to proceed with surgical reconstruction. Intraoperatively, we confirmed substantial articular damage on both sides of the joint. We proceeded with hemi-hamate autograft for 80% of the middle phalanx base. We used a cobalt chrome proximal phalanx component. After healing, the patient returned to all daily-living and athletic activities with resolution of preoperative pain, stiffness, and deformity. Twelve years after surgey, she had no pain or substantial limitations because of the finger. We measured 80° of proximal interphalangeal joint motion. The grip and fingertip-pinch strength were 91% and 73%, respectively, of the contralateral dominant hand. Radiographs showed no progressive changes compared to 3 years after surgery.
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http://dx.doi.org/10.1016/j.jhsg.2022.02.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9120795PMC
May 2022

Passive Manipulation for Proximal Interphalangeal Joint Extension Contractures.

J Hand Surg Am 2022 Mar 8. Epub 2022 Mar 8.

The Curtis National Hand Center, Baltimore, MD. Electronic address:

Purpose: We investigated closed passive manipulation as an alternative to surgery for certain proximal interphalangeal (PIP) joint extension contractures.

Methods: We retrospectively reviewed all patients with PIP joint extension contractures treated with passive manipulation at our institution between 2015 and 2019. The included patients were a minimum of 12 weeks from their initial injury/surgery (median 179 days; interquartile range: 130-228 days), had plateaued with therapy, and underwent a 1-time passive manipulation. All included fingers had congruent PIP joints and no indwelling hardware that could have had direct adhesions. Most (80%) patients had a direct injury to the finger ray(s) that led to the contractures. Most (75%) patients had the manipulation performed under local anesthesia in the office. Available measures of passive range of motion (PROM) and active range of motion (AROM) immediately, within 6 weeks, between 6 and 12 weeks, and at >12 weeks after the manipulation were recorded.

Results: Twenty-eight patients and 46 digits met the criteria. The median PIP joint PROM improved from 50° to 90° immediately following the manipulation. The median PROM values within 6 weeks, between 6 and 12 weeks, and at >12 weeks following manipulation were 80°, 85°, and 85°, respectively. The median AROM immediately after the manipulation improved from 40° to 90°, and the median AROM values within 6 weeks, between 6 and 12 weeks, and at >12 weeks were 70°, 50°, and 60°, respectively. None of the patients experienced worsening of PIP joint range of motion. One patient who had 4 fingers manipulated had a 45° distal interphalangeal joint extension lag for one of the fingers after the manipulation. Eight fingers underwent later flexor tenolysis or reconstruction to improve AROM after the gains in PROM via manipulation were maintained.

Conclusions: Passive manipulation is an alternative to surgical release for select PIP joint extension contractures.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2022.01.023DOI Listing
March 2022

Comparison of 3 Dynamic External Fixation Devices for Proximal Interphalangeal Joint Dorsal Fracture-Dislocations in a Cadaver Model.

J Hand Surg Am 2022 Mar 4. Epub 2022 Mar 4.

Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD. Electronic address:

Purpose: Several improvised dynamic external fixation devices are used for treating unstable dorsal proximal interphalangeal (PIP) joint fracture-dislocations. We compared the effectiveness of 3 constructs for simulated dorsal PIP joint fracture-dislocations in a cadaver model.

Methods: We tested 30 digits from 10 fresh-frozen, thawed cadaver hands. We aimed to remove the palmar 50% of the base of each digit's middle phalanx (P2), simulating an unstable dorsal PIP joint fracture-dislocation. Each PIP joint was then stabilized via external fixation with either a pins-and-rubber-bands construct, pins-only construct, or tuberculin syringe-pins construct. We allocated 10 digits per fixation group. The finger tendons were secured to a computer-controlled stepper motor-driven linear actuator. Via this mechanism, all PIP joints were taken through 1,400 cycles of flexion-extension. With the PIP joint in neutral extension, we measured the P2 dorsal translation at baseline, after fixator stabilization, and after the motion protocol.

Results: The actual mean P2 palmar defect created was 48% of the base. All PIP joints were unstable after creating the defect, with a mean initial P2 dorsal displacement of 3.7 mm. After application of the fixators, all PIP joint dislocations were reduced. The median residual P2 dorsal displacements were 0.0 mm for the pins-rubber bands group, 0.1 mm for the pins-only group, and 0.5 mm for the syringe-pins group. There were no cases of PIP joint redislocation after flexion-extension cycling, and the median dorsal P2 displacements were 0.0 mm for the pins-rubber bands group; 0.0 mm for the pins-only group; and 0.5 mm for the syringe-pins group.

Conclusions: All 3 external fixators restored PIP joint stability following simulated dorsal fracture-dislocation, with all reductions maintained after motion testing. The syringe-pins construct had significantly greater median residual P2 dorsal displacement after the initial reduction and motion testing, which is of unclear clinical importance.

Clinical Relevance: This study informs surgeon decision-making when considering dynamic external fixator options for dorsal PIP joint fracture-dislocations.
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http://dx.doi.org/10.1016/j.jhsa.2022.01.019DOI Listing
March 2022

Surprise Out-of-Network Bills for Hand and Upper Extremity Trauma Patients.

J Hand Surg Am 2021 Nov 8. Epub 2021 Nov 8.

Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD. Electronic address:

Purpose: Patients may receive surprise out-of-network bills even when they present to in-network facilities. Surprise bills are common following emergency care. We sought to characterize and determine risk factors for surprise billing in hand and upper extremity trauma patients in the emergency department (ED).

Methods: We used IBM MarketScan data to evaluate hand and upper extremity trauma patients who received care in the ED from 2010 to 2017. Our primary outcome was the surprise billing incidence, defined as encounters in in-network EDs with out-of-network claims. We used descriptive and bivariate analyses to characterize surprise billing and used multivariable logistic regression to evaluate independent factors associated with surprise billing.

Results: Of 710,974 ED encounters, 97,667 (14%) involved surprise billing. The incidence decreased from 26% in 2010 to 11% in 2017. Mean coinsurance payments were higher for surprise billing encounters and had double the growth from 2010 to 2017 compared to those without surprise billing. Receiving care from different provider types-especially therapists, radiologists, and pathologists, as well as hand surgeons-was associated with significantly higher odds of surprise billing. Transfer to another facility was not significantly associated with surprise billing.

Conclusions: Although the incidence of surprise billing decreased, more than 10% of patients treated in an ED for hand trauma remain at risk. Coinsurance for surprise billing encounters increased by twice as much as encounters without surprise billing. Patients requiring services from therapists, radiologists, pathologists, and hand surgeons were at greater risk for surprise bills. The federal No Surprises Act, passed in 2020, targets surprise billing and may help address some of these issues.

Clinical Relevance: Many hand and upper extremity patients requiring ED care receive surprise bills from various sources that result in higher out-of-pocket costs.
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http://dx.doi.org/10.1016/j.jhsa.2021.09.015DOI Listing
November 2021

Thumb Carpometacarpal Arthritis Surgery: The Patient Experience.

Plast Reconstr Surg 2021 Oct;148(4):809-815

From The Curtis National Hand Center, MedStar Union Memorial Hospital.

Background: Patients with symptomatic recalcitrant thumb carpometacarpal arthritis often undergo surgery. Although most surgical patients do well, the authors anticipated that a substantial portion of their thumb carpometacarpal surgery patients would have unsatisfactory experiences and express unmet expectations, dissatisfaction, and regret, regardless of surgical procedure performed. The authors hypothesized those experiences would correlate with patient-reported outcomes scores.

Methods: The authors identified patients who had undergone trapeziectomy alone or with ligament reconstruction 1 to 4 years previously for primary thumb carpometacarpal arthritis. One hundred twelve patients completed Quick Disabilities of the Arm, Shoulder and Hand and visual analogue scale pain, expectations, satisfaction, and regret questionnaires.

Results: More than 40 percent of patients expected to "return to normal" after surgery for pain, strength, and/or function. Including all patients, 7, 19, and 11 percent had unmet expectations for improvement in pain, strength, and function, respectively. Twelve percent expressed dissatisfaction with their outcome. Although just 4 percent regretted undergoing surgery, 13 percent would likely not recommend the procedure to someone they care about. There were no statistically significant differences for any patient-reported outcomes between trapeziectomy-alone (n = 20) and trapeziectomy with ligament reconstruction (n = 92). Visual analogue scale and Quick Disabilities of the Arm, Shoulder and Hand questionnaire scores were both moderately correlated with expectations being met for pain, strength, and function and for satisfaction with surgical outcome.

Conclusions: Patients' thumb carpometacarpal surgical experiences vary considerably. Many express dissatisfaction or a lack of expectations met with the two most common procedures. A thorough understanding and review of expectations preoperatively may be uniquely pertinent for these patients. Further research should determine predictors and potentially modifiable factors for unsatisfactory outcomes.
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http://dx.doi.org/10.1097/PRS.0000000000008313DOI Listing
October 2021

Comparison of Lag Versus Nonlag Screw Fixation for Long Oblique Proximal Phalanx Fractures: A Biomechanical Study.

J Hand Surg Am 2022 05 8;47(5):476.e1-476.e6. Epub 2021 Jul 8.

Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD. Electronic address:

Purpose: To compare lag versus nonlag screw fixation for long oblique proximal phalanx (P1) fractures in a cadaveric model of finger motion via the flexor and extensor tendons.

Methods: We simulated long oblique P1 fractures with a 45° oblique cut in the index, middle, and ring fingers of 4 matched pairs of cadaveric hands for a total of 24 simulated fractures. Fractures were stabilized using 1 of 3 techniques: two 1.5-mm fully threaded bicortical screws using a lag technique, two 1.5-mm fully threaded bicortical nonlag screws, or 2 crossed 1.14-mm K-wires as a separate control. The fixation method was randomized for each of the 3 fractures per matched-pair hand, with each fixation being used in each hand and 8 total P1 fractures per fixation group. Hands were mounted to a custom frame where a computer-controlled, motor-driven, linear actuator powered movement of the flexor and extensor tendons. All fingers underwent 2,000 full flexion and extension cycles. Maximum interfragmentary displacement was continuously measured using a differential variable reluctance transducer. Our primary outcome was the difference in the mean P1 fragment displacement between lag and nonlag screw fixation at 2,000 cycles.

Results: The observed differences in mean displacement between lag and nonlag screw fixation were not statistically significant throughout all time points. A two one-sided test procedure for paired samples confirmed statistical equivalence in the fragment displacement between these fixation methods at all time points, including the primary end point of 2,000 cycles.

Conclusions: Nonlag screws provided equivalent biomechanical stability to lag screws for simulated long oblique P1 fractures during cyclic testing in this cadaveric model.

Clinical Relevance: Fixation of long oblique P1 fractures with nonlag screws has the potential to simplify treatment without sacrificing fracture stability during immediate postoperative range of motion.
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http://dx.doi.org/10.1016/j.jhsa.2021.06.001DOI Listing
May 2022

Disparities Limit the Effect and Benefit of a Web-Based Clinic Intake System.

Orthopedics 2021 May-Jun;44(3):e434-e439. Epub 2021 May 1.

With increasing value being placed on patient-centered care and the focus on efficiency and workflow in health care delivery, the authors have implemented a web-based system for demographic, medical history, and patient-reported outcomes data collection for every clinical visit at their specialty upper-extremity center. They evaluated initial success and disparities in use after 12 months. The authors evaluated questionnaire parameters from 2018 patients, focusing primarily on the new patient intake form. They analyzed form-completion time relative to appointment time and form-completion percentage at various times before the appointment. The authors grouped patients by age, sex, race, income, education, employment status, transportation access, self-reported pain, and quality-of-life scores. Waiting room time was evaluated. Of new patients, 94% used the web-based platform to complete the intake form. Of the 4898 completed forms, 69.7% were done more than 1 hour before appointment time, indicating that a personal device was used. When grouped by patient characteristics and controlling for all demographic factors, patients who were male, non-White, and older than 40 years; had lower family income; and had a high school education or less were significantly associated with later form completion. Of the 1136 patients for whom the authors had adequate waiting room time data, late form completion significantly increased odds of waiting more than 15 minutes to be placed into an examination room. These data indicate that the authors are reliably capturing important patient information before appointment time. This could improve clinical workflow and overall quality of care and also identify limits in access and online system use, providing opportunities to improve capture by developing targeted interventions for specific patient populations. [. 2021;44(3):e434-e439.].
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http://dx.doi.org/10.3928/01477447-20210415-02DOI Listing
July 2021

High-Fidelity Wrist Fracture Phantom as a Training Tool to Develop Competency in Orthopaedic Surgical Trainees.

J Am Acad Orthop Surg Glob Res Rev 2021 05 18;5(5):e20.00224-8. Epub 2021 May 18.

From the Department of Mechanical Engineering, Carnegie Mellon University, Philadelphia, PA (Mr. Raeker-Jordan, Mr. Martinez, and Dr. Shimada); the Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD (Dr. Aziz and Dr. LaPorte); the Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD (Dr. Miles); andThe Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD (Dr. Miles, Dr. Means, and Dr. Giladi).

Background: This article will describe the development of a low-cost 3D-printed medical phantom of the arm with a distal radius fracture (DRF) to facilitate training of reduction and splinting techniques. The phantom incorporates tactile responses and visual stimuli from fluoroscopy to assist skill acquisition in a clinical setting. This provides feedback to trainees to help them develop competency and knowledge before providing care to patients.

Methods: Phantoms were developed through advice and feedback from fellowship-trained hand surgeons and orthopaedic senior and junior residents. Phantoms were then pilot tested during a surgical skills examination, with residents having minimal previous exposure to distal radial reduction techniques. Residents were evaluated on procedure speed and accuracy by attending surgeons using the objective structured assessment of technical skills. Residents then completed a written knowledge examination about relevant requirements of DRF management and feedback on their opinion of the exercise using the Likert scale.

Results: Residents who passed the hands-on examination also scored higher on the written examination. All residents reported that the phantom was beneficial and motivating as part of their overall training.

Discussion: Real-time feedback using a phantom limb and fluoroscopic imaging, in conjunction with guidance from surgeons, allows residents to learn and practice DRF reduction and splinting techniques. These educational exercises are relatively low-cost and remove the risk of potential harm to patients during early skill acquisition. This training method may be a predictor of surgical performance in addition to providing assessment of background knowledge. Additional training sessions will be required to determine the effect of repeat exposure to residents' proficiency and comprehension.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-20-00224DOI Listing
May 2021

Assessing the Relationship Between Bone Density and Loss of Reduction in Nonsurgical Distal Radius Fracture Treatment.

J Hand Surg Am 2021 05 16;46(5):377-385.e2. Epub 2021 Mar 16.

The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore. Electronic address:

Purpose: Whether low bone mineral density affects loss of reduction for distal radius fractures (DRFs) managed without surgery is unknown. Our purpose was to understand how bone mineral density, based on second metacarpal cortical percentage (2MCP) measurement, affects DRF healing after nonsurgical treatment.

Methods: We retrospectively reviewed 304 patients from 2 health systems with DRFs treated without surgery. The AO classification, 2MCP (<50% indicating osteoporosis), and fracture stability based on Lafontaine criteria were determined from prereduction radiographs. Radial inclination, radial height, volar tilt, ulnar variance, and intra-articular stepoff were measured on initial and 6-week final follow-up radiographs and compared. Bivariate analysis was used to evaluate the association between Lafontaine criteria or 2MCP and changes in radiographic parameters. Radiographic parameters with significant associations in bivariate analysis were evaluated in multivariable models adjusted for age, sex, initial radiographic parameters, reduction status, and AO fracture type.

Results: Across all patients, after 6 weeks of nonsurgical treatment, ulnar variance (shortening of the radius) increased by an average of 1.4 mm. Bivariate analysis showed that lower 2MCP and unstable fractures per Lafontaine criteria were each significantly associated with an increase in ulnar variance (P < .05). In adjusted multivariable models, having both 2MCP less than 50% and an unstable fracture together was associated with an additional 1.2-mm increase in ulnar variance (P < .05).

Conclusions: A 2MCP in the osteoporosis range and unstable fractures by Lafontaine criteria were each associated with a significant increase in ulnar variance after nonsurgical treatment for DRFs. Patients with unstable fractures and 2MCP less than 50% are likely to have an additional increase of greater than 1 mm in ulnar variance at the end of nonsurgical fracture treatment than patients with similar injuries, but without these features. Using initial radiographs to identify patients with low bone mineral density that may be at risk for more substantial loss of reduction can assist with decision making for managing DRFs.

Type Of Study/level Of Evidence: Prognostic IV.
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http://dx.doi.org/10.1016/j.jhsa.2021.02.002DOI Listing
May 2021

Minimally Invasive Intramedullary Screw Versus Plate Fixation for Proximal Phalanx Fractures: A Biomechanical Study.

J Hand Surg Am 2021 06 8;46(6):518.e1-518.e8. Epub 2021 Jan 8.

Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD. Electronic address:

Purpose: To compare the maximum interfragmentary displacement of short oblique proximal phalanx (P1) fractures fixed with an intramedullary headless compression screw (IMHCS) versus a plate-and-screws construct in a cadaveric model that generates finger motion via the flexor and extensor tendons of the fingers.

Methods: We created a 30° oblique cut in 24 P1s of the index, middle, ring, and little fingers for 3 matched pairs of cadaveric hands. Twelve fractures were stabilized with an IMHCS using an antegrade, dorsal articular margin technique at the P1 base. The 12 matched-pair P1 fractures were stabilized with a radially placed 2.0-mm plate with 2 bicortical nonlocking screws on each side of the fracture. Hands were mounted to a frame allowing a computer-controlled, motor-driven, linear actuator powered movement of fingers via the flexor and extensor tendons. All fingers underwent 2,000 full-flexion and extension cycles. Maximum interfragmentary displacement was continuously measured using a differential variable reluctance transducer.

Results: The observed mean displacement differences between IMHCS and plate-and-screws fixation was not statistically significant throughout all time points during the 2,000 cycles. A 2 one-sided test procedure for paired samples confirmed statistical equivalence in fracture displacement between fixation methods at the final 2,000-cycle time point.

Conclusions: The IMHCS provided biomechanical stability equivalent to plate-and-screws for short oblique P1 fractures at the 2,000-cycle mark in this cadaveric model.

Clinical Relevance: Short oblique P1 fracture fixation with an IMHCS may provide adequate stability to withstand immediate postoperative active range of motion therapy.
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http://dx.doi.org/10.1016/j.jhsa.2020.11.013DOI Listing
June 2021

Understanding and Measuring Long-Term Outcomes of Fingertip and Nail Bed Injuries and Treatments.

Hand Clin 2021 02;37(1):125-153

The Curtis National Hand Center @ MedStar Union Memorial Hospital, Baltimore, MD, USA.

There are many outcome measures to choose from when caring for or studying fingertip and nail bed trauma and treatments. This article outlines general outcome measures principles as well as guidelines on choosing, implementing, and interpreting specific tools for these injuries. It also presents recent results from the literature for many of these measures, which can help learners, educators, and researchers by providing a clinical knowledge base and aiding study design.
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http://dx.doi.org/10.1016/j.hcl.2020.09.011DOI Listing
February 2021

Applying Evidence to Inform Carpal Tunnel Syndrome Care.

J Hand Surg Am 2021 03 1;46(3):223-230.e2. Epub 2020 Nov 1.

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

Carpal tunnel syndrome (CTS) is one of the most common problems treated by hand surgeons. As our understanding of the condition has improved and focus on quality and evidence-based care has evolved, management of CTS has shifted as well. Although for many patients the diagnosis and treatment plan are relatively straightforward, understanding how to decide what diagnostics are appropriate, how to avoid complications especially in high-risk patients, and even which surgical option to offer remains a challenge. As CTS research efforts broaden and available evidence grows, understanding the different research findings in order to implement the evidence into practice is critical for all surgeons. In this article, we approach commonly encountered challenges in CTS management and take a methodological viewpoint to guide evidence-based practice.
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http://dx.doi.org/10.1016/j.jhsa.2020.09.007DOI Listing
March 2021

Biomechanical Analysis of Zone 2 Flexor Tendon Repair With a Coupler Device Versus Locking Cruciate Core Suture.

J Hand Surg Am 2020 Sep 8;45(9):878.e1-878.e6. Epub 2020 Apr 8.

Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD. Electronic address:

Purpose: To compare flexor tendon repair strength and speed between a tendon coupler and a standard-core suture in a cadaver model.

Methods: In 5 matched-pair fresh cadaver hands, we cut the flexor digitorum profundus tendon of each finger in zone 2 and assigned 20 tendons to both the coupler and the suture groups. Coupler repair was with low-profile stainless steel staple plates in each tendon stump, bridged by polyethylene thread. Suture repair was performed using an 8-strand locking-cruciate technique with 4-0 looped, multifilament, polyamide suture. One surgeon with the Subspecialty Certificate in Surgery of the Hand performed all repairs. Via a load generator, each flexor digitorum profundus was loaded at 5 to 10 N and cycled through flexion just short of tip-to-palm and full extension at 0.2 Hz for 2,000 cycles to simulate 6 weeks of rehabilitation. We recorded repair gapping at predetermined cycle intervals. Our primary outcome was repair gapping at 2,000 cycles. Tendons that had not catastrophically failed by 2,000 cycles were loaded to failure on a servohydraulic frame at 1 mm/s.

Results: Tendon repair gapping was similar between coupled and sutured tendons at 2,000 cycles. Tendons repaired with the coupler had higher residual load to failure than sutured tendons. Mean coupler repair time was 4 times faster than suture repair.

Conclusions: Zone 2 flexor repair with a coupler withstood simulated early active motion in fresh cadavers. Residual load to failure and repair speed were better with the coupler.

Clinical Relevance: This tendon coupler may eventually be an option for strong, reproducible, rapid flexor tendon repair.
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http://dx.doi.org/10.1016/j.jhsa.2020.02.015DOI Listing
September 2020

Contact Pressure between Digital Flexors and Plates for Distal Radius Approaches.

J Wrist Surg 2020 Feb 20;9(1):52-57. Epub 2019 Dec 20.

Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, Maryland.

 Flexor tendon irritation or rupture following open reduction and volar plate fixation of distal radius fractures can cause significant morbidity and necessitate additional surgical intervention.  To compare the impact of the extended flexor carpi radialis (e-FCR) and standard flexor carpi radialis (FCR) approaches on contact pressures between the flexor tendons and volar distal radius plates.  Eight matched pairs of fresh frozen cadavers had each limb randomized to undergo either the e-FCR or standard FCR approach. After the approach, a locking plate was applied to the volar distal radius more distally than ideally to create a worst-case scenario for the digital flexor tendons. Electronic pressure sensors were secured to the volar aspect of each locking plate. Each wrist was pinned in 20 degrees of extension during testing. Using a computer-controlled stepper motor system attached to the digital flexor and extensor tendons, the digits were taken through 4,000 cycles simulating 12 weeks of active flexion and extension.  There were no statistically or clinically significant differences when comparing the contact pressures of the e-FCR approach with the standard FCR approach at any time intervals. The e-FCR had statistically significantly higher radial-sided contact pressures than ulnar-sided contact pressures during early-to-intermediate testing intervals. These differences resolved at late and final testing intervals.  When comparing the standard FCR approach with the e-FCR approach, with the wrist in 20 degrees of extension, there is no significant difference in contact pressures that occur between the digital flexor tendons and volar distal radius plates.  Further study and technique modifications may eventually lead to better methods of avoiding flexor tendon rupture during the volar plating of distal radius fractures.
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http://dx.doi.org/10.1055/s-0039-3402081DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7000249PMC
February 2020

The Effects of Capitate Height Alteration on Dorsal Intercalated Segment Instability.

J Wrist Surg 2020 Feb 30;9(1):29-33. Epub 2019 Sep 30.

Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, Maryland.

 Carpal kinematics may be influenced by the manipulation of carpal dimensions. This may provide a surgical alternative to unpredictable soft tissue reconstruction for scapholunate dissociation. The purpose of this study was to determine if altering capitate height can correct dorsal intercalated segment instability (DISI).  Five cadaveric wrists had baseline radiolunate (RL) angles and scapholunate (SL) intervals measured fluoroscopically, confirming no baseline DISI. We simulated open- and clenched-fist testing via a constant load of the wrist extensors and sequential loading of the digital flexors. We confirmed no baseline static/dynamic DISI. The SL ligament and secondary stabilizers (scapho-trapezio-trapezoid [STT] and dorsal intercarpal ligaments) were transected. Repeat loading and fluoroscopic measurements confirmed creation of static DISI. Capitate height was altered in three interventions: 2 mm shortening osteotomy of capitate waist, 7 mm shortening osteotomy of capitate waist, and 2 mm lengthening of original capitate height by insertion of a spacer at capitate waist. The osteotomized capitate was stabilized with a Kirschner wire; RL angles and SL intervals were measured via fluoroscopy during open- and clenched-fist testing. Primary and secondary outcomes were change in RL angle and SL interval, from the DISI stage to each capitate shortening and lengthening stage.  SL ligament and secondary stabilizers sectioning created a DISI pattern, with abnormal RL angles (>15°) and widened SL intervals. Neither capitate shortening nor overexpansion corrected RL angles or SL intervals in any DISI-induced wrists.  Under the conditions studied, isolated capitate shortening or lengthening did not correct radiographic DISI posturing of the lunate following sectioning of the SL and STT interosseous ligaments. Further study of carpal kinematics with more substantial bone changes and loading of adjacent joints may be beneficial.  Surgeons performing capitate shortening osteotomy in isolation should not expect to improve DISI.
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http://dx.doi.org/10.1055/s-0039-1697651DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7000254PMC
February 2020

Relative Tissue Oxygenation and Temperature Changes for Detecting Early Upper Extremity Skin Ischemia.

Plast Reconstr Surg 2019 10;144(4):907-910

From The Curtis National Hand Center, MedStar Union Memorial Hospital; William Beaumont Army Medical Center; Uniformed Services University; and Madigan Army Medical Center.

The authors' purpose was to determine whether there are reliable noninvasive methods of assessing upper extremity ischemia regardless of skin pigmentation. The authors conducted a study of healthy subjects classified based on skin pigmentation using the Fitzpatrick scale, the von Luschan color scale, and self-described race (two Hispanics, three Caucasians, and four African Americans). A surface temperature probe and a near-infrared spectroscopy monitor were placed on the posterior interosseous artery skin territory. Temporary upper limb ischemia was induced by tourniquet insufflation. Readings from both devices were taken at baseline and every 15 seconds for a total of 10 minutes of ischemia. During tourniquet insufflation, the authors found a reliable decrease in tissue oxygenation measured by near-infrared spectroscopy in all subjects and no significant change in temperature readings for any subjects. There was an average decrease of 19 percent in tissue oxygenation using near-infrared spectroscopy, with measurements on average starting at 77 percent and ending at 57 percent. There was no significant difference in the change in near-infrared spectroscopy oxygenation between participants with Fitzpatrick skin types 3, 4, and 5 or when participants were grouped into Fitzpatrick skin type less than or equal to 3 versus greater than 3, or when grouped into Fitzpatrick skin type less than or equal to 4 versus greater than 4. There was also no significant difference in participants grouped into von Luschan scores less than or equal to 20 versus greater than 20. In this healthy subjects study, near-infrared spectroscopy rapidly identified ischemia in all cases, whereas skin surface temperature did not. Near-infrared spectroscopy may be a reliable way of noninvasively monitoring for ischemia regardless of skin pigmentation degree. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Diagnostic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000006024DOI Listing
October 2019

A Prospective Pilot Study of Vascular Assessment of the Upper Extremity With Laser Angiography.

Hand (N Y) 2020 11 21;15(6):870-876. Epub 2019 Mar 21.

The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, USA.

Our goal was to investigate patients' upper extremity tissue perfusion changes using an indocyanine green laser angiography imaging system for various pathologic states and interventions. This prospective observational study used Spy Elite/LUNA laser angiography to evaluate perfusion in patients with upper extremity vascular compromise. All patients had Spy Elite/LUNA imaging as well as clinical and handheld Doppler examinations preintervention, intraoperatively, if applicable, and at 1 week, 2 weeks, and 2 months postintervention. For each laser angiography scan, we used an unaffected control area with uninjured skin to quantitatively compare with the dysvascular tissues. Twelve patients, 7 men and 5 women, had a total of 16 upper extremities evaluated. The mean age was 53 years, and half of the patients entering the study were smokers. Etiologies of vascular compromise were trauma, primary and secondary vasospastic disease, scleroderma, and intravascular drug injection. Interventions included surgical repair/reconstruction, botulinum toxin injections, and/or systemic medications. Improvement in perfusion following intervention was statistically significant, demonstrated by an increase in Spy Elite/LUNA quantitative score postintervention compared with preintervention scans. Adjusting for other variables, such as smoking and handheld Doppler signal status, demonstrated an independent statistically significant increase in Spy Elite/LUNA scores at all postintervention time points compared with preintervention scores. Laser angiography was able to confirm adequate vascular status, with ultimate tissue survival, in some cases when Doppler signals were not initially present. Laser angiography provided objective data to document improved upper extremity tissue perfusion following various interventions.
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http://dx.doi.org/10.1177/1558944719837023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7850253PMC
November 2020

Antibiotic Use in Hand Surgery: Surgeon Decision Making and Adherence to Available Evidence.

Hand (N Y) 2020 07 22;15(4):534-541. Epub 2018 Nov 22.

The Curtis National Hand Center, Baltimore, MD, USA.

There are no clearly defined guidelines from hand surgical societies regarding preoperative antibiotic prophylaxis. Many hand surgeons continue to routinely use preoperative prophylaxis with limited supporting evidence. This study aimed to determine for which scenarios surgeons give antibiotics, the reasons for administration, and whether these decisions are evidence-based. An anonymous 25-question survey was e-mailed to the 921-member American Society for Surgery of the Hand listserv. We collected demographic information; participants were asked whether they would administer antibiotics in a number of surgical scenarios and for what reasons. Respondents were broken into 3 groups based on when they said they would administer antibiotics: Group 1 (40 respondents) would give antibiotics in the case of short cases, healthy patients, without hardware; group 2 (9 respondents) would not give antibiotics in any scenario; and group 3 (129 respondents) would give antibiotics situationally. The Fisher exact test compared demographic variables, frequency of use, and indications of antibiotic prophylaxis. Of the 921 recipients, 178 (19%) responded. Demographic variables did not correlate with the antibiotic use group. Operative case time >60 minutes, medical comorbidity, and pinning each increased antibiotic use. Group 1 respondents were more likely to admit that their practice was not evidence-based (74.4%) and that they gave antibiotics for medical-legal concern (75%). Twenty-two percent of respondents reported seeing a complication from routine prophylaxis, including infection. Antibiotics are still given unnecessarily before hand surgery, most often for medical-legal concern. Clear guidelines for preoperative antibiotic use may help reduce excessive and potentially inappropriate treatment and provide medical-legal support.
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http://dx.doi.org/10.1177/1558944718812161DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7370387PMC
July 2020

The Relationship Between Hemihamate Graft Size and Proximal Interphalangeal Joint Flexion for Reconstruction of Fracture-Dislocations: A Biomechanical Study.

J Hand Surg Am 2019 Aug 9;44(8):696.e1-696.e6. Epub 2018 Nov 9.

Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD. Electronic address:

Purpose: The purpose of this study was to determine the relationship between hemihamate graft size and proximal interphalangeal (PIP) joint flexion in a biomechanical fracture-dislocation model.

Methods: We simulated middle finger PIP fracture-dislocations in 5 cadaver hands by resecting 50% of the palmar articular surface of the middle phalanx (P2) base. Fluoroscopy was used to confirm dorsal subluxation of the middle phalanx base after resection. A 10-mm osteochondral hamate graft was contoured to reconstruct the volar lip of the middle phalanx and was progressively downsized by 2-mm increments for each trial. A computer-controlled articulator and jig simulated active flexion and extension of the fingers. Maximum PIP flexion was measured at each graft size using fluoroscopy and digital imaging software. Clinically significant flexion block was defined as PIP flexion less than 90°.

Results: The actual mean size of the volar defect created was 52% (3.5 mm) of the middle phalanx articular surface, which created instability and dorsal subluxation in all tested fingers. After hemihamate reconstruction, all specimens were stable throughout flexion and extension for all graft sizes. A flexion block of 90° occurred at a mean graft size of 191% of the defect (6.5 mm). With regard to the volar lip of the P2, grafts that projected an average 0.8 mm past the native volar lip position had 98° (range, 84°-107°) maximum PIP flexion. Grafts that projected an average of 3.1 mm past the native volar lip position had 90° (range, 69°-100°) maximum PIP flexion. Linear regression modeling incorporating all of the results predicted flexion block to occur at a graft size as small as 166% of the 50% volar P2 defect. In this model, for every 50% (1.7-mm) increase in graft size relative to the defect, PIP flexion decreased by approximately 6°.

Conclusions: Nonanatomical hemihamate grafts produce a PIP flexion block at extreme sizes, predicted to occur at greater than 166% of a 50% P2 base articular defect in our model. This suggests that relatively large grafts can be used for reconstruction of PIP fracture-dislocations without substantial biomechanical block to PIP flexion. We suggest sizing no larger than 3 mm past the native P2 volar lip position to avoid an important mechanical block to PIP flexion.

Clinical Relevance: The information from this study helps surgeons understand how large a hemihamate graft can be used for P2 volar base reconstruction before having a negative impact on PIP flexion.
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http://dx.doi.org/10.1016/j.jhsa.2018.09.017DOI Listing
August 2019

The Effect of Skin Pigmentation on Determination of Limb Ischemia.

J Hand Surg Am 2018 01 2;43(1):24-32.e1. Epub 2017 Nov 2.

Curtis National Hand Center, Baltimore, MD. Electronic address:

Purpose: Timely identification of tissue ischemia is critical, both in the traumatized limb and following free tissue transfer. The purpose of this study was to determine if skin pigmentation affects the ability to detect limb ischemia.

Methods: We conducted a study of healthy controls exposed to limb ischemia. The subjects were classified based on skin pigmentation using a defined skin type assessment tool, a visual color scale, and self-description of race. Participants were randomized by limb and tourniquet status; surgeons were blinded to both. Ischemia was induced by tourniquet insufflations, and board-certified orthopedic and plastic surgeons who had completed an accredited hand surgery fellowship conducted physical examinations. The surgeons monitored the forearms at 2, 6, and 10 minutes based on appearance of ischemia, capillary refill, and color in 3 locations on the limbs (posterior interosseous artery flap skin territory, radial forearm flap skin territory, and the digits).

Results: We found a significant decrease in the ability to detect ischemia in participants with increased skin pigmentation, as documented by all metrics, when evaluating the posterior interosseous artery and radial forearm flap skin territories at all time points. For example, when monitoring the posterior interosseous artery flap with the tourniquet insufflated at time 10 minutes, 92.9% of Caucasians were correctly identified as being ischemic whereas only 23.3% of African Americans were correctly identified.

Conclusions: Skin pigmentation significantly affects the identification of an ischemic limb/skin flaps on physical examination. Whereas the standard treatment for monitoring of free tissue transfer is clinical examination, that may not be sufficient for patients with increased skin pigmentation. Surgeons should exercise particular vigilance during physical examination of a potentially ischemic limb/skin flaps with greater skin pigmentation.

Type Of Study/level Of Evidence: Diagnostic II.
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http://dx.doi.org/10.1016/j.jhsa.2017.09.002DOI Listing
January 2018

Suture-Button Device Stabilization Following Ring Finger Ray Amputation: A Comparative Cadaver Study.

Hand (N Y) 2018 07 30;13(4):435-440. Epub 2017 Jun 30.

2 The Curtis National Hand Center, Baltimore, MD, USA.

Background: The purpose of this study was to determine whether placing the suture-button device between the long and small finger metacarpals following ring finger ray amputation may better close the intermetacarpal gap and allow early range of motion without increasing the risk of malrotation than soft tissue repair alone.

Methods: We performed ray amputation of the ring finger of 14 cadaver specimens by performing an osteotomy of the base of the ring finger metacarpal and then excising the remainder of the digit. We first performed a soft tissue repair of the transverse metacarpal ligaments and then cycled the fingers in simulated active flexion and extension on a custom computer-controlled device to re-create 6 weeks of range of motion. We then placed a suture-button device across the long and small finger metacarpals and tested the specimens again, thereby using each hand as an internal control.

Results: The distance between the ring and small finger metacarpals was reduced following suture-button device placement compared with the initial control; this spacing was maintained following complete cycling of the fingers. The angle between the metacarpals was divergent following soft tissue repair, and then became slightly convergent after insertion of the suture-button device. None of the hands developed clinically relevant scissoring of the digits before or after application of the suture-button device.

Conclusions: The suture-button device provides stable fixation to withstand early range of motion following ring finger ray amputation and significantly closes the gap and angle between the adjacent metacarpals without causing scissoring.
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http://dx.doi.org/10.1177/1558944717715104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6081778PMC
July 2018

Viability of Hand and Wrist Photogoniometry.

Hand (N Y) 2018 05 9;13(3):301-304. Epub 2017 Apr 9.

1 The Curtis National Hand Center at MedStar Union Memorial Hospital, Baltimore, MD, USA.

Background: No goniometric technique is both maximally convenient and completely accurate, although photogoniometry (ie, picture taking to facilitate digital angle measurement) shows promise in this regard. Our purpose was to test the feasibility and reliability of a photogoniometric protocol designed to measure wrist and digit range of motion in general.

Methods: Two independent observers examined a sample of joints in both normal and abnormal hands according to a photogoniometric protocol. Interrater and intrarater correlation were calculated, and these measurements were compared with measurements made by a third independent examiner with a manual goniometer.

Results: The photo-based measurements were reliable within and between observers; however, only a minority of these measurements were in agreement with manually collected values.

Conclusions: At present, photogoniometry is not an acceptable alternative to manual goniometry for determining wrist and digit range of motion in general. Joint-specific photogoniometry should be the subject of future study, as should relevant imaging and software technology.
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http://dx.doi.org/10.1177/1558944717702471DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5987967PMC
May 2018

Comparison of patient-reported outcomes after traumatic upper extremity amputation: Replantation versus prosthetic rehabilitation.

Injury 2016 Dec 19;47(12):2783-2788. Epub 2016 Oct 19.

Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, United States. Electronic address:

Background: After major upper extremity traumatic amputation, replantation is attempted based upon the assumption that outcomes for a replanted limb exceed those for revision amputation with prosthetic rehabilitation. While some reports have examined functional differences between these patients, it is increasingly apparent that patient perceptions are also critical determinants of success. Currently, little patient-reported outcomes data exists to support surgical decision-making in the setting of major upper extremity traumatic amputation. Therefore, the purpose of this study is to directly compare patient-reported outcomes after replantation versus prosthetic rehabilitation.

Methods: At three tertiary care centers, patients with a history of traumatic unilateral upper extremity amputation at or between the radiocarpal and elbow joints were identified. Patients who underwent either successful replantation or revision amputation with prosthetic rehabilitation were contacted. Patient-reported health status was evaluated with both DASH and MHQ instruments. Intergroup comparisons were performed for aggregate DASH score, aggregate MHQ score on the injured side, and each MHQ domain.

Results: Nine patients with successful replantation and 22 amputees who underwent prosthetic rehabilitation were enrolled. Aggregate MHQ score for the affected extremity was significantly higher for the Replantation group compared to the Prosthetic Rehabilitation group (47.2 vs. 35.1, p<0.05). Among the MHQ domains, significant advantages to replantation were demonstrated with respect to overall function (41.1 vs. 19.7, p=0.03), ADLs (28.3 vs. 6.0, p=0.03), and patient satisfaction (46.0 vs. 24.4, p=0.03). Additionally, Replantation patients had a lower mean DASH score (24.6 vs. 39.8, p=0.08).

Conclusions: Patients in this study who experienced major upper extremity traumatic amputation reported more favorable patient-reported outcomes after successful replantation compared to revision amputation with prosthetic rehabilitation.
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http://dx.doi.org/10.1016/j.injury.2016.10.004DOI Listing
December 2016

Changes in Wrist Motion After Simulated Scapholunate Arthrodesis: A Cadaveric Study.

J Hand Surg Am 2016 Sep;41(9):e285-93

Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD. Electronic address:

Purpose: A high incidence of nonunion and relatively poor outcomes with prior fixation techniques has precluded scapholunate (SL) arthrodesis as a standard treatment for SL instability. Our purpose was to determine the impact on range of motion (ROM) of simulated SL arthrodesis via headless screw fixation.

Methods: We performed baseline wrist ROM for 10 cadaveric wrists using a standardized mounting-and-weights system. Extension, flexion, radial deviation, ulnar deviation, dart-thrower's extension, and dart-thrower's flexion were assessed. Two 3.0-mm headless compression screws were inserted across the SL joint to simulate SL arthrodesis. Goniometric measurements and fluoroscopic imaging were repeated to assess ROM differences after simulated SL arthrodesis. We assessed SL angle and gap during testing to ensure there was no significant motion between the scaphoid and lunate, thus confirming stable simulated fusion. Differences in ROM were compared between baseline and simulated SL arthrodesis using paired t tests.

Results: Mean SL angle remained constant between pre- and post-arthrodesis imaging (47° ± 6° vs 46° ± 4°) and did not change during post-arthrodesis ROM testing, indicating a stable simulated fusion. Compared with baseline, SL arthrodesis had a statistically significant reduction in maximum flexion of 6° and 9° based on fluoroscopy and goniometry, respectively, in dart-thrower's extension of 5° and 9° based on fluoroscopy and goniometry, respectively, and in dart-thrower's flexion of 6° for both fluoroscopy and goniometry. No other ROMs after simulated SL arthrodesis were significantly different compared with baseline.

Conclusions: The effects of simulated SL arthrodesis on radiocarpal and midcarpal motion compare favorably with motion after SL soft tissue repair and other reconstructive techniques that have been previously reported. The statistically significant decreases in wrist flexion and dart-thrower's extension-flexion after simulated SL arthrodesis are of questionable clinical importance.

Clinical Relevance: These results may support reconsidering SL arthrodesis as a viable treatment option for acute or chronic SL instability with regard to apparent minimal adverse effects on functional wrist ROM.
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http://dx.doi.org/10.1016/j.jhsa.2016.07.056DOI Listing
September 2016

Endoscopic Compared with Open Operative Treatment of Carpal Tunnel Syndrome.

JBJS Rev 2016 06;4(6)

The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, Maryland.

Carpal tunnel syndrome is the most common peripheral nerve compression syndrome. Treatment options include wrist-neutral bracing, corticosteroid injections, operative release of the transverse carpal ligament, and symptom-relief options. Endoscopic carpal tunnel release may give patients a faster recovery compared with traditional open release, but there are no ultimate differences in outcome among the various surgical options.
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http://dx.doi.org/10.2106/JBJS.RVW.15.00071DOI Listing
June 2016

Cadaveric Investigation of Active Finger Range of Motion for Detection of Intratendinous Needle Placement.

Plast Reconstr Surg 2016 Aug;138(2):268e-272e

Baltimore, Md.

Background: The authors' purpose was to determine if investigators can predict whether a needle is within a finger's flexor tendon by postinsertion tactile and visualization evaluation in an active range-of-motion cadaver model.

Methods: In 48 cadaver fingers, a 25-gauge needle, with a 1-cc syringe attached, was placed into one of three randomly assigned positions at the A2 pulley level: within the flexor digitorum profundus, within the flexor digitorum superficialis, or outside both flexors and the sheath. Each finger was cycled through full active range of motion as three hand surgeons, blinded to each other's responses and needle position, recorded whether they thought the needle was intratendinous. The initial investigator confirmed needle position after each surgeon's assessment.

Results: Active cadaver finger range of motion did not allow surgeons to accurately determine whether a needle was in a flexor tendon. There was no statistically significant agreement among the surgeons about whether the needle was intratendinous.

Conclusion: Because of poor interobserver agreement, sensitivity, and negative predictive value, we conclude that finger range of motion is not a reliable test to detect intratendinous needle placement in this cadaver model.
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http://dx.doi.org/10.1097/PRS.0000000000002370DOI Listing
August 2016

A Multicenter, Prospective, Randomized, Pilot Study of Outcomes for Digital Nerve Repair in the Hand Using Hollow Conduit Compared With Processed Allograft Nerve.

Hand (N Y) 2016 Jun 17;11(2):144-51. Epub 2016 Feb 17.

Curtis National Hand Center, Baltimore, MD, USA.

Background: Current repair options for peripheral nerve injuries where tension-free gap closure is not possible include allograft, processed nerve allograft, and hollow tube conduit. Here we report on the outcomes from a multicenter prospective, randomized, patient- and evaluator-blinded, pilot study comparing processed nerve allograft and hollow conduit for digital nerve reconstructions in the hand.

Methods: Across 4 centers, consented participants meeting inclusion criteria while not meeting exclusion criteria were randomized intraoperatively to either processed nerve allograft or hollow conduit. Standard sensory and safety assessments were conducted at baseline, 1, 3, 6, 9, and 12 months after reconstruction. The primary outcome was static 2-point discrimination (s2PD) testing. Participants and assessors were blinded to treatment. The contralateral digit served as the control.

Results: We randomized 23 participants with 31 digital nerve injuries. Sixteen participants with 20 repairs had at least 6 months of follow-up while 12-month follow-up was available for 15 repairs. There were no significant differences in participant and baseline characteristics between treatment groups. The predominant nerve injury was laceration/sharp transection. The mean ± SD length of the nerve gap prior to repair was 12 ± 4 mm (5-20 mm) for both groups. The average s2PD for processed allograft was 5 ± 1 mm (n = 6) compared with 8 ± 5 mm (n = 9) for hollow conduits. The average moving 2PD for processed allograft was 5 ± 1 mm compared with 7 ± 5 mm for hollow conduits. All injuries randomized to processed nerve allograft returned some degree of s2PD as compared with 75% of the repairs in the conduit group. Two hollow conduits and one allograft were lost due to infection during the study.

Conclusions: In this pilot study, patients whose digital nerve reconstructions were performed with processed nerve allografts had significantly improved and more consistent functional sensory outcomes compared with hollow conduits.
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http://dx.doi.org/10.1177/1558944715627233DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4920529PMC
June 2016

Ultrasonography for Hand and Wrist Conditions.

J Am Acad Orthop Surg 2016 Aug;24(8):544-54

From Georgia Hand, Shoulder & Elbow, Atlanta, GA (Dr. Starr), MedStar Orthopaedics and Sports Medicine, Ellicott City, MD (Dr. Sedgley), and the Curtis National Hand Center, Baltimore (Dr. Means and Dr. Murphy).

Ultrasonography facilitates dynamic, real-time evaluation of bones, joints, tendons, nerves, and vessels, making it an ideal imaging modality for hand and wrist conditions. Ultrasonography can depict masses and fluid collections, help locate radiolucent foreign bodies, characterize traumatic or overuse tendon or ligament pathology, and help evaluate compressive peripheral neuropathy and microvascular blood flow. Additionally, this modality improves the accuracy of therapeutic intra-articular or peritendinous injections and facilitates aspiration of fluid collections, such as ganglia.
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http://dx.doi.org/10.5435/JAAOS-D-15-00170DOI Listing
August 2016

Therapeutic augmentation of the growth hormone axis to improve outcomes following peripheral nerve injury.

Expert Opin Ther Targets 2016 Oct 24;20(10):1259-65. Epub 2016 May 24.

a Department of Plastic and Reconstructive Surgery , Johns Hopkins University School of Medicine , Baltimore , MD , USA.

Introduction: Peripheral nerve injuries often result in debilitating motor and sensory deficits. There are currently no therapeutic agents that are clinically available to enhance the regenerative process. Following surgical repair, axons often must regenerate long distances to reach and reinnervate distal targets. Progressive atrophy of denervated muscle and Schwann cells (SCs) prior to reinnervation contributes to poor outcomes. Growth hormone (GH)-based therapies have the potential to accelerate axonal regeneration while at the same time limiting atrophy of muscle and the distal regenerative pathway prior to reinnervation.

Areas Covered: In this review, we discuss the potential mechanisms by which GH-based therapies act on the multiple tissue types involved in peripheral nerve regeneration to ultimately enhance outcomes, and review the pertinent mechanistic and translational studies that have been performed. We also address potential secondary benefits of GH-based therapies pertaining to improved bone, tendon and wound healing in the setting of peripheral nerve injury.

Expert Opinion: GH-based therapies carry great promise for the treatment of peripheral nerve injuries, given the multi-modal mechanism of action not seen with other experimental therapies. A number of FDA-approved drugs that augment the GH axis are currently available, which may facilitate clinical translation.
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http://dx.doi.org/10.1080/14728222.2016.1188079DOI Listing
October 2016
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