Paper 01: Nerve Injury Predicts Functional Outcomes in Pediatric

Supracondylar Humerus Fractures: A Prospective Study Best Papers - Thursday, September 10, 3:19 - 3:24 PM

Prognosis/Outcomes,Elbow and Forearm,Congenital and Pediatric Problems,Nerve

Level 2 Evidence

Justin J. Ernat, MD

Anthony I. Riccio, MD

Robert L. Wimberly, MD

Christine A. Ho, MD

David A. Podeszwa, MD

Hypothesis

The purpose of this study is to prospectively evaluate the relationship between neurologic deficit

at presentation and functional outcome in children with supracondylar humerus fractures

(SCHFX) using validated outcome measures. We hypothesized that patients with nerve injury

would have decreased functional outcomes compared to those who did not sustain nerve

injuries.

Methods

An IRB approved prospective enrollment of consecutive patients with operative SCHFX was

performed over a 3-year period. Among other injury parameters, the presence and type of any

neurologic deficit was documented by the treating surgeon at presentation and throughout the

follow-up period. Functional outcome was assessed at final follow-up using the Pediatric

Outcomes Data Collection Instruments (PODCI) and the quick Disabilities of the Arm, Shoulder,

and Hand (QuickDASH) Outcome Measure. Multiple regression analysis was used to determine

the relationship between the presence/type of nerve injury and functional outcome while

controlling for other injury parameters including patient age, fracture classification, fracture

pattern, vascular abnormality and presence of an open fracture.

Results

752 patients were enrolled during the study period of which 199 (average age 6.7 years)

completed functional outcome measures at final follow-up. Of these, 22 (11%) patients had a

neurologic deficit at the time of initial presentation with 25 nerve injuries noted: 10 (40%)

anterior interosseous nerve (AIN) deficits, 5 (20%) posterior interosseous nerve (PIN) deficits, 4

(16%) ulnar nerve deficits, 3 (12%) median nerve deficits, and 3 (12%) radial nerve deficits. As a

group, patients with neurologic injury demonstrated significantly lower There were no significant

differences in outcomes scores when comparing different types of nerve injuries. All nerve

injuries resolved without further intervention with no residual nerve deficits in at final follow-up.

Summary Points

• In children with operative SCHFX, the presence of a nerve deficit at presentation is predictive

of poorer outcomes with regards to pain, function, mobility and satisfaction at final follow-up

despite complete spontaneous resolution.

• This is the first study to prospectively determine an association between neurologic deficit

and functional outcome using validated outcome measures following the operative

treatment of children with SCHFX.

Reference 1: Guner, S., et al., Iatrogenic or fracture-related nerve injuries in supracondylar

humerus fracture: is treatment necessary for nerve injury? Eur Rev Med Pharmacol Sci, 2013.

17(6): p. 815-9.

Reference 2: Ramachandran, M., R. Birch, and D.M. Eastwood, Clinical outcome of nerve injuries

associated with supracondylar fractures of the humerus in children: the experience of a specialist

referral centre. J Bone Joint Surg Br, 2006. 88(1): p. 90-4.

Reference 3: Gosens, T. and K.J. Bongers, Neurovascular complications and functional outcome

in displaced supracondylar fractures of the humerus in children. Injury, 2003. 34(4): p. 267-73.

Reference 4: Gillespie, B., et al. Recovery of Motor Nerve Injuries Associated with Displaced,

Extenion-Type Pediatric Supracondylar Humerus Fractures. in American Society for Surgery of

the Hand Annual Meeting. 2014. Boston, MA.

Paper 02: The Detrimental Effect of Decentralization in Digital

Replantation in the United States Best Papers - Thursday, September 10, 3:24 - 3:29 PM

Treatment,Historical Information,Prognosis/Outcomes,Hand and Wrist

Level 3 Evidence

Joshua William Hustedt, MD, MHS

Patricia Klempf, MD

Lloyd P. Champagne, MD

Hypothesis

Recent reports suggest a decrease in success rates in digital replantation in the United States.

We hypothesize that this may be occurring due to the decentralization of replantations away

from centers of excellence.

Methods

All amputation injuries and digital replantations from the national inpatient sample database

were collected from 1998-2012. Success rates at high volume and low volume centers were

determined based on hospital (>20 replants per year) and surgeon volume (>5 replants per year)

in the database. Univariate, correlation, and multivariate regression were used to determine

statistical relationships between study variables.

Results

101,693 amputations injuries resulting in 15,821 replantations occurred during the fifteen-year

study period. The overall rate of success of replantations dropped from 74.5% to 65.7% (P <

0.001) during the study period. The percentage of high volume centers (15.5% to 8.9%; P <

0.001) and high volume surgeons (14.4% to 2.6%; P < 0.001) has dropped significantly over the

study period. High volume surgeons outperformed low volume surgeons (79.3% vs 72.2%; P <

0.001) and high volume hospitals outperformed low volume hospitals (77.1% vs 70.9%; P <

0.001) in success rates. High volume surgeons operating at high volume hospitals had

significantly higher success rates than low volume surgeons operating at low volume hospitals

(92.0% vs 72.1%; P < 0.001). In addition, high volume surgeons at high volume hospitals

attempted replantations at greater rates than low volume surgeons operating at low volume

centers (21.5% vs 11.0%; P < 0.001). Overall, an amputation injury presenting to a high volume

surgeon at a high volume center has a 2.5 times greater likelihood of obtaining a successful

replantation than to a low volume surgeon at a low volume hospital.

Summary Points

• Decreased success rates of digital replantation in the United States are strongly linked to the

decentralization of digital replantation away from high volume surgeons at high volume

centers.

• Establishment of national centers of excellence for digital replantation referral may greatly

increase overall replantation success rates in the United States.

Paper 02_Image01

Paper 02_Image02

Reference 1: Berlin et al. Digit replantation in children: a nationwide analysis of outcomes and

trends of 455 pediatric patients. Hand (2014) 9:244-252.

Reference 2: Barzin et al. Adverse events following digital replantation in the elderly. J Hand

Surg (2011) 36A:870-874

Reference 3: Shale et al. A nationwide review of the treatment patters of traumatic thumb

amputations. Ann Plast Surg (2013) 70(6):647-651

Reference 4: Friedrich et al. Epidemiology of upper extremity replantation surgery in the United

States. J Hand Surg (2011) 36A:1835-1840.

Paper 03: Late Onset Upper Extremity Lymphedema Following Elective

Hand Surgery in Breast Cancer Survivors Best Papers - Thursday, September 10, 3:29 - 3:34 PM

Evaluation/Diagnosis,Treatment,Patient Education,Prognosis/Outcomes

Level 3 Evidence

Heather L. Baltzer, MD, FRCSC

Jamison Harvey, BSc

Steven L. Moran, MD

Hypothesis

The safety of elective hand surgery in women previously treated for same-sided breast cancer is

controversial due to concerns of developing late onset upper extremity lymphedema. We

hypothesized that the prevalence of lymphedema following elective hand surgery among breast

cancer survivors would be low but may be more likely depending on the type of axillary

dissection and adjuvant treatment received.

Methods

A retrospective cohort of breast cancer patients treated with axillary lymph node dissection

(ALND), sentinel lymph node biopsy (SLNB) and/or radiation therapy (RT) was identified between

1997-2012. Patients with ipsilateral elective hand surgery following their breast cancer

treatment were included if there was at least 1 year of follow up and no history lymphedema

following breast cancer treatment. The primary outcome was documented lymphedema

following hand surgery. Demographic data and clinical information pertaining to both hand

surgery and breast cancer treatment and were compared between patients with and without

lymphedema. Dichotomous and continuous variables were compared with Fisher’s exact and

Student T-tests, respectively.

Results

The analysis included 103 patients, of which four (3.8%) had documented lymphedema following

hand surgery, which developed early and was self-limited. Patient with and without

lymphedema were similar in age, hand surgery procedure, and tourniquet use. Average

tourniquet time was greater among women without lymphedema (23 vs. 9 minutes, P =0.02). All

patients (4/4) with late-onset lymphedema received adjuvant chemotherapy (vs. 29% in non-

lymphedema group, P = .009) and RT with either ALND or SLNB (vs 41% of patients without

lymphedema, P = .01). Radiotherapy or any type of axillary dissection alone was not associated

with lymphedema following elective hand surgery. Lymphedema was associated with a shorter

interval between hand surgery and completion of breast cancer surgery (2.1 vs. 6.2 years, P <

.01) and RT (2.0 vs. 3.3 years, P = .051).

Summary Points

• Lymphedema is uncommon and self-limited following elective hand surgery among breast

cancer survivors.

• A combination of RT and ALND or SLNB and a shorter interval between hand surgery and

breast cancer treatments (ALND/SLNB and RT) appears to put these women at higher risk of

developing late onset lymphedema after elective hand surgery.

• Tourniquet use appears to be safe for elective hand surgery among this patient population.

Reference 1: Habbu, R, MBBS, Adams, J. HAND SURGERY FOLLOWING BREAST CANCER

TREATMENT (2011) JHS, 36A: 1537-9.

Paper 04: Arthroscopic All-Inside Suture Fixation and Bone Grafting of

Osteochondritis Dissecans Lesions of the Capitellum Best Papers - Thursday, September 10, 3:34 - 3:39 PM

Treatment,Surgical Technique,Elbow and Forearm

Level 4 Evidence

Steven M. Koehler, MD

Amanda Walsh, MD

Jason Stuart Pruzansky, MD

Michael R. Hausman, MD

Royalty: Smith And Nephew (Pruzansky)

Other (Please describe): stock options: Checkpont Surgical NDI Medical SPR Therapeutics

(Pruzansky)

Hypothesis

We hypothesize that a novel technique for all-arthroscopic fixation of capitellum osteochondritis

dissecans (OCD) lesions using suture fixation and autogenous iliac crest bone grafting offers a

successful alternative to open, internal fixation techniques as measured by validated, patient

reported outcomes scores.

Methods

Our technique utilizes arthroscopic all-inside suture fixation with iliac crest autogenous bone

grafting. The procedure was performed on four adolescents presenting with five unstable

capitellum OCD lesions. The patients were all elite-level athletes: two gymnasts, one baseball

pitcher, and one lacrosse player. All patients presented with elbow pain, limited range-of-

motion (ROM), and decreased ability to play. MRI provided the diagnosis of an unstable OCD

lesion, which was correlated with arthroscopy at the time of surgery. Postoperatively, all

patients were immobilized in a long arm cast for 2 months. ROM exercises were then initiated

with return to activity as tolerated over a period of 8 weeks. Patients were evaluated

prospectively with DASH, Oxford Elbow and Mayo Elbow scores, VAS scores, postoperative ROM

and return to play.

Results

Three females and one male aged 13 to 15 years old underwent the procedure. Three patients

demonstrated a loss of preoperative terminal extension (average 28 degrees). Two patients

underwent failed prior procedures at outside institutions (one retrograde drilling and one

internal fixation). Average final follow-up was 2.8 years. All patients went on to union as seen

on MRI at an average of 3 months. At follow-up, the average loss of extension was 2 degrees.

The average flexion was 153 degrees. There was no loss of supination or pronation. The average

DASH score was 11. The average Mayo Elbow score was 88. The average Oxford Elbow score

was 42. The average VAS was 2. Average return-to-play was 4 months. All patients continued to

compete at an elite level. There were no infections, failure of fixation, need for conversion to

open surgery, or revision surgeries.

Summary Points

• Arthroscopic all-inside fixation of unstable OCD lesions is a successful technique, facilitating

athletes to return to elite level of play

• Our technique results in outcomes comparable to those reported in the literature for open

fixation and arthroscopic-assisted fixation (1-3).

• Drilling from posterior to anterior through the humerus avoids the need for articular surface

violation and limits the manipulation of tenuous fragments.

• Absorbable suture is used, precluding the need for hardware removal should collapse or

progression of the lesion occur.

Reference 1: Nobuta S, Ogawa K, Sato K, Nakagawa T, Hatori M, Itoi E. Clinical outcome of

fragment fixation for osteochondritis dissecans of the elbow. Upsala J Med Sci 2008; 113: 201-

208.

Reference 2: Hardy P, Menguy F, Guillot S. Arthroscopic treatment of capitellum fracture of the

humerus: case report. Arthroscopy 2002; 18: 422-426.

Reference 3: Takeda J, Takahashi T, Hino K, Watanabe S, Imai H, Yamamoto H. Arthroscopic

technique for fragment fixation using absorbable pins for osteochondritis dissecans of the

humeral capitellum: a report of 4 cases. Knee Surg Sports Traumatol Arthrosc 2010; 18: 831-835.

Paper 05: Evaluating Nerve Repair Outcomes in Upper Extremity Nerve

Injuries Utilizing Processed Nerve Allografts, Tube Conduit, and Nerve

Autograft Best Papers - Thursday, September 10, 3:39 - 3:44 PM

Surgical Technique,Prognosis/Outcomes,Hand and Wrist,Elbow and Forearm,Nerve

Level 2 Evidence

Gregory M. Buncke, MD

Brian Rinker, MD

Wesley P. Thayer, MD, PhD

Jason Ko, MD

Dmitry Tuder, MD

Bauback Safa, MD

Speakers Bureau: AxoGen Inc (Buncke)

Contracted Research: AxoGen Inc (Buncke, Thayer)

Speakers Bureau: AxoGen, Inc. (Safa)

Hypothesis

Functional outcomes following peripheral nerve reconstruction for upper extremity injuries can

be dependent upon the treatment option used to bridge the discontinuity. To examine these

differences a control arm was added to an ongoing national nerve registry on processed nerve

allografts (PNA). Based on scientific evidence and historical controls, we hypothesized that the

cumulative registry would continue to demonstrate meaningful recovery for injuries spanning 5

to 65mm; and that observable outcomes for PNA would be similar to nerve autograft and

significantly better than hollow tube conduit.

Methods

The RANGER registry is designed to collect injury, repair, safety and outcomes data for PNA

(Avance® Nerve Graft, AxoGen, Inc), nerve autografts, and hollow tube conduits.. The expanded

enrollment in the registry doubled the number of PNA repairs with quantitative data, from 51 to

102 repairs since its first published reports. Outcome measures for upper extremity injuries in

the cumulative PNA registry were reported and then stratified for comparison to controls; gap

lengths 20mm were compared to nerve autograft. Meaningful recovery was defined as S3/M3 or

greater (MRCC scale).

Results

Quantitative outcomes data for 98 subjects (mage = 41 ± 16 [18, 77]) with 102 upper extremity

repairs (80 sensory, 19 mixed, 3 motor) was available from the cumulative PNA registry. For

injuries treated with PNA, recovery of meaningful sensory function was reported in 85% of the

repairs (69 sensory/16 mixed) and meaningful motor function was reported in 75% of repairs (16

mixed/2 motor). The comparative analysis included 154 repairs; PNA 20 (n= 50, mgap = 30 ±

11.5) vs. nerve autograft (n=14, mgap = 40 ± 18.5). Subject demographics, medical history, and

concomitant injuries were comparable between treatment groups. Meaningful levels of recovery

for the PNA were statistically different from the conduit (51%), but not from the nerve autograft

(64%). See Table 1 for a summary of treatment groups.

Summary Points

• Processed nerve allograft continues to demonstrate meaningful functional recovery in

sensory, mixed, and motor nerve injuries between 5 and 65 mm

• Outcomes are comparable to nerve autograft and exceed those for nerve conduit in

historical and registry controls (P < 0.001).

• The RANGER® registry including the remains ongoing; additional clinical data collected from

participating sites will allow for further comparisons of these treatment options.

Paper 05_Image01

Reference 1: Brooks D, Weber RV, Chao JD, Rinker BD, Zoldos J, Robichaux MR, et al. Processed

nerve allografts for peripheral nerve reconstruction: A multicenter study of utilization and

outcomes in sensory, mixed, and motor nerve reconstructions. Microsurgery 2012; 32:1-85.

Reference 2: Cho MS, Rinker BD, Weber RV, Chao JD, Ingari JV, Brooks D, Buncke GM, Functional

outcome following nerve repair in the upper extremity using processed nerve allograft. J Hand

Surg Am. 2012 Nov; 37 (11):2340-9.

Reference 3: Lundborg, G., A 25-yr perspective of peripheral nerve surgery: evolving

neuroscientific concepts and clinical significance. Journal of Hand Surgery [Am], 2000. 25: p. 391-

414.

Reference 4: Frykman, G. and K. Gramyk, Results of nerve grafting, in Operative nerve repair and

reconstruction, R. Gelberman, Editor. 1991, JB Lippincott: Philadelphia.

Reference 5: Mackinnon, S.E. and A.L. Dellon, Results of Nerve Repair and Grafting, in Surgery of

Peripheral Nerve. 1988, Thieme Medical: New York.

Reference 6: Noble, J., et al., Analysis of Upper and Lower Extremity Peripheral Nerve Injuries in

a Population of Recipients with Multiple Injuries. The Journal of Trauma, 1998. 45: p. 116-122.

Reference 7: Taras JS, Jacoby SM, Lincoski CJ. Reconstruction of digital nerves with collagen

conduits. J Hand Surg Am, 2011;36:1441-6.

Reference 8: Haug A, Bartels A, Kotas J, Kunesch E., Sensory recovery 1 year after bridging digital

nerve defects with collagen tubes. J Hand Surg Am. 2013 Jan;38(1):90-7.

Paper 06: A Prospective, Randomized Comparison of Volar Plate and

External Fixation for Intra-articular Distal Radius Fractures Best Papers - Thursday, September 10, 3:44 - 3:49 PM

Treatment,Surgical Technique,Prognosis/Outcomes,Hand and Wrist

Level 1 Evidence

Young Hak Roh, MD

Jong Ryoon Baek, MD

Young Ho LEE, MD

Hyun Sik Gong, MD

Goo Hyun Baek, MD

Hypothesis

We hypothesized that at 12 months volar locking plating (VP) would provide better clinical and

radiologic outcomes than external fixation (EF) for the treatments of AO-type C2 and C3 DRFs

without additional complications.

Methods

From an initial group of 92 patients with AO-type C2 and C3 distal radius fractures who were

enrolled in a prospective, randomized study comparing volar plate fixation with external fixation

(+/- intra-focal fixation), 74 patients were studied. Functional assessments (wrist range of

motion, grip strength, Michigan Hand Questionnaire) were evaluated at each patient visit and

radiographic assessment (radial inclination, volar tilt, ulnar variance, and articular congruity)

were measured at month 12.

Results

The grip strength of the VP group was significantly greater than that of the EF group at 3 and 6

months. The range of motion was significantly greater in the VP group than in the EF group at 3

months. There were no significant differences in the range of motion and grip strength between

the 2 groups at 12 months. The Michigan Hand Questionnaire score was higher in the VP group

than in the EF group at 3 months but were same at 12 months. There was no significant

difference between the 2 groups with respect to volar tilt or radial inclination. The VP group

showed superior radiologic outcomes in terms of the ulnar variance. One patient in the VP group

and 3 in the EF group had an intra-articular step-off deformity greater than 2mm. This difference

did not reach statistical significance.

Summary

The VP group showed superior results for functional recovery and radiologic outcomes in terms

of the ulnar variance. However, there were no significant differences in functional scores

between the VP and EF groups at 12 months.

Paper 06_Image01

Paper 06_Image02

Reference 1: Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States in the treatment

of distal radial fractures in the elderly. J Bone Joint Surg Am. 2009;91(8):1868-1873.

Reference 2: Williksen JH, Frihagen F, Hellund JC et al. Volar locking plates versus external

fixation and adjuvant pin fixation in unstable distal radius fractures: a randomized, controlled

study. J Hand Surg Am. 2013;38(8):1469-1476.

Reference 3: Kreder HJ, Hanel DP, Agel J et al. Indirect reduction and percutaneous fixation

versus open reduction and internal fixation for displaced intra-articular fractures of the distal

radius: a randomised, controlled trial. J Bone Joint Surg Br. 2005;87(6):829-836.

Reference 4: Kawaguchi S, Sawada K, Nabeta Y et al. Recurrent dorsal angulation of the distal

radius fracture during dynamic external fixation. J Hand Surg Am. 1998;23(5):920-925.

Reference 5: Bini A, Surace MF, Pilato G. Complex articular fractures of the distal radius: the role

of closed reduction and external fixation. J Hand Surg Eur Vol. 2008;33(3):305-310.

Reference 6: Jeudy J, Steiger V, Boyer P et al. Treatment of complex fractures of the distal radius:

a prospective randomised comparison of external fixation 'versus' locked volar plating. Injury.

2012;43(2):174-179.

Reference 7: Grewal R, MacDermid JC, King GJ et al. Open reduction internal fixation versus

percutaneous pinning with external fixation of distal radius fractures: a prospective, randomized

clinical trial. J Hand Surg Am. 2011;36(12):1899-1906.

Reference 8: Rozental TD, Blazar PE, Franko OI et al. Functional outcomes for unstable distal

radial fractures treated with open reduction and internal fixation or closed reduction and

percutaneous fixation. A prospective randomized trial. J Bone Joint Surg Am. 2009;91(8):1837-

1846.

Reference 9: Rizzo M, Katt BA, Carothers JT. Comparison of locked volar plating versus pinning

and external fixation in the treatment of unstable intraarticular distal radius fractures. Hand (N

Y). 2008;3(2):111-117.

Reference 10: Wright TW, Horodyski M, Smith DW. Functional outcome of unstable distal radius

fractures: ORIF with a volar fixed-angle tine plate versus external fixation. J Hand Surg Am.

2005;30(2):289-299.

Paper 07: Distal Radius Fractures: AAOS Appropriate Use Criteria versus

Actual Management at a Level One Trauma Center Best Papers - Thursday, September 10, 3:49 - 3:54 PM

Treatment,Hand and Wrist

Level 4 Evidence

James C. Kyriakedes, MD

Eugene Tsai, MD

Charles Yu, BA

Harry A. Hoyen, MD

Kevin James Malone, MD

Blaine Todd Bafus, MD

Consulting Fee: Synthes, Axogen, Stryker (Hoyen)

Ownership Interest: Stocks in Axogen Inc (Bafus)

Hypothesis

The AAOS Appropriate Use Criteria (AUC) for distal radius fractures recommends a higher

frequency of operative management of distal radius fractures than is actually performed by a

group of hand fellowship-trained orthopaedic surgeons at a high-volume, level one urban

trauma center.

Methods

Between August 2011 to August 2012, 829 patients presented with wrist fractures to our trauma

center (identified by ICD-9 codes). We retrospectively reviewed these patients in the electronic

medical record (EMR), and 112 patients met our inclusion criteria. Patients were excluded if they

were younger than 16 years of age, had other significant injuries, had a delayed presentation, or

were not seen by our orthopaedic hand surgeons. These 112 patients were evaluated using the

AUC web-based application, which takes into account each patient’s AO/OTA fracture type (A, B,

or C), mechanism of injury (high vs. low energy), activity level (normal, high functional,

independent, or homebound), ASA status (1-3 or 4), and the presence of select associated

injuries into its treatment recommendation. Statistical analyses included chi-square tests and

post-hoc Z-tests, and statistical significance was set at a P-value of less than 0.05.

Results

Of the 112 patients, 64 (57%) received treatment that would have matched the AAOS AUC

recommendation. After grouping fractures into AO/OTA type A, B, and C, actual management

matched the AUC recommendation 100% of the time (42/42, p55 year olds as compared to 16-

40 year olds. Within the follow-up period, there was no crossover between the treatment

groups. Following or not following AUC treatment recommendations would not have resulted in

a statistically significant difference in the incidence of major complications.

Summary Points

• To our knowledge, this is the first clinical application of an AAOS AUC in the literature.

• AAOS AUC favors surgery for all intraarticular distal radius fractures.

• Actual treatment recommendations at our high-volume, level one urban trauma center were

dependent on intraarticular fracture displacement.

• Treating clinicians may find a modified AUC that includes intraarticular fracture displacement

as a variable more useful.

Paper 07_Image01

Paper 07_Image02

Reference 1: Appropriate Use Criteria for Treatment of Distal Radius Fractures. Rosemont, IL:

American Academy of Orthopaedic Surgeons Board of Directors; [updated March 18, 2013;

accessed November 29th, 2014]. http://www.aaos.org/research/Appropriate_Use/DRF_AUC.pdf.

Reference 2: Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States in the treatment

of distal radial fractures in the elderly. J Bone Joint Surg Am. 2009;91A:1868 –1873.

Reference 3: Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm

fractures in the United States. J Hand Surg Am 2001;26(5):908-915.

Reference 4: Court-Brown CM, Aitken SA, Forward D, O’Toole RV. The epidemiology of fractures.

In: Bucholz RW, Court-Brown CW, Heckman JD, Tornetta P, eds. Rockwood and Green’s Fractures

in Adults. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:53-84.

Reference 5: Hammert WC, Kramer RC, Graham B, Keith MW. AAOS appropriate use criteria:

treatment of distal radius fractures. J Am Acad Orthop Surg. 2013;21(8):506-509.

Reference 6: Murray J, Gross L. Treatment of distal radius fractures. J Am Acad Orthop Surg.

2013;21(8):502-505.

Reference 7: Shauver MJ, Yin H, Banerjee M, Chung KC. Current and future national costs to

Medicare for the treatment of distal radius fractures in the elderly. J Hand Surg Am.

2011:36A:1282-1287.

Paper 08: An Epidemiologic Perspective on Scaphoid Fracture Treatment

and Frequency of Nonunion Best Papers - Thursday, September 10, 3:54 - 3:59 PM

Treatment,Prognosis/Outcomes,Hand and Wrist,General Principles

Level 3 Evidence

Christopher J. Dy, MD, MPH

Jack D. Baty, BA

Nikolas H. Kazmers, MD MSE

Daniel A. Osei, MD

Hypothesis

The purpose of this general US population-based study was to estimate the incidence of

scaphoid fractures and to analyze patterns in treatment and outcomes. We investigated the

incidence density of scaphoid fracture treatment, the frequency of nonunion after treatment,

and risk factors for nonunion. We also analyzed trends in the treatment for scaphoid fractures

and the frequency of scaphoid nonunion over a 6-year period.

Methods

An administrative database of private commercial insurance beneficiaries (Truven Health

MarketScan(®) Research Database) was queried for all treatment (casting and surgery) records of

closed scaphoid fractures over a 6-year period. We examined subsequent claims to determine

the frequency of undergoing additional surgical procedures for scaphoid nonunion treatment

(revision fixation or vascularized bone grafting) or salvage procedures (proximal row carpectomy

or radiocarpal or midcarpal arthrodesis). Trend analyses were used to determine whether

changes in the frequency of surgical treatment, revision procedures, or salvage treatments

occurred over the study period. Multivariable regression analysis was performed to determine

the risk factors for non-union.

Results

The estimated incidence of scaphoid fracture is 10.6 per 100,000 person-years. Of the 8,923

closed scaphoid fractures from 2006 to 2012, 29% were treated surgically and 71% were treated

with casting. The frequency of surgical treatment significantly rose from 22.1% in 2006 to 34.1%

in 2012 (P < 0.001; Figure 1). The frequency of non-union during the study period was 10.8%

after surgery and 3% after casting (P < 0.001; Figure 1). The frequency of non-union did not

change over time for either the surgery or casting groups. Multivariable regression modeling

indicates that younger age, male sex, and undergoing surgical treatment significantly increase

the risk of nonunion. Salvage procedures were rare, occurring in 0.29% of all scaphoid fractures

during the 6-year evaluation period.

Summary

Our estimated incidence of scaphoid fracture (10.6 per 100,000 person-years) is higher than

previously estimated (1.5 per 100,000 person-years)[1]. There has been increased enthusiasm in

the United States to surgically treat scaphoid fractures, as reflected by our trend analysis. The

frequency of non-union after surgical management for closed scaphoid fractures exceeds 10%

and remained consistent during the study period. Younger patients, men, and those treated

surgically are at increased risk for nonunion, all of which may reflect the higher energy

mechanism of injury typically associated with scaphoid fractures. Given the increased utilization

of surgery, both surgeons and patients should be aware of the frequency of nonunion to inform

preoperative counseling and to guide postoperative treatment decisions.

Paper 08_Image01

Reference 1: Van Tassel DC, Owens BD, Wolf JM. Incidence Estimates and Demographics of

Scaphoid Fracture in the U.S. Population. J Hand Surg Am 2010 Aug; 35 (8): 1242-5.

Paper 09: Is Triangular Fibrocartilage Complex Injury Associated with

Extensor Carpi Ulnaris Tendinitis or Tenosynovitis? A Case-control

Comparative Study Clinical Paper Session 01: Wrist - Friday, September 11, 8:45 - 8:52 AM

Evaluation/Diagnosis,Anatomy,Prognosis/Outcomes,Hand and Wrist

Level 3 Evidence

Toshikazu Tanaka, MD

Takeshi Ogawa, MD, PhD

Sho Kohyama, MD

Eriko Okano, MD

Naoyuki Ochiai, MD, PhD

Hypothesis

After treatment of triangular fibrocartilage complex (TFCC) injuries, the ulnar wrist may

experience persisting pain, suggesting the presence of some other pathology. We compared the

wrists of patients who have TFCC injuries before treatment with those of volunteers who have

no ulnar wrist pain. We hypothesized that TFCC injuries are frequently complicated by extensor

carpi ulnaris (ECU) tendinitis or tenosynovitis.

Methods

Altogether, 46 volunteers (21 male, 25 female; mean age 30.8 years) who had no pain in the

ulnar wrist and 46 TFCC patients (22 male, 24 female; mean age 35.5 years) with a positive fovea

sign and whose pain diminished after injection of 0.5ml lidocaine at the ulnar fovea were

compared. In all, 20 right and 26 left wrists of the volunteers were evaluated, as were 22 right

and 24 left wrists of the patients. Wrists of both groups underwent magnetic resonance imaging

(MRI). Wrists were imaged with the subject prone, arms over the head, and forearm pronated. A

microscopy coil was placed on the center of the ulnar head. All MRI scans were obtained using a

1.5-T system (Gyroscan NT Intera; Philips Medical Systems, Best, The Netherlands). Coronal and

axial two-dimensional gradient-echo images were obtained. ECU tendon pathology

(tendinopathy or tear) was classified into three categories (T1: normal; T2: multiple cracks; T3:

changed intensity of tendon). Surrounding ECU tendon pathologies (e.g., tenosynovitis) were

also classified into three categories (S1: normal; S2: effusion in sheath; S3 disruption of

sheath)(Figure 1). There were some overlaps. The width, depth, opening angle, and radius of the

curvature of the ECU groove were determined using imaging software based on a previous

report(Figere 2) (reference 1). The image slice in which the ECU groove was largest was chosen

for measurement. Statistical analysis was performed with Mann–Whitney’s U-test. A P < 0.05

significance level was used in all cases.

Results

T2 pathology in the patient group (T1: 29; T2: 15; T3: 20) was significantly more frequent than in

the volunteers (39; 4; 20, respectively). Surrounding pathology S2 was significantly more

frequent in the patient group (S1: 35; S2:11; S3: 0) than in the volunteers (40; 4; 0, respectively).

There were no significant differences between groups regarding the width, depth, opening

angle, or radius of the curvature.

Summary

Injured TFCCs are frequently complicated by ECU tendinitis and/or tenosynovitis.

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Paper 09_Image02

Reference 1: ML Iorio et al. J Hand Surg Am 2014;39:2412–6

Paper 10: Arthroscopy of the Distal Radioulnar Joint: Its Role in the

Evaluation and Management of Ulnar Sided Wrist Pain and the

Development of a Classification System for Proximal Partial Thickness

Triangular Cartilage Complex Pathology Clinical Paper Session 01: Wrist - Friday, September 11, 8:52 - 8:59 AM

Evaluation/Diagnosis,Treatment,Surgical Technique,Hand and Wrist,Elbow and Forearm,Diseases

and Disorders

Level 3 Evidence

Michael Boland, MBChB

Eimear Conroy, FRCSI

Royalty: Arthrex (Boland)

Speakers Bureau: Acumed Lecture Fee (Boland)

Hypothesis

Proximal triangular fibrocartilage complex (TFC) pathology can be underdiagnosed on MRI and a

normal radiocarpal view of the TFC does not exclude pathology. The Hypothesis is that pathology

exists within the distal radioulnar joint that is not seen on Radiocarpal arthroscopy alone. The

aim of the study is to report a retrospective review of findings of DRUJ Arthroscopy and develop

a classification system of partial thickness TFC pathology.

Methods

A retrospective review of all wrist arthroscopic surgery completed by a single surgeon was

performed. All cases (94) over a one year period were reviewed and all arthroscopic surgery with

a normal TFC on inspection through radiocarpal portals were included. All radiology was

reviewed to determine the sensitivity and specificity of MRI in helping diagnose proximal TFC

pathology. All radiographs were reviewed to determine if ulnar variance had any impact on the

presence of proximal TFC tears. Intraoperative findings were then reviewed and the identified

pathology classified into subgroups depending on the location and type of tear.

Results

34 wrist arthroscopies were included all of whom had a normal TFC on radiocarpal arthroscopy.

There was no correlation with ulnar variance and the presence of proximal TFC pathology. The

sensitivity of MRI in detecting a proximal TFC tear was 70%. A Positive indentation sign was

identified in 12 patients with proximal TFC pathology, while sensitivity of this finding is 35% it

may be useful indicator that pathology may exist in proximal TFC.

Tears were classified according to location on the TFC, they were described as delaminating, flap

lacerations or fibrillated. Chondromalacia of the ulnar head and DRUJ stability and lunotriquetral

pathology was also assessed and included in the classification.

Summary

This study highlights the importance of performing distal radioulnar joint arthroscopy. MRI is a

useful preoperative investigation but has poor sensitivity in the diagnosis of proximal TFC

pathology. Ulnar variance is not predictive of proximal TFC pathology. Proximal TFC pathology

frequently exists in the presence of an apparently normal TFC on radiocarpal arthroscopy. Subtle

change in the lunotriquetral joint and TFC on radiocarpal arthroscopy that may indicate a

proximal TFC pathology. The development of a classification system for describing these

proximal TFC pathologies is useful for further clinical and scientific research. We recommend

DRUJ arthroscopy as is useful adjunct to wrist arthroscopy and significant pathologies can be

identified.

Paper 11: Importance of Computed Tomography in Determining

Displacement of Scaphoid Fractures Clinical Paper Session 01: Wrist - Friday, September 11, 8:59 - 9:06 AM

Evaluation/Diagnosis,Hand and Wrist

Level 3 Evidence

Emily Gilley, MD

Sameer Puri, MD

Samir K. Trehan, MD

Krystle A. Hearns, MA

Andrew J. Weiland, MD

Michelle Gerwin Carlson, MD

Hypothesis

Scaphoid fracture displacement has been shown to correlate with higher risk of nonunion. We

reviewed images from scaphoid fractures to determine if computed tomography (CT) changed

the diagnosis of displacement compared to plain radiography.

Methods

Thirty-nine pre-operative radiographs and CT scans were evaluated by two blinded observers.

Measurements of displacement and angular deformity were recorded. The readers were asked

to judge the fracture as displaced or nondisplaced. A displaced fracture was defined as having

>1 millimeter of displacement between cortices. Scapholunate, radiolunate, and intrascaphoid

angles were measured. Independent samples t-tests were used to assess radiographic measures

of fractures that were read nondisplaced on radiographs but displaced on CT compared to

fractures reported nondisplaced on both imaging modalities. Kappa statistics were calculated to

evaluate the reliability of diagnosing displacement between raters. Intraclass correlation

coefficient (ICC) was calculated to determine the reliability of the intrascaphoid angle measured

on radiograph and CT.

Results

Reader one identified 13 fractures (33%) as displaced on radiographs, and 26 (67%) as displaced

on CT scan. Thirteen fractures were recorded as nondisplaced on radiograph, but displaced on

CT scan (33%). (Figure 1) Reader two identified 16 fractures (41%) as displaced on radiograph,

and 26 (67%) displaced on CT scan. Ten fractures were reported, by Reader two, as

nondisplaced on radiograph, but displaced on CT scan (26%). Interobserver reliability for

diagnosing displacement on radiograph was substantial (Kappa=0.73; P < 0.001), but

interobserver reliability for diagnosing displacement on CT was perfect (Kappa=1.00; P < 0.001).

None of the radiographic measurements were found to be predictors of displacement on CT

scan. In addition, there was no reliability between intrascaphoid angle (“humpback deformity”)

measured on radiograph and CT scan (ICC =-0.29; P = 0.767).

Summary Points

• 26-33% of scaphoid fractures were judged nondisplaced on radiograph, but displaced on CT

scan.

• Recognizing displacement and deformity is important when deciding on surgical intervention,

as it may alter the treatment and surgical approach to the fracture. For this reason, we

recommend CT scan to evaluate all scaphoid fractures.

• Although interobserver reliability between readers on radiographs was substantial (73%), the

reliability between readers on CT scan was perfect (100%). Amongst different readers, CT

scan can provide a more reliable diagnosis of displacement.

• The poor reliability of determining the intrascaphoid angle on radiograph compared to CT

scan underscores the difficulty in recognizing the flexion or humpback deformity using plain

radiography alone.

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Paper 11_Image02

Reference 1: Szabo RM, Manske D. Displaced fractures of the scaphoid. Clin Orthop Relat Res

1988 May;(230):30-8.

Reference 2: Dabezies EJ, Mathews R, Faust DC. Injuries to the carpus: fractures of the scaphoid.

Orthopedics. 1982;5:1510-15.

Reference 3: Bhat M, McCarthy M, Davis TR, Oni JA, Dawson S. MRI and plain radiography in the

assessment of displaced fractures of the waist of the carpal scaphoid. J Bone Joint Surg Br. 2004

Jul;86(5):705-13.

Reference 4: Langhoff O, Andersen JL. Consequences of late immobilization of scaphoid

fractures. J Hand Surg Br. 1988 Feb;13(1):77-9.

Reference 5: Cooney WP, Dobyns JH, Lincheid RL. Fractures of the Scaphoid: A Rational

Approach to Management. Clin Orthop, 149; 90-97, 1980.

Reference 6: Bain GI, Bennett JD, MacDermid JC, Slethaug GP, Richards RS, Roth JH.

Measurement of the scaphoid humpback deformity using longitudinal computed tomography:

intra- and interobserver variability using various measurement techniques. J Hand Surg, 23A: 76-

81, 1998.

Paper 12: Factors Associated with Re-operation after Surgery for

Scaphoid Nonunion Clinical Paper Session 01: Wrist - Friday, September 11, 9:06 - 9:13 AM

Treatment,Surgical Technique,Prognosis/Outcomes,Hand and Wrist

Level 4 Evidence

Ali Moradi, MD

Amir Reza Kachooei, MD

Tessa Drijkoningen, MD

George S. M. Dyer, MD

David C. Ring, MD, PhD

Royalty: Wright;Medartis;Skeletal Dynamics;Biomet (Ring)

Consulting Fee: Wright;Skeletal Dynamics;Acumed;Biomet (Ring)

Fees for Non-CME Services Received Directly from a Commercial Interest or its Agent: AO (Ring)

North America;AO International (Ring)

Contracted Research: Skeletal Dynamics;Biomet (Ring)

Ownership Interest: Illuminos (Ring)

Hypothesis

To determine the rate of unplanned reoperation after surgery for scaphoid nonunion, the

reasons for unplanned reoperation, and factors associated with unplanned reoperation.

Methods

Using an institutional database, we identified 190 patients that had surgery for a scaphoid non-

union from 2000 to 2013. There were 172 men and 18 women with an average age of 26±11

years (Range, 16 to 84 years). The result of the surgery was categorized as follows: no

unplanned reoperation and healed fracture; unplanned reoperation for any reason; unplanned

repeat surgery recommended but not done; and unknown status. We tested age, sex, affected

side, interval between injury and operation, operation duration, fracture location, dorsal

intercalated segment instability, surgeon perception of avascular necrosis of proximal pole,

fixation device, type of bone graft, surgeon, and operative approach for association with

unplanned repeat surgery.

Results

After the index operation to treat scaphoid non-union in 190 wrists, 100 (53%) had no

unplanned reoperation and healed; 39 (21%) had an unplanned reoperation; in 34 (18%)

unplanned repeat surgery was recommended but not done; and in 17 the status was unknown

(9%). After all subsequent surgeries, 110 patients (58%) healed (10 after one or more

subsequent surgeries), 49 (26%) had persistent nonunion, 5 (3%) had a salvage procedure (e.g.

excision of the distal pole of the scaphoid), and the status of 26 patients was unknown (14%).

The indication for surgery in all 73 patients who had unplanned reoperation or recommended

unplanned reoperation was persistent nonunion. In bivariate and multivariable analysis, the only

factor related to reoperation was Kirschner wire rather than compression screw fixation of the

scaphoid.

Summary Points

• Persistent nonunion is common after surgery for scaphoid non-union.

• Surgeries for persistent nonunion is even less successful.

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Paper 12_Image02

Reference 1: Munk B, Larsen CF. Bone grafting the scaphoid nonunion: a systematic review of

147 publications including 5,246 cases of scaphoid nonunion. Acta orthop Scand.

2004;75(5):618-829.

Reference 2: Merrell GA, Wolfe SW, Slade JF, 3rd. Treatment of scaphoid nonunions:

quantitative meta-analysis of the literature. J Hand Surg. 2002;27(4):685-691.

Reference 3: Kawamura K, Chung KC. Treatment of scaphoid fractures and nonunions. J Hand

Surg Am. 2008;33(6):988-997.

Reference 4: Reigstad O, Thorkildsen R, Grimsgaard C, et al. Is revision bone grafting worthwhile

after failed surgery for scaphoid nonunion? Minimum 8 year follow-up of 18 patients. J Hand

Surg Eu. 2009;34(6):772-777.

Reference 5: Osterman AL, Mikulics M. Scaphoid nonunion. Hand clin. 1988;4(3):437-455.

Reference 6: Cooney WP, Linscheid RL, Dobyns JH. Scaphoid fractures. Problems associated with

nonunion and avascular necrosis. Orthopedic Clin North Am. 1984;15(2):381-391.

Reference 7: Stark HH, Rickard TA, Zemel NP, et al. Treatment of ununited fractures of the

scaphoid by iliac bone grafts and Kirschner-wire fixation. J bone joint surg Am. 1988;70(7):982-

991.

Paper 13: Complications with the Use of BMP-2 in Scaphoid Nonunion

Surgery Clinical Paper Session 01: Wrist - Friday, September 11, 9:13 - 9:20 AM

Treatment,Surgical Technique,Hand and Wrist

Level 4 Evidence

Patrick Brannan, MD

Glenn R. Gaston, MD

Dan Lewis, MD

Bryan J. Loeffler, MD

Royalty: Biomet (Gaston)

Consulting Fee: Biomet, Smith & Nephew (Gaston)

Speakers Bureau: Auxillium (Gaston)

Hypothesis

The use of BMP-2 for revision scaphoid nonunion ORIF can increase union rate with a low

incidence of complications.

Methods

We retrospectively reviewed cases of revision scaphoid nonunion ORIF (all having failed a

previous scaphoid ORIF) treated with revision fixation, bone graft, and BMP-2. All patients were

consented for off-label use of BMP-2. Union was determined by CT in all cases. Complications of

nonunion, heterotopic bone formation, delayed wound healing, loss of motion, and need for

revision surgery are reported. Final range of motion is presented.

Results

6 cases of BMP-2 use in revision scaphoid nonunion ORIF were identified between 2011 and

2014. All patients had failed an initial attempt at ORIF (all initially were cases of delayed union or

nonunion). Time from injury to index ORIF ranged from 4 months to 4 years (mean 24 months).

Revision surgery with BMP was performed at an average of 13 months from the index ORIF. 4 of

6 cases achieved CT proven union. There were two cases of persistent nonunion of which one

underwent scaphoid excision and midcarpal fusion, while the other continues to be treated

nonoperatively. 4 cases developed significant heterotopic ossification (2 of which required

revision surgery). There were no cases of delayed wound healing. Only 1 of the 6 patients

healed without any complications. Complications by case:

• Case 1: heterotopic ossification, final ROM 60 flexion, 40 extension

• Case 2: heterotopic ossification, final ROM 45 flexion, 45 extension

• Case 3: heterotopic ossification, persistent nonunion, 4 corner fusion, final ROM 45

flexion 20 extension

• Case 4: no complications, final ROM 70 flexion, 60 extension

• Case 5: persistent nonunion, current ROM 40 flexion, 10 extension

• Case 6: heterotopic ossification, revision HO resection, final ROM 25 flexion, 10

extension

Summary Points

• BMP-2 use in scaphoid nonunion carries significantly higher risk than previously reported.

• 1/3 of revision cases treated with BMP-2 went on to persistent nonunion.

• 2/3 of cases developed significant heterotopic ossification.

• Only 1 of 6 cases healed without complication.

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Paper 14: Neonatal Brachial Plexus Injury Alters Muscle Satellite Cell

Behavior Clinical Paper Session 02: Brachial Plexus/Nerve - Friday, September 11, 8:45 - 8:52 AM

Basic Science,Congenital and Pediatric Problems,Nerve

N/A - Not a clinical study

Roger Cornwall, MD

Athanasia Nikolaou, PhD

Christopher Casstevens, MD

Liangjun Hu, MS

Hypothesis

Contractures following neonatal brachial plexus injury (NBPI) are associated with impaired

growth of denervated muscle, but the mechanism of growth impairment is unknown. Muscle

growth in the neonatal period is uniquely dependent on addition of myonuclei from muscle stem

cells, or satellite cells (SCs). SCs harvested from neonatally denervated muscle are capable of

myogenesis in vitro, yet their behavior in vivo following neonatal denervation has not been

investigated. The current study uses an established mouse model of elbow flexion contracture

following NBPI to test the hypothesis that neonatal denervation-induced muscle contractures

are associated with altered in vivo behavior of SCs.

Methods

Unilateral global (C5-T1) NBPIs were created by surgical extraforaminal nerve root excision in 5-

day-old CD-1 mice under general anesthesia. At four weekly time points following denervation,

bilateral biceps and brachialis muscles were harvested for analysis of in vivo SC activation state,

apoptosis, proliferation, and activity of the Notch signaling pathway, a regulator of SC behavior.

SC activation state was assessed by immunohistochemical staining for transcriptional markers of

quiescence, proliferation, and differentiation. Apoptosis was assessed using TUNEL analysis.

Proliferation was assessed in a subset of mice that underwent BrdU injection following

denervation and prior to sacrifice. Notch signaling activity was assessed in proliferating SCs using

immunohistochemical staining for the Notch intracellular domain.

Results

Following neonatal denervation, no increase in SC apoptosis was seen. In fact, SCs comprised a

significantly higher proportion of myonuclei in denervated than control muscle, despite similar

rates of SC proliferation. However, a significantly higher than normal proportion of the SCs in

denervated muscle were in the quiescent state. Most of these quiescent SCs had undergone at

least one cell division, as indicated by BrdU incorporation, suggesting that following denervation,

SCs activated and proliferated, but then most daughter cells returned to quiescence (self-

renewed) rather than differentiating into myoblasts. Notch signaling is an important driver of SC

self-renewal over differentiation, and a significantly higher proportion of proliferating SCs

displayed activated Notch signaling in the denervated than control muscle.

Summary

Satellite cells remain abundant in vivo in neonatally denervated muscle. Following neonatal

denervation, satellite cells proliferate normally, but a disproportionate number of daughter cells

return to quiescence instead of differentiating into the myoblasts necessary for neonatal muscle

growth. Correcting this imbalance between SC self-renewal and differentiation, potentially by

manipulating Notch signaling, could allow us to harness this population of SCs to maintain

muscle growth and prevent contractures following neonatal brachial plexus injury.

Reference 1: Nikolaou S1, Peterson E, Kim A, Wylie C, Cornwall R. Impaired growth of denervated

muscle contributes to contracture formation following neonatal brachial plexus injury. J Bone

Joint Surg Am. 2011;93:461-70.

Reference 2: White RB, Bierinx AS, Gnocchi VF, Zammit PS. Dynamics of muscle fibre growth

during postnatal mouse development. BMC Dev Biol. 2010;10:21–32.

Reference 3: Wen Y1, Bi P, Liu W, Asakura A, Keller C, Kuang S. Constitutive Notch activation

upregulates Pax7 and promotes the self-renewal of skeletal muscle satellite cells. Mol Cell Biol.

2012;32:2300-11.

Paper 15: Intercostal Nerve Transfer to Restore Elbow Flexion Clinical Paper Session 02: Brachial Plexus/Nerve - Friday, September 11, 8:52 - 8:59 AM

Treatment,Surgical Technique,Prognosis/Outcomes,Elbow and Forearm,Congenital and Pediatric

Problems,Nerve,General Principles

Level 3 Evidence

Eric Wagner, MD

Caroline A. Hundepool, MSc

Michelle Kircher, BS

Robert Spinner, MD

Allen Bishop, MD PhD

Alexander Y. Shin, MD

Salary: Mayo Clinic (Shin)

Royalty: Trimed (Shin)

Contracted Research: Bacterin International (Shin)

Other (Please describe): editor Techniques Hand Upper Extremity (Shin)

Hypothesis

The purpose of this study is to evaluate the outcomes of intercostal nerve transfer to the

musculocutaneous motor branch for restoration of elbow flexion.

Methods

Over a 10-year period, 85 patients underwent intercostal nerve transfers to the

musculocutaneous nerve at a single institution. The average age at surgery was 30.5 years (17-

65), mean BMI 29, with 11 females, and were 18 smokers. All patients had brachial plexus

injuries with 19 having C5-C7 avulsions while most had C5-T1 avulsions (n=66). All (n=85)

patients had grade 0 biceps strength preoperatively. Patients underwent intercostal nerve (ICN)

transfer involving combinations of ICN 3-7 to the musculocutaneous nerve. Fifty-five (65%)

patients underwent a simultaneous free gracilis muscle transfer to augment elbow flexion (n=24)

or obtain wrist/finger flexion (n=31). Eleven patients had a preexisting arterial (subclavian or

axillary) injury.

Results

At an average follow-up of 2.8 years (range, 1.0-9.2), 46 (54%) of patients recovered at grade III

or better elbow flexion strength. 69 (81%) of patients demonstrated signs of muscle recovery on

EMG at last follow-up. The mean elbow flexion was 88 degrees (range, 0-150). The patients

DASH scores improved from 48.5 preoperatively to 36.5 postoperatively (P < 0.001), and VAS

scores decreased from 5.9 (out of 10) to 4.8 postoperatively (P = 0.03). The number (2, 3, or 4)

intercostal nerves used did not have a significant impact on any of the final outcomes.

The use of a free muscle transfer improved postoperative elbow flexion strength, with 33 (total

n=55, 60%) having greater than or equal to III muscle strength, compared to 12 (total n=30, 40%)

of those without a free muscle transfer (P = 0.04). There also were improvements in elbow

range of motion (92 vs 78) and EMG signs of recovery (85% vs 70%), but these did not reach

statistical significance. Free muscle transfer did significantly improve DASH scores (33 vs 44, P =

0.03).

Patients with vascular injuries (n=11) had significantly worse rates of elbow flexion recovery,

including worse muscle strengths (P < 0.01), DASH scores (P < 0.01), and rates of EMG recover (P

< 0.03). 45/75 (61%) of patients without vascular injuries obtained grade III elbow flexion or

greater.

Summary Points

• Intercostal nerve transfer in the setting of a complete or near complete brachial plexus injury

leads to reasonable rates of recovery of elbow flexion.

• Preexisting vascular injuries portend a poor outcome.

• In these patients with very limited options, intercostal nerve transfer represents a reasonable

nerve transfer option.

Paper 16: A Systematic Review of Contralateral C7 Transfer for the

Treatment of Traumatic Brachial Plexus Injury Clinical Paper Session 02: Brachial Plexus/Nerve - Friday, September 11, 8:59 - 9:06 AM

Prognosis/Outcomes,Nerve

Level 3 Evidence

Guang Yang, MD

Kate W.C. Chang, MA

Kevin C. Chung, MD, MS

Hypothesis

Contralateral C7 (CC7) transfer has been widely applied for treatment of traumatic brachial

plexus injury. However, the effectiveness and safety of the procedure remain controversial. The

purpose of this systematic review is to study the overall outcomes of CC7 transfer and

investigate the donor-site morbidity after CC7 transfer in traumatic brachial plexus injuries.

Methods

Using PubMed and EMBASE databases, we identified original articles related to CC7 transfer for

traumatic brachial plexus injury. For outcomes study, we extracted the objective outcomes of

CC7 transfer to the recipient nerves, and normalized modifications of MRC and other outcome

measures into an MRC-based outcome scale. For donor-site morbidity study, the incidence,

recovery rate and time of sensory abnormality and motor deficit were extracted. The sensory

abnormality areas and muscles involved in motor weakness were also summarized.

Results

Thirty-nine studies were identified in outcome study. The outcomes were categorized based on

the three major recipient nerves. In the median nerve group, 11% of patients regained MRC

grade M4 wrist flexion and 38% achieved M3 (Table 1). Grade M4 finger flexion was achieved by

7% of patients whereas 36% achieved M3. Finally, 56% of patients regained S3 or greater in the

median nerve territories. In the musculocutaneous nerve group, 38% of patients achieved grade

M4 elbow flexor strength and 37% regained M3. In the radial/triceps nerve group, 25% regained

elbow or wrist extension strength to grade M4 and 25% regained to M3. A total 904 patients

from 27 studies were included in donor-site morbidity study. Overall, 74% of patients

experienced sensory abnormalities after CC7 transfer, and 98% of patients recovered to normal;

the mean recovery time was 3 months (Table 2). For motor function, 20% of patients had motor

deficits and 91% regained normal motor functions; mean recovery time was 6 months.Sensory

abnormality mainly occurred in the median innervated area of the hand, whereas motor deficit

most often involved radial nerve innerved muscles. There were 2% of patients with long-term

morbidity.

Summary Points

• Outcome measures in the included studies were not consistently reported to uncover true

patient-related benefits from the CC7 transfer. Reliable and validated outcome instruments

should be applied to critically evaluate patients undergoing CC7 transfer.

• The incidence of donor-site morbidity after CC7 transfer was relatively high, and severe and

long-term defects occurred occasionally. CC7 transfer should be indicated only when other

donor nerves are not available, and with a comprehensive knowledge of the potential risks.

Paper 16_Image01

Paper 16_Image02

Paper 17: Comparison of Functional Recovery Outcomes by Gap

between Processed Nerve Allograft and Hollow Tube Conduits for Digital

Nerve Repairs Clinical Paper Session 02: Brachial Plexus/Nerve - Friday, September 11, 9:06 - 9:13 AM

Treatment,Surgical Technique,Prognosis/Outcomes,Hand and Wrist,Nerve

Level 2 Evidence

Jason Ko, MD

Bauback Safa, MD

Mitchell A. Pet, MD

Wesley P. Thayer, MD, PhD

Harry Hoyen, MD

Gregory M. Buncke, MD

Speakers Bureau: AxoGen, Inc.(Ko, Bucke)

Contracted Research: Received research grant from Axogen (Thayer, Buncke)

Consulting Fee: Synthes, Axogen, Stryker (Hoyen)

Hypothesis

Processed nerve allograft and tube conduit both offer convenient options for digital nerve gap

repair. Despite their wide availability, no consensus exists as to the optimal treatment for digital

gaps up to 2cm. To evaluate for potential differences in recovery outcomes with theses repair

methods, we added contemporary control cohorts to a national nerve registry. We

hypothesized that processed nerve allografts would perform consistently well while the quality

of recovery with conduit would decrease as gap length increased.

Methods

The RANGER registry is an active database designed to continuously monitor and collect injury,

repair, safety and outcomes data for processed nerve allografts (Avance® Nerve Graft, AxoGen,

Inc). In 2013, a contemporary control was added to allow for comparisons of recovery outcomes

to tube conduits. The database was queried for digital nerve injuries with gaps up to 20mm.The

dataset was stratified into two gap length groups, gaps < 10mm and11-20mm. Meaningful

sensory recovery was defined by the MRCC scale at S3 or greater. Comparisons of meaningful

recovery outcomes were completed by repair method between and across the gap length

groups.

Results

Four sites contributed data for both types of repairs. Thirty nine subjects with 63 injuries were

included. The < 10mm gap group consisted of 20 PNA and 8 conduit repairs. The 11-20mm gap

group consisted of 20 PNA and 15 conduit repairs. Subject, medical history, and concomitant

injuries were comparable between treatment groups. Overall meaningful levels of recovery were

reported in 90% for the PNA group as compared to 44% for the conduit. In the < 10mm gap

group, PNA and conduit reported 100% and 75% meaningful recovery respectively with no

revisions. In the 11-20mm gap length group, PNA and conduit reported 80% and 33% recovery

respectively (P < 0.0132) with four revisions reported in the conduit group. See Table 1 for a

group demographics and summary of outcomes. See Figure 1 for a distribution of MRCC scores

by group.

Summary Points

• Processed nerve allograft performed consistently well across both gap length groups.

• Reported levels of meaningful recovery for processed nerve allografts exceed that of tube

conduits across all gaps and groups.

• Conduits reported a statistically significant difference by gap length with < 10mm repairs

reporting more consistent levels of recovery as compared to gaps at 11-20mm.

• The RANGER registry remains ongoing; additional clinical data collected from participating

sites will allow for further comparisons of PNA to conduit.

Paper 17_Image01

Paper 17_Image02

Reference 1: Brooks DN, Weber RV, Chao JD, et al. Processed nerve allografts for peripheral

nerve reconstruction: a multicenter study of utilization and outcomes in sensory, mixed, and

motor nerve reconstructions. Microsurgery, 2012;32:1-14.

Reference 2: Cho MS, Rinker BD, Weber RV, et al. Functional outcome following nerve repair in

the upper extremity using processed nerve allograft. J Hand Surg Am, 2012;37A:2340-9.

Reference 3: Karabekmez FE, Duymaz A, Moran SL. Early clinical outcomes with the use of

decellularized nerve allograft for repair of sensory defects within the hand. Hand (NY),

2009;4:245-9.

Reference 4: Chiriac S, Facca S, Diaconu M, et al. Experience of using the bioresorbable

copolyester poly(DL-lactide-e-caprolactone) nerve conduit guide Neurolac™ for nerve repair in

peripheral nerve defects: report on a series of 28 lesions. J Hand Surg Eur, 2012;37:342-9.

Reference 5: Taras JS, Jacoby SM, Lincoski CJ. Reconstruction of digital nerves with collagen

conduits. J Hand Surg Am, 2011;36:1441-6.

Reference 6: Haug A, Bartels A, Kotas J, Kunesch E., Sensory recovery 1 year after bridging digital

nerve defects with collagen tubes. J Hand Surg Am. 2013 Jan;38(1):90-7.

Reference 7: Schmauss, D, et al., Nerve Regeneration after Reconstruction with Collagen Nerve

Conduits Terminated after 12 months? The Long-Term Follow-Up of Two Prospective Clinical

Studies. J Reconstr Microsurg 2014;30:561–568. doi: 10.1055/s-0034-1375237

Paper 18: Evaluation of Outcomes from Processed Nerve Allograft and

Nerve Autograft Repairs in Upper Extremity Mixed Nerve Injuries Clinical Paper Session 02: Brachial Plexus/Nerve - Friday, September 11, 9:13 - 9:20 AM

Treatment,Prognosis/Outcomes,Nerve

Level 2 Evidence

Bauback Safa, MD

Jason Ko, MD

Mitchell A. Pet, MD

Wesley P. Thayer, MD, PhD

Harry Hoyen, MD

Gregory M. Buncke, MD

Speakers Bureau: AxoGen, Inc. (Safa, Buncke)

Contracted Research: Axogen (Thayer, Buncke)

Hypothesis

The historical standard for peripheral nerve gap repair has been the nerve autograft. Recently

processed nerve allografts have been established as a viable alternative. To examine the

differences we added contemporary control cohorts to a national nerve registry. Based on

scientific evidence and historical controls, we hypothesized that processed nerve allografts

would perform similar to nerve autograft in mixed nerve injuries of the upper extremity.

Methods

The RANGER registry is an active database designed to collect injury, repair, safety and outcomes

data for processed nerve allografts (Avance® Nerve Graft, AxoGen, Inc) according to an IRB

approved protocol. Contemporary controls added to the established registry allow for

comparisons of recovery outcomes between treatment groups. The database was queried for

subjects presenting with mixed nerve gap injuries up to 70 mm repaired with either processed

nerve allograft (PNA) or nerve autograft. Identified subjects reporting quantitative outcomes

with a minimum of nine months follow up were included in the dataset. Subject demographics

and repair characteristics, and recovery of function were compared. Meaningful recovery was

defined as S3/M3 or greater (MRCC scale).

Results

Twenty subjects with 22 injuries were included. The groups consisted of PNA (n=14) and nerve

autograft (n=8). Subject demographics, medical history, and concomitant injuries were

comparable between treatment groups. The PNA group reported a higher incidence of high

energy traumatic injuries. Repair techniques varied between the groups. The PNA repairs

included size matched fascicular or caliber matched epineural repairs while all the nerve

autografts were multi-strand cabled repairs. The average nerve gap between the groups varied

at 30+14mm and 44+11 mm for PNA and nerve autograft respectively. Available quantitative

data reported meaningful recovery in 86% in PNA group as compared to 88% for nerve

autograft. See Table 1 for a summary of treatment groups. See Figure 2 for a distribution of

sensory and motor MRCC scores by repair group. There were no reported adverse events related

to the treatment groups.

Summary Points

• Processed nerve allografts can be used to repair mixed nerve injuries for return of both

sensory and motor function.

• Reported levels of meaningful recovery for processed nerve allografts are comparable to

nerve autograft.

• Outcomes from both groups were comparable to those reported in historical controls.

• The RANGER registry remains ongoing; additional clinical data collected from participating

sites will allow for further comparisons of repair modalities.

Paper 18_Image01

Reference 1: Brooks, D. N. et al. Processed nerve allografts for peripheral nerve reconstruction: a

multicenter study of utilization and outcomes in sensory, mixed, and motor nerve

reconstructions. Microsurgery 32, 1–14 (2012).

Reference 2: Cho, M. S. et al. Functional outcome following nerve repair in the upper extremity

using processed nerve allograft. J. Hand Surg. 37, 2340–2349 (2012).

Reference 3: Kim, D. H., Han, K., Tiel, R. L., Murovic, J. A. & Kline, D. G. Surgical outcomes of 654

ulnar nerve lesions. J. Neurosurg. 98, 993–1004 (2003).

Reference 4: Kim, D. H., Kam, A. C., Chandika, P., Tiel, R. L. & Kline, D. G. Surgical management

and outcomes in patients with median nerve lesions. J. Neurosurg. 95, 584–594 (2001).

Reference 5: Isaacs, J. Major peripheral nerve injuries. Hand Clin. 29, 371–382 (2013).

Reference 6: Vastamäki, M., Kallio, P. K. & Solonen, K. A. The results of secondary microsurgical

repair of ulnar nerve injury. J. Hand Surg. Edinb. Scotl. 18, 323–326 (1993).

Reference 7: Ruijs, A. Meta-Analysis: Repair of Median and Ulnar Nerve Transection Injuries. J.

Hand Surg. 28B, 2003

Paper 19: Prediction of Operative Intervention for Distal Radius

Fractures Based on Osteoporosis Status Clinical Paper Session 03: Distal Radius - Friday, September 11, 10:05 - 10:12 AM

Evaluation/Diagnosis,Treatment,Hand and Wrist

Level 3 Evidence

Neil Gregory Harness, MD

Andrew Ritting, MD

William Dahl, MD

Hillard T. Spencer, MD

Hypothesis

Osteoporosis may result in increased distal radius fracture severity and the need for surgical

intervention. We hypothesized that patients who have a lower bone density will have a tendency

toward operative management of a distal radius fracture when compared to patients of similar

age with higher bone density scores.

Methods

A retrospective cohort study was performed, including all Kaiser Permanente Southern California

(KPSC) enrollees who were aged 55 years or older between January 1, 2007 and December 31,

2012 and underwent treatment for a distal radius fracture. IRB approval was obtained. All

patients over the age of 50 who sustain a distal radius fracture are evaluated with a DXA scan

within 3 months of the injury within KPSC. Of the non-operative patients, 48 did not have DXA

data and were excluded from analysis. Radiographs were classified using the AO classification for

distal radius fractures. 761 non-operative cases were included in the analysis. The total study

population (operative and non-operative) was 890. Demographic data and T-scores were

recorded from the distal radius fracture operative registry, administrative databases and the

medical record.

Results

There were 737 fractures in women and 153 fractures in men. The mean age was 69.9 years

(range, 55-96). The mean T-score was -1.95 (SD 0.97). There were 283 AO type A fractures, 150

type B fractures, and 381 type C fractures. Treatment was non-operative for 761 fractures (86%),

and surgical for 129 fractures (14%). There was no difference in T-score between fractures in

the surgical and non-operative cohorts, but patients treated surgically were younger than

patients treated non-operatively. T-scores were higher in men than women, and higher in type B

fractures than in type A or C fractures. Increasing age and AO fracture type B were associated

with lower odds ratio for surgical treatment. Age and sex significantly influenced T-score, and

age significantly influenced treatment group (decreasing surgery with increasing age), but that

AO fracture classification was not sequentially increased by decreasing T-score and did not itself

influence treatment group.

Summary Points

• Non-operative treatment of distal radius fractures is more common in elderly patients

despite lower T-scores.

• T-scores decline at a faster rate in men as compared to women as one ages.

• T-score did not predict surgical intervention when controlling for age, gender and AO

classification.

• Fracture severity (AO classification) was independent of T-score.

• Decision making for surgery may include subjective factors such as patient/physician

preference and objective fracture characteristics not accounted for by the AO classification.

Paper 19_Image01

Paper 19_Image02

Paper 20: Which Joint Fragment is Mostly Related to the Surgical

Outcome of the Distal Radius Fracture? An Analysis Using Postoperative

Computed Tomography Clinical Paper Session 03: Distal Radius - Friday, September 11, 10:12 - 10:19 AM

Evaluation/Diagnosis,Treatment,Anatomy,Prognosis/Outcomes,Hand and Wrist

Level 3 Evidence

Kwang-Hyun Lee, MD

Sung-Jae Kim, MD

Wan-Sun Choi, MD

Chang-Hun Lee, MD

Young Seok Lee, MD

Joo-Hak Kim, MD

Hypothesis

We evaluated the fragment specific articular surface reduction with computed tomography (CT),

and determined which joint fragment is mostly related to the outcome of distal radius fracture

surgically treated with volar locking plate (VLP).

Methods

Total 124 patients with surgically treated distal radius fracture using VLP were eligible for current

study. At final, 99 patients had met the selection criteria and permitted to participate in current

study, and their wrist was evaluated with CT at final follow-up. To evaluate the fragment specific

articular surface reduction, it was divided into six specific fragments; scaphoid, volar lunate and

dorsal lunate facet, central portion, dorsal and volar rim. The articular surface mismatch within

each fragment were evaluated with three-grade ordinal scale; “no mismatch”, “mismatch less

than 2mm”, “mismatch more than 2mm”. To evaluate the alignment of the distal radius, simple

radiograph were examined. For clinical evaluation, the Disability of the Arm, Shoulder and Hand

(DASH), and modified Mayo wrist score (MMWS), were completed at final follow-up. Subjects

were divided into two groups according to final DASH and MMWS score, and compared.

Correlation analysis between several parameters and DASH, MMWS were performed. Multiple

logistic regression analysis was performed to evaluate cause-effect relationship between surgical

outcome and various parameters, and to control confounding effect of each parameter.

Results

Mean follow-up period was 13.9 (range, 12 to 52) months. There were no parameters showing

significant difference between two groups divided by the result of DASH score. Parameters

showed significant correlation with DASH score were dorsal lunate facet, central depression. The

dorsal lunate facet showed the strongest correlation with DASH score (spearman’s rho= 0.218, P

= 0.030). Articular surface mismatch at dorsal lunate facet, central depression, and volar rim

were significantly greater in the group with worse MMWS score (P < 0.001, 0.036, 0.042).

Variables showed significant correlation with MMWS were the articular surface mismatch at

scaphoid facet and dorsal lunate facet, and central portion. The mismatch of dorsal lunate facet

also showed strongest correlation with MMWS (spearman’s rho= -0.367, P < 0.001). The result

of multiple logistic regression analysis showed that the mismatch of the dorsal lunate facet has

significantly high odds ratio of having worse result of MMWS.

Summary Points

• The degree of articular surface mismatch within dorsal lunate facet seems to the surgical

treatment of distal radius fracture.

• With the case involved the dorsal lunate facet, surgeons should be cautious about its

reduction during surgery using VLP.

Reference 1: Marcano A, Taormina DP, Karia R, Paksima N, Posner M, Egol KA. Displaced Intra-

Articular Fractures Involving the Volar Rim of the Distal Radius. The Journal of hand surgery.

2014.

Reference 2: Dario P, Matteo G, Carolina C, Marco G, Cristina D, Daniele F, et al. Is it really

necessary to restore radial anatomic parameters after distal radius fractures? Injury. 2014.

Reference 3: Finsen V, Rod O, Rod K, Rajabi B, Alm-Paulsen PS, Russwurm H. The relationship

between displacement and clinical outcome after distal radius (Colles') fracture. The Journal of

hand surgery, European volume. 2013;38(2):116-26.

Reference 4: Ranjeet N, Estrella EP. Distal radius fractures: does a radiologically acceptable

reduction really change the result? Journal of clinical and diagnostic research : JCDR.

2012;6(8):1388-92.

Reference 5: Kim JK, Cho SW. The effects of a displaced dorsal rim fracture on outcomes after

volar plate fixation of a distal radius fracture. Injury. 2012;43(2):143-6.

Reference 6: Gavaskar AS, Muthukumar S, Chowdary N. Fragment-specific fixation for complex

intra-articular fractures of the distal radius: results of a prospective single-centre trial. The

Journal of hand surgery, European volume. 2012;37(8):765-71.

Reference 7: Ng CY, McQueen MM. What are the radiological predictors of functional outcome

following fractures of the distal radius? The Journal of bone and joint surgery British volume.

2011;93(2):145-50.

Reference 8: Huard S, Leclerc G, Sergent P, Serre A, Gasse N, Lepage D, et al. [Distal radius

fracture with dorsal displacement: correlation between functional score, reduction quality and

fixation]. Chirurgie de la main. 2010;29(6):366-72.

Reference 9: Synn AJ, Makhni EC, Makhni MC, Rozental TD, Day CS. Distal radius fractures in

older patients: is anatomic reduction necessary? Clinical orthopaedics and related research.

2009;467(6):1612-20.

Paper 21: Three-Dimensional Analysis of Malunited Distal Radius

Fractures with Limitation of Forearm Rotation Clinical Paper Session 03: Distal Radius - Friday, September 11, 10:19 - 10:26 AM

Hand and Wrist

Level 4 Evidence

Shingo Abe, MD

Kunihiro Oka, MD, PhD

Tsuyoshi Murase, MD, PhD

Yohei Kawanishi, MD

Keiichiro Oura, MD

Atsuo Shigi, MD

Hypothesis

Malunited distal radius fractures (DRFs) occasionally limit forearm rotation; however, the

relationship between deformity and forearm rotation restriction is unclear. This study assessed

in vivo three-dimensional (3D) forearm motion with malunited DRF to elucidate the relationship

between deformity and restricted rotation.

Method

Sixteen malunited DRFs with restricted forearm rotation were investigated (10 females, six

males). The mean patient age was 45 years (range 10–77 years), and the average interval from

first injury to examination was 11 months. Computed tomography of the bilateral forearm was

performed for two rotational positions (maximum pronation and supination), and 3D bone

surface models of the radius and ulna were created. Kinematic variables were measured by

superimposing the ulna in a supinated position on the images of pronated position using a

surface-based registration technique. The rotation axis of the radius relative to the ulna was

calculated using a screw displacement axis system. The path of the distal radioulnar ligament

(DRUL), which consists of four limbs (palmar/dorsal and deep/superficial), were created based on

anatomical locations; each shortest path length avoiding bone obstacles was calculated. Each

limb length was compared with the contralateral side in neutral position (Fig. 1.).

The 3D deformity, forearm motion range, and DRUL length were quantitatively analyzed.

Results

The average pronation and supination were 55.4° and 50.2°, respectively. Eleven cases had

dorsal angulation deformity (average 25.8°), and 11 cases had internal rotation deformity

(average 16.3°). The deformity in the direction of volar flexion and internal rotation related to

the restriction of supination [correlation coefficients (R) 0.70 (P < 0.01) and 0.57 (P = 0.02)]. The

dorsal angulation and external rotation deformity correlated with limited pronation [R = 0.86 (P <

0.01) and R = 0.60 (P = 0.01)]. In cases with limited pronation, the length of the deep dorsal and

superficial dorsal limbs were elongated in the maximum pronated position [R = -0.63 (P < 0.01)

and R = -0.66 (P < 0.01)]. In cases with limited supination, relationships between deep palmar

and superficial palmar limbs and maximum supination range were similar [R = -0.85 (P < 0.01)

and R = -0.78 (P < 0.01)].

Summary

Limited forearm rotation with malunited DRF is related to the direction and amount of radius

deformity. Limited pronation and supination are considered to result from the effect of radius

deformity on overstretching dorsal and palmar ligaments (Fig. 2).

Paper 21_Image01

Paper 21_Image02

Paper 22: Failure of Fixation of Volar Locked Plating of Distal Radius

Fractures Clinical Paper Session 03: Distal Radius - Friday, September 11, 10:26 - 10:33 AM

Evaluation/Diagnosis,Treatment,Surgical Technique,Hand and Wrist

Level 3 Evidence

David J. Lee, MD

Jason Ghodasra, MD

Scott Mitchell, MD

Hypothesis

Fracture specific parameters can predict loss of fixation after volar locked plating of AO

classification 23-C3 distal radius fractures

Methods

We designed a case-control study to examine variables associated with early failure of volar

locking plate fixation. All intra-articular distal radius fractures treated surgically at our institution

between 2005-2013 by three board certified hand surgeons were screened . We identified 187

patients with AO classification 23-C3 fracture (multifragmentary, complete articular) treated

with volar locked plating and with adequate imaging and follow-up through fracture healing.

Our failure of treatment cohort consisted of 19 patients who experienced postoperative loss of

reduction sufficient to result in intra-articular screw penetration and/or joint subluxation. Our

control cohort consisted of 19 age and gender matched patients with AO 23-C3 fractures treated

with volar locked plating who maintained radiographic reduction at final followup. Injury,

immediate postoperative, and follow-up radiographs were examined for radial inclination, radial

length, ulnar variance, volar tilt, teardrop angle, radial subsidence, carpal subluxation, articular

displacement and dimensions of the primary styloid and lunate fragments. Differences in mean

values between cohorts were assessed using a two-tailed students t-test.

Results

There were no significant differences between demographic characteristics between cohorts.

Significant differences were observed between cohorts for several variables on injury

radiographs. The average length of the radial styloid fragment, measured longitudinally from the

styloid tip to the fracture line on PA views, was smaller in the failure cohort (15.8mm (failure) vs

20.3mm (control), P = 0.034). The articular width of the volar lunate facet fragment, measured

from the ulnar corner of the lunate facet to the edge of the fracture on PA view, was smaller in

the failure group (11.6mm (failure) vs 15.1mm (control), P = 0.019). Ulnar variance on injury

films was greater in the failure group (+5.6mm (failure) vs + 3.4mm (control), P = 0.021).,

Residual articular displacement on immediate postoperative radiographs was greater in the

failure cohort. (2.1 mm (Failure) vs 0.5mm (control). No significant differences were observed

between cohorts for the remaining variables.

Summary Points

• Significant differences were observed between failure and control cohorts for the following

variables: pre-reduction ulnar variance, length of the radial styloid fragment, articular width

of the lunate facet fragment, and articular displacement on immediate postoperative films.

• Distal fracture lines, small key articular fragments, and radial shortening on injury

radiographs, as well as non-anatomic articular reduction represent risk factors for loss of

reduction following volar plate fixation of AO C3 distal radius fractures.

Paper 23: The Minimal Clinically Important Difference of the Patient-

Rated Wrist Evaluation Score for Patients with Distal Radius Fractures. A

prospective cohort study Clinical Paper Session 03: Distal Radius - Friday, September 11, 10:33 - 10:40 AM

Evaluation/Diagnosis,Prognosis/Outcomes,Hand and Wrist

Level 2 Evidence

Monique Walenkamp, MD, MSc

Lara M. Vos, MD

Robert-Jan de Muinck Keizer, MD

Melvin P. Rosenwasser, MD

J. Carel Goslings, MD, PhD

Niels WL Schep, MD, PhD

Hypothesis

The purpose of this study was to determine the Minimal Clinically Important Difference (MCID)

of the Patient-Rated Wrist Evaluation (PRWE) score in patients with distal radius fractures. The

MCID of the PRWE was examined previously in patients suffering from chronic wrist conditions.

However, the MCID of the PRWE has never been determined in patients with a distal radius

fracture. We hypothesised that the MCID in patients with this acute condition is not necessarily

similar to the MCID for patients who suffer from a chronic condition.

Methods

We prospectively included 102 patients with a median age of 59 years (Interquartile Range 48 –

66). All participants completed the PRWE questionnaire during two separate visits. Additionally,

patients were asked to indicate the degree of clinical change they appreciated on a scale from -5

(much worse) to +5 (much better) through 0 (no change). Accordingly, patients were categorized

into two groups: (1) minimally improved; or (2) no change. These groups were used to 'anchor’

the changes observed in the PRWE to patients’ perspective of what is clinically important. We

determined the MCID according to the ROC method. In this context, the change in PRWE is

considered a diagnostic test and the anchor (minimally improved or no change) is the gold

standard. The optimal ROC cut-off point reflects the value of the MCID.

Results

The majority of patients indicated to experience marked improvement and the PRWE score

between the first and the second measurement differed significantly (P < 0.001, Wilcoxon Signed

Rank Test). The MCID of the PRWE was 11.5 points.

Summary Points

• A change of 11.5 points on the PRWE represents a clinically important difference for patients

with distal radius fractures.

• We recommend using this value to interpret treatment effects and for sample size

calculations.

Paper 24: Biomechanical Evaluation of Flexor Tendon Graft with

Different Repair Techniques and Graft Surface Modification Clinical Paper Session 04: Tendon - Friday, September 11, 10:05 - 10:12 AM

Surgical Technique

Level 5 Evidence

Jingheng Wu, MD

Hypothesis

The purpose of this study was to investigate the biomechanical properties of modified repair

techniques for flexor tendon reconstruction and the effects of surface modification using

carbodiimide-derivatized synovial fluid plus gelatin (cd-SF-G), compared to the traditional repair

techniques.

Methods

The second and fifth digits from 16 canine forepaws were randomly divided into 4 groups: 1)

traditional graft repairs (TGR group) including distal Bunnell repair and proximal Pulvertaft weave

repair; 2) modified graft repairs (MGR group) including distal graft bony attachment repair and

proximal step-cut repair; 3) Group TGR coated with cd-SF-G (TGR-C group); and 4) Group MGR

coated with cd-SF-G (MGR-C group). Digit normalized work of flexion (nWOF), ultimate failure

strength, and stiffness were measured

Results

The nWOF in MGR group was significantly less than TGR group (P < 0.05). The nWOF in groups

treated with cd-SF-G was significantly less than their untreated counterparts (P < 0.05). Ultimate

load to failure of the MGR-C group was significantly greater than the TGR-C group (P < 0.05), but

no significant difference in stiffness was found between these two groups.

Summary

The modified techniques can not only improve tendon gliding abilities but can also improve

breaking strength. Additionally, surface modification with cd-SF-G significantly decreased the

work of flexion.

Paper 24_Image01

Paper 24_Image02

Reference 1: Kang N, Pratt A, Burr N. 2003. Miniplate fixation for avulsion injuries of the flexor

digitorum profundus insertion. J Hand Surg Br 28:363-368.

Reference 2: Bertelli JA, Santos MA, Kechele PR, et al. 2007. Flexor tendon grafting using a

plantaris tendon with a fragment of attached bone for fixation to the distal phalanx: a

preliminary cohort study. J Hand Surg Am 32:1543-1548.

Reference 3: Pulvertaft RG. 1984. Tendon grafting for the isolated injury of flexor digitorum

profundus. Bull Hosp Jt Dis Orthop Inst 44:424-434.

Reference 4: Atik B, Tan O, Dogan A, et al. 2008. A new method in tendon repair: angular

technique of interlocking (ATIK). Ann Plast Surg 60:251-253.

Reference 5: Tanaka T, Amadio PC, Zhao C, et al. 2003. Gliding resistance versus work of flexion--

two methods to assess flexor tendon repair. J Orthop Res 21:813-818

Paper 25: Tenocyte Transdifferentiation Underlies Enthesis

Regeneration Clinical Paper Session 04: Tendon - Friday, September 11, 10:12 - 10:19 AM

Anatomy,Basic Science,Hand and Wrist,Elbow and Forearm,Shoulder and Arm,General Principles

N/A - Not a clinical study

Rowena McBeath, MD, PhD

A. Lee Osterman, MD

Hypothesis

The structure attaching tendon to bone – the enthesis -- comprises four distinct zones: tendon,

fibrocartilage, mineralized fibrocartilage, and bone (1). The molecular and cellular signaling

events responsible for human enthesis formation are unclear. Prior in vitro studies of human

tenocytes have demonstrated tenocytes transdifferentiate into fibrochondrocytes (2). We

hypothesize that tenocytes transdifferentiate to mineralized fibrocartilage and bone depending

on changes in their microenvironment, and use our results to develop an enthesis-like construct.

Methods

Human tendon tissue was isolated from patients undergoing revision amputation from traumatic

hand injury (3). Tenocytes were isolated, then cultured in hypoxic (1% 02) and normoxic (22%

02) environments in low, medium and high cell densities. Tenocyte cultures were harvested and

underwent immunofluorescent staining for collagen I, collagen II, and aggrecan; and light

microscopic staining for mineralization (alkaline phosphatase and alizarin red) and lipid droplet

formation. Tenocytes were also harvested for quantitative RT-PCR analysis of tenocyte markers

(tenomodulin, scleraxis), fibrochondrocyte markers (collagen II, aggrecan) mineralized

fibrochondrocyte markers (collagen X, alkaline phosphatase) and lipids (LPL). Biochemical assays

for RhoA and Rac1 GTPase activity are as described (4). Activation of RhoA and Rac1 GTPase

using adenoviral transduction is as described (5). Tenocyte implantation in electrospun nanofiber

constructs is as described (6).

Results

In a hypoxic environment (1% 02), tenocytes cultured at low cell density displayed increased

stress fibers, increased aggrecan production, and time-dependent matrix mineralization via

alizarin red staining, consistent with transdifferentiation to mineralized fibrochondrocytes.

Tenocytes cultured at medium cell density retained the tenocyte phenotype. Interestingly,

tenocytes cultured at high cell density formed lipid droplets. When analyzed for biochemical

activity, tenocytes that had transdifferentiated into mineralized fibrochondrocytes displayed

concomitant high RhoA and low Rac1 GTPase activity. Conversely, tenocytes that displayed

characteristics of intramedullary bone (e.g. adipocyte formation) displayed concomitant low

RhoA and low Rac1 GTPase activity. These differential tenocyte phenotypes were maintained

when cultured in a three dimensional electrospun nanofiber construct.

Summary Points

• Depending on the microenvironment, human tenocytes transdifferentiate into the cells of

the enthesis.

• Mineralization of fibrochondrocytes occurs in a time-dependent fashion, and is controlled by

differential activity of the RhoA and Rac1 GTPases.

• Manipulation of RhoA and Rac1 GTPase activity via adenoviral transduction, and three-

dimensional control via an electrospun nanofiber construct, maintains the

transdifferentiated phenotype.

• Recreation of the human enthesis through tenocyte transdifferentiation in vitro represents a

novel mode of cellular therapy, applicable to finger, wrist, elbow and shoulder pathology.

Reference 1: Cooper RR and Misol S (1970) J Bone Joint Surg 52A: 160-170

Reference 2: Yao L et al. (2006) Tissue Eng 12(7): 1843-9

Reference 3: Qiu Y et al. (2013) J Tissue Eng Regen Med Aug 29 Epub

Reference 4: Ren XD et al. (2000) Methods Enzymol 325: 264-72

Reference 5: Pattabiraman PP et al. (2010) Am J Physiol Cell Physiol 298(3): C749-63

Reference 6: Fisher MB and Mauck RL (2013) Nanomedicine (Lond) 8(4): 505-508

Paper 26: Tissue Engineered Collagen Specific Anchors Increase Cellular

Integration in a Tendon Injury Model Clinical Paper Session 04: Tendon - Friday, September 11, 10:19 - 10:26 AM

Basic Science,Hand and Wrist

Level 1 Evidence

Mark L. Wang, MD, PhD

Pedro K. Beredjiklian, MD

Andrzej Fertala, PhD

Hypothesis

Current strategies to enhance tendon healing are limited by the inability to retain therapeutic

cells within the injury site, presenting challenges regarding the safety and efficiency of cellular-

based treatments. Previously, our laboratory has demonstrated that a novel tissue engineered

cellular construct, expressing an inducible Artificial Collagen-Specific Anchor (ACSA), decreases

cellular migration and improves cellular attachment to collagen-rich sites, without disrupting cell

survival. The purpose of this Study is to 1) evaluate the performance of this Collagen Specific

Anchor in an Ex Vivo Tendon Injury Model, and 2) determine whether its expression improves

cellular integration into the injury site, enhancing tendon laceration healing. Potential

advantages of this construct may include improved safety and efficiency of future cellular

therapies, with enhanced tissue healing.

Methods

Our previously engineered cellular construct exhibits these features: Murine fibroblasts (NIH

3T3), anchored to human type I collagen (C-terminus, a2 chain), tetracycline (Tet)-responsive

promoter, and GFP tag (Fig 1A). Stable expression of the ACSA-GFP construct in transfected

cells, has previously been established (Fig. 1B). This construct was tested in a bioreactor system

(LigaGen), utilizing an ex vivo rabbit Achilles tendon injury model. Cells expressing ACSA-GFP

were seeded on a polyglycolic acid (PGA) scaffold, inserted into defect sites, maintained under

mechanical stimulation, in the presence or absence of Dox. Histological analysis was performed

on samples treated with both engineered and control cells. Fluorescence microscopy confirmed

ACSA-GFP expression of integrated cells at the tendon defect sites.

Results

Tissue engineered cellular constructs expressing ACSA-GFP demonstrated efficient integration of

cells at the injury defect site, and within collagen-rich elements of the native tendon (Fig 2).

Fluorescent microscopy exhibited GFP signal at the tendon injury interface and the surrounding

native tissue. Cellular constructs not expressing ACSA-GFP demonstrated poor integration at the

scaffold-tendon junction, with no significant evidence of cellular penetration into the

surrounding tissue. Fluorescent microscopy corroborated these findings.

Summary Points

• Existing strategies of tendon healing are limited by the inability to retain therapeutic cells

within the injury site, resulting in their inefficient and non-specific delivery.

• We propose a novel strategy enabling the controlled expression of collagen specific anchors

at the surface of therapeutic cells, facilitating cellular retention within collagen-rich sites.

• Tissue engineered constructs expressing ACSA-GFP exhibited improved cellular integration at

the scaffold-tendon junction, with increased penetration into the surrounding collagen-rich

native tendon tissue.

• Potential benefits may include improved safety and efficiency of future cellular therapies,

with enhanced tissue healing.

Paper 26_Image01

Paper 26_Image02

Reference 1: Steplewski A, Fertala J, Beredjiklian P, Wang ML, Fertala A. Matrix-Specific Anchors:

A New Concept for Targeted Delivery and Retention of Therapeutic Cells. Tissue Eng Part A. 2014

Nov 30. [Epub ahead of print]

Reference 2: Fertala J, Kostas J, Hou C, Steplewski A, Beredjiklian P, Abboud J, Arnold WV,

Williams G, Fertala A. Testing the anti-fibrotic potential of the single-chain Fv antibody against

the a2 C-terminal telopeptide of collagen I. Connect Tissue Res. 2014 Apr;55(2):115-22. doi:

10.3109/03008207.2013.862528.

Reference 3: Fertala J, Steplewski A, Kostas J, Beredjiklian P, Williams G, Arnold W, Abboud J,

Bhardwaj A, Hou C, Fertala A. Engineering and characterization of the chimeric antibody that

targets the C-terminal telopeptide of the a2 chain of human collagen I: a next step in the quest

to reduce localized fibrosis. Connect Tissue Res. 2013;54(3):187-96. doi:

10.3109/03008207.2013.778839.

Reference 4: Ansboro, S., Greiser, U., Barry, F., and Murphy, M. Strategies for improved targeting

of therapeutic cells: implications for tissue repair. Eur Cell Mater. 2012 Apr 21;23:310-8;

discussion 318-9.

Reference 5: Qiu, Y., Lim, J.J., Scott, L., Jr., Adams, R.C., Bui, H.T., and Temenoff, J.S. PEG-based

hydrogels with tunable degradation characteristics to control delivery of marrow stromal cells

for tendon overuse injuries. Acta Biomater. 2011 Mar;7(3):959-66. doi:

10.1016/j.actbio.2010.11.002.

Reference 6: James, R., Kesturu, G., Balian, G., and Chhabra, A.B. Tendon: biology, biomechanics,

repair, growth factors, and evolving treatment options. J Hand Surg Am. 2008 Jan;33(1):102-12.

doi: 10.1016/j.jhsa.2007.09.007.

Paper 27: Mechanical Strength of Side-to-side Tendon Repair with a

Modified Krackow Method Clinical Paper Session 04: Tendon - Friday, September 11, 10:26 - 10:33 AM

Surgical Technique,Hand and Wrist

N/A - Not a clinical study

Keisuke Ueno, MD

Kazuki Kuniyoshi, MD, PhD

Takane Suzuki, MD

Koji Sukegawa, MD

Hitoshi Kiuchi, MD

Aya Kanazuka, MD

Hypothesis

The interlacing weave suture technique is generally used for strong tendon transfer fixation, but

is difficult to use when a tendon is short and the area of overlap is small. In that case, we often

use a side-to-side tendon repair with a simple mattress suture technique, which is weaker than

the interlacing weave technique. We sought to compare the mechanical strength of side-to-side

tendon repairs using a modified Krackow method, traditionally used as a pull-out suture, and

side-to-end tendon repairs using the interlacing suture technique for flexor tendon repair.

Our hypothesis was that in clinical practice a modified Krackow method is likely to be as strong

as the interlacing suture technique.

Methods

We harvested tendons from the flexor digitorum superficialis (FDS), flexor digitorum profundus

(FDP), and flexor pollicis longus (FPL) from 8 unembalmed frozen cadavers. We compared the

load to failure (N) of 41 repairs between 3 groups: repairs with the modified Krackow method

involving 8 locking loops on the overlap space (K repairs); repairs with the interlacing suture

technique consisting of 2 weaves (I repairs), with 2 mattress sutures for each weave and 2

mattress sutures on each side of the overlap region; and repairs with 8 mattress sutures placed

on the overlap (M repairs). For all repairs, the length of the overlap region was 25 mm and

suture material was 4-0 nylon. Subsequently, we compared displacement (mm) between 31 K

and I repairs with a cyclic loading test. The load in cyclic loading test was 5 N to 75 N for 200

cycles. We defined displacement on this test as that from the second cycle to 200 cycles.

Biomechanical testing data were analyzed using an ANOVA followed by an SNK test and a paired

or unpaired t test. Significant difference was assumed for P < 0.05.

Results

The peak load to failure for the K repairs was 155 ± 45 N, for I repairs was 122 ± 18 N, and for M

repairs was 94 ± 36 N. There was a significant difference in the peak load to failure between K

repairs and I repairs, and K and M repairs. K repairs showed significantly less displacement (2.9 ±

1.4 mm) than I repairs (4.0 ± 0.8 mm).

Summary

Side-to-side repair using the modified Krackow method is likely to be better in clinical practice

than the interlacing suture technique given similar small areas of overlap.

Paper 27_Image01

Paper 27_Image 02

Reference 1: Krackow KA, Thomas SC, Jones LC. A new stitch for ligament-tendon fixation.

JBJS.1986;68A(5):764-766.

Reference 2: Deramo DM, White KL, Parks B. Krackow locking stitch versus nonlocking

premanufactured loop stitch for soft-tissue fixation:a biomechanical study.

Arthoroscopy;2008:24(5):599-603.

Reference 3: Savage, R. In vitro studies of a new method of flexor tendon repair. J. Hand Surg. Br.

1985.2, 135–141.

Reference 4: Silfverskiold KL, May EJ, Tornvall AH. Flexor digitorum profundus excursions during

controlled motion after flexor tendon repair in excursions during controlled motion after flexor

tendon repairs in zone II: a prospective clinical study. J Hand Surg 1992;17A:122–131.

Reference 5: Brown SH, Hentzen ER, Kwan A, Ward SR, Friden J, Lieber RL. Mechanical strength

of the side-to-side versus pulvertaft weave tendon repair. J Hand Surg Am. 2010, 35(4): 540-545.

Reference 6: Fuchs SP, Walbeehm ET, Hovius SER. Biomechanical evaluation of the Pulvertaft

versus the ‘wrap around’ tendon suture technique. J Hand Surg Eur. 2011, 36(6): 461-466.

Reference 7: Hashimoto T, Thoreson AR, An KN, Amadio PC, Zhao C. Comparison of step-cut and

Pulvertuft attachment for flexor tendon graft: a biomechanics evaluation in an in vitro canine

model. J Hand Surg Eur. 2012, 37(9): 848-854.

Reference 8: Tanaka T, Zhao C, Ettema AM, Zobitz ME, An KN, Amadio PC. Tensile strength of a

new suture for Fixation of tendon grafts when using a weave technique. J Hand Surg. 2006,

31(6): 982-986.

Reference 9: Walbeehm ET, Hovius SER, Mcgrouther DA. Influence of core suture geometry on

tendon deformation and gap formation in porcine flexor tendons. J hand Surg Eur. 2009, 34(2):

190-195.

Reference 10: Emilio Wagner, MD, Cristian Ortiz, MD, Pablo Wagner, MD. Biomechanical

Evaluation of Various Suture Configurations in Side-to-Side Tenorrhaphy. J Bone Joint Surg Am.

2014;96:232-6

Paper 28: In Vitro Evaluation of Tenocyte Growth of Human Tendon of

the Hand into Adjacent Synthetic Tendon Clinical Paper Session 04: Tendon - Friday, September 11, 10:33 - 10:40 AM

Basic Science,Hand and Wrist

N/A - Not a clinical study

Shalimar Abdullah, MD

Hypothesis

A three dimensional synthetic tendon scaffold allows ingrowth of adjacent human tenocyte cells

from human tendon.

Methods

Upper limb tendons are harvested from patients indicated for upper limb amputation after

consent has been obtained. Upper limb tendons are sutured to the synthetic tendon (both sides

of 0.5 cm of synthetic scaffold will be sutured to 1 cm of extensor or flexor tendon and specimen

is cultured in growth medium). Eight samples will be prepared and maintained in CO2 incubator

with medium change 3 times a week. At the end of 2,4,6,and 8 weeks, samples of the tendon

from the designated weeks will be fixed with formalin overnight ,embedded in paraffin and cut

from paraffin blocks using a microtome. Haemoxylin and Eosin staining are performed . Tissue

characteristics and percentage of growth of tenocytes are examined by a pathologist.

Results

There is no tenocyte growth seen in the first 2 weeks of incubation. However at 4 weeks,

tenocytes are seen migrating towards thejunction between the tendon and synthetic scaffold. At

6 weeks, more tenocytes are seen growing into the synthetic scaffold and at 8 weeks, tenocytes

are seen in abundance in the synthetic tendon.

Summary

Tenocytes from human tendons of the hand can proliferate into adjacent synthetic tendon.

There is potential for synthetic tendon to slowly acquire characteristics of natural tendon.

Synthetic tendon which can mimic normal tendons can solve problem of limited donor tendon

availability.

Paper 28_Image01

Paper 28_Image02

Reference 1: Jennings, A., Sefton, G. & Newman, R. 2004. Repair of acute rupture of the Achilles

tendon: a new technique using polyester tape without external splintage. Annals of the Royal

College of Surgeons of England 86(6): 445-448.

Reference 2: Bagnaninchi, P. O., Yang, Y., El Haj, A. J. & Maffulli, N. 2007. Tissue engineering for

tendon repair. British Journal of Sports Medicine 41(8): e10-e10

Reference 3: S. Zaffagnini, De Pasquale V, Montanari C et al. Histological and ultrastructural

evaluation of Leeds-Keio ligament 20 years after implant: A Case report. Knee Surg Sports

Traumatol Arthrosc 1997;5(2):89-94

Reference 4: AG Jennings, GK Sefton. Chronic rupture of tendo Achilles: Long-term results of

operative management using Polyester tape. JBJS 2002;84(3):361-3

Reference 5: Murray AW, Macnicol MF. 10-16 year results of Leeds-Keio anterior cruciate

ligament reconstruction. Knee. 2004 Feb;11(1):9-14.

Reference 6: Fujikawa K, Iseki F, Seedhom BB. Arthroscopy after anterior cruciate reconstruction

with the Leeds-Keio ligament. J Bone Joint Surg Br. 1989 Aug;71(4):566-70.

Paper 29: Return to Play Following Hand Injuries in the National

Basketball Association Clinical Paper Session 05: Hand 1 - Friday, September 11, 11:25 - 11:32 AM

Historical Information,Prognosis/Outcomes,Hand and Wrist

Level 3 Evidence

Kyle W. Morse, BS

Michelle Gerwin Carlson, MD

Hypothesis

Time to return to play after hand injuries in elite athletes has not been described. We report the

return to play from metacarpal fractures, phalangeal fractures, and thumb ligament tears over a

five-year period in the National Basketball Association (NBA).

Methods

The NBA transaction report was analyzed from January 2009 to May 2014. Players were

identified who were added to the injured list (IL), missed games due to injury, or underwent

surgery for a hand injury. Games missed, days spent on the IL, and age at injury were calculated

by injury type and location. Associations between position and injury type were analyzed using

Chi-square tests. Independent samples t-tests were used to compare return to play between

surgically treated and non-surgically treated injuries. Welch’s Robust ANOVA with Games-Howell

correction was used to compare return to play between injury type and position. A Pearson

correlation was used to correlate age with return to play. Statistical significance was defined as

p<0.05.

Results

One hundred and thirty seven injuries were identified, including 39 hand injuries 98 finger

injuries. Three frequent injuries were identified and analyzed: metacarpal fractures, phalangeal

fractures, and thumb ligament tears.(Table 1) Return to play was calculated from the date of

injury to the date of return. Thumb ligament tears were treated surgically and had the longest

return to play of 67.5±17.7 days (p<0.05). Return to play for metacarpal fractures treated

surgically (56.7±26.3 days) was significantly greater than non-surgically repaired metacarpal

fractures (26.3±12.1 days, (p<0.01). Return to play for surgically repaired phalangeal fractures

(46.2±10.8 days) trended greater, but was not significantly different than phalangeal fractures

that were not treated surgically (33.3±28.5 days, p>0.05). Player position and age were not

related to injury type or time to return to play (p>0.05).

Summary Points

• Hand injuries in professional basketball players can lead to prolonged periods of time away

from competition, especially following surgery.

• Thumb ligament tears resulted in the longest return to play (67.5 days) compared to

phalangeal fractures and metacarpal fractures.

• Return to play was twice as long for metacarpal fractures treated surgically than for

metacarpal fractures treated non-surgically (56.7 vs 26.3 days), contradicting anecdotal

information stating surgical fixation speeds return to play.

• Return to play was not significantly different between phalangeal fractures treated surgically

and those not treated surgically.

• This study provides guidelines on expected return to play in the NBA for these common

injuries.

Paper 29_Image01

Paper 30: Hypothenar Hammer Syndrome: Long-term Results of

Vascular Reconstruction Clinical Paper Session 05: Hand 1 - Friday, September 11, 11:32 - 11:39 AM

Treatment,Prognosis/Outcomes,Hand and Wrist

Level 4 Evidence

Ryan D Endress, MD

Hypothesis

Hypothenar hammer syndrome (HHS) is an uncommon cause of digital ischemia, and many

patients ultimately require vascular reconstruction to alleviate critical ischemia. Long-term

patency rates and related outcomes are not well established, and purpose of this study is to

evaluate these endpoints following vascular reconstruction of HHS. Additionally, we aim to

identify any patient or treatment related factors that may contribute to differences in outcome

Methods

Color flow ultrasound was utilized to determine the patency of 18 vein graft reconstructions of

the ulnar artery at the wrist in 16 patients. Validated questionnaires evaluated patients’

functional disability with the Disabilities of the Arm, Shoulder and Hand (DASH) score, pain with

the Visual Analog Scale (VAS), and cold intolerance with the Cold Intolerance Symptom Severity

survey (CISS). Patient demographics, clinical data, and surgical factors were analyzed for

association with graft failure. Patients were asked to grade the result of treatment on a 0-10

scale.

Results

Fourteen of 18 grafts (78%) were occluded at a mean 118 months postoperatively. Patients with

patent grafts had significantly less disability related to cold intolerance according to the CISS

survey (mean 21.8 versus 55.0) in addition to significantly less pain on the VAS scale. There was

no statistical difference in DASH scores between patent and occluded grafts. Patients graded the

result significantly higher in patent reconstructions (9.5 versus 6.8).

Summary

The present study demonstrates a higher rate of graft occlusion than previously reported at a

mean follow-up of 9.8 years, which represents one of the longer duration follow-up studies of

surgical treatment of HHS to date. Despite a high percentage of occlusion, patients overall

remained very satisfied with low functional disability, and all patients would recommend surgical

reconstruction. This study suggests that improved outcomes may result from patent grafts long-

term.

Paper 30_Image01

Reference 1: Nitecki S, Anekstein Y, Karram T, Peer A, Bass A. Hypothenar hammer syndrome:

Apropos of six cases and review of the literature. Vasc. 2008;16(5):279-282

Paper 31: Assessment of Tendon Graft Rings for A2 and A4 Hand Pulley

Reconstruction Clinical Paper Session 05: Hand 1 - Friday, September 11, 11:39 - 11:46 AM

Treatment,Surgical Technique,Anatomy,Basic Science,Hand and Wrist

N/A - Not a clinical study

Lioubov Soulii, MD

Farid Amirouche, PhD

Giovanni Solitro, PhD

Mark H. Gonzalez, MD, PhD

Alfonso Mejia, MD, MPH

Michael C. Weisburger, MD

Hypothesis

Simultaneous loss of the of the A-2 and A-4 pulleys can cause significant bowstringing of the

flexor digitorum profundus. Pulley repair is commonly done with a palmaris tendon loop about

the proximal or middle phalanx. The number of loops and the location of the loops can effect the

degree of bowstringing. The purpose of this study was to investigate whether repair of the A2

pulley alone in a digit having A2 and A4 pulley incompetence could lead to a good functional

outcome and to determine the number of graft rings necessary for proper repair.

Methods

A motorized apparatus was constructed using potentiometers to measure angular rotation of

the digit as a function of tendon excursion. After control (undamaged pulleys) testing, we

recorded finger angular rotation as a function of tendon excursion of eleven cadaveric fingers

after the following interventions: 1) complete excision of A2 and A4 pulley, 2) repair of distal part

of the A2 pulley with one ring of tendon graft, 3) repair of the A2 pulley with two rings of tendon

graft, 4) repair of the A2 pulley with two rings of tendon graft and the A4 pulley with one ring.

The loss of flexion at full tendon excursion was measured both at the PIP and MCP joint and was

calculated as a percentage loss as compared to controls.

Results

The loss of the A-2 and A-4 pulleys caused a loss of 32% angular excursion at the MCP joint and

19.6 % at the PIP joint. At the PIP joint One ring showed a 14% loss in PIP rotational angle

compared to control, 2 rings showed a 17% decrease while the use of three rings, that is, two at

A2 and one at A4, had a decrease of 5%. At the MCP joint, with one ring, the decrease in

rotational angle was 12% with a second ring 16% whereas with the 3 ring scenario it was 14%.

Summary Points

There is significant loss of rotation at both the MCP and PIP associated with loss of the A-2 and

A-4 pulley. A double loop at the proximal phalanx fostered no advantage to the single loop. This

may involve issues of increased tendon drag. The best reconstruction was the 2 plus 1 pulley

reconstruction. The study indicates clinically that in cases of loss of both the A-2 and A-4 pulley,

reconstruction of both pulleys should be considered.

Paper 31_Image01

Paper 31_Image02

Reference 1: Connor J, Amirouche F, Gonzalez M. Understanding the kinematics and dynamics of

the digit. J Bone Joint Surg Am. 2009 Nov;91 Suppl 6:74-8.

Reference 2: Elftman H. Biomechanics of muscle with particular application to studies of gait. J

Bone Joint Surg Am. 1996 Mar;48(2):363-77.

Reference 3: Doyle JR. Palmar and digital flexor tendon pulleys. Clin Orthop Res. 2001

Feb;(383):84-96.

Reference 4: Peterson WW, Manske PR, Bollinger BA, Lesker PA, McCarthy JA. Effect of pulley

excision on flexor tendon biomechanics. J Orthop Res. 1986;4(1):96-101.

Reference 5: Tomaino M, Mitsionis G, Basitidas J, Grewal R, Pfaeffle J. The effect of partial

excision of the A2 and A4 pulleys on the biomechanics of finger flexion. J Hand Surg.

1998;23B:50–52

Reference 6: Schöffl VR, Schöffl I. Injuries to the finger flexor pulley system in rock climbers:

current concepts. J Hand Surg Am. 2006 Apr;31(4):647-54

Reference 7: Franko OI, Lee NM, Finneran JJ, Shillito MC, Meunier MJ, Abrams RA, Lieber RL.

Quantification of partial or complete A4 pulley release with FDP repair in cadaveric tendons. J

Hand Surg Am. 2011 Mar;36(3):439-45

Reference 8: Marco RA, Sharkey NA, Smith TS, Zissimos AG. Pathomechanics of closed rupture of

the flexor tendon pulleys in rock climbers. J Bone Joint Surg Am. 1998 Jul;80(7):1012-9

Reference 9: Bollen SR. Injury to the A2 pulley in rock climbers. J Hand Surg 1990;15B:268 – 270

Reference 10: Hume EL, Hutchinson DT, Jaeger SA, Hunter JM. Biomechanics of pulley

reconstruction. J Hand Surg Am. 1991 Jul;16(4):722-30

Paper 32: Individualized Reconstruction of Chronic Fractures Affecting

the PIP Joint Clinical Paper Session 05: Hand 1 - Friday, September 11, 11:46 - 11:53 AM

Treatment,Surgical Technique,Prognosis/Outcomes,Hand and Wrist

Level 4 Evidence

Jiuzhou Lu, MD, PhD

Lei Xu, MD,PhD

Jianguang Xu, MD

Yudong Gu, MD

Hypothesis

Chronic fractures affecting the PIP joint present a big challenge for hand surgeons. There is no

classification for this problem. The purpose of the study is to classify this chronic fracture. We

hypothesize that each stage of chronic PIP joint fractures have different appropriate treatment.

Methods

Consecutive patients with chronic PIP joint fractures presented to our center from May 2007 to

Dec 2014 were included in the study. Patients who were indicated for reconstructive surgery

were divided into 5 different groups according to severity of the joint injuries, and received

relevant reconstructive procedures. Outcome measurements included radiographic evidence of

bone healing, joint alignment and/or collapse, ROM of PIP joint, and the donor site morbidity.

Results

There were 36 patients with chronic PIP joint fractures presented to our center during the

period. Among them, 23 patients received reconstructive surgery. The average age was 32 (15-

54) years, with 21 males. These patients were divided into 5 groups: 2 cases of nonunion, 6 cases

of malunion, 9 cases of partial osteochondral defect, 3 cases of posttraumatic arthritis, and 4

cases of joint collapse. Surgeries were performed 1 months to 3 years after the fracture or

previous surgery. Following procedures were performed: ORIF + BG for nonunion, corrective

osteotomy for malunion, osteochondral graft for partial osteochondral defect, vascularised joint

transfer for posttraumatic arthritis, and vascularised joint transfer following distraction for joint

collapse. The average arc of motion for the involved PIP joint was 79° (35°–95°). The distal

interphalangeal (DIP) joint average arc of motion was 50° (0°-65°). Bony union was obtained in

22 patients. There was one painful degenerative arthritis after osteochondral bone graft and one

refracture after vascularized joint transfer who converted to a revision surgery. Twenty-one

patients had no pain, and 20 patients were satisfied with their function.

Summary Points

• Treat PIP joint nounion and malunion as soon as it is recognized, excellent recovery can be

achieved with minor donor site sacrifice.

• For partial articular defect, anatomical reconstruct can be achieved by osteochondral grafts

with satisfactory outcome.

• If vascularised toe joint transfer is performed, donor site can be well preserved by IC bone

graft and canulate screw.

Paper 32_Image01

Paper 32_Image02

Reference 1: Freeland A, Benoist LA: Open reduction and internal fixation method for fractures

at the proximal interphalangeal joint. Hand Clin 10239-250, 1994

Reference 2: Eaton RG, Malerich M: Volar plate arthroplasty of the proximal interphalangeal

joint: A review of ten years' experience. J Hand Surg 5x260-268, 1980.

Reference 3: Teoh LC, Yong FC, Chong KC. Condylar advance- ment osteotomy for correcting

condylar malunion of the finger. J Hand Surg [Br]. 2002;27:31-5.

Reference 4: Hastings H, Capo J, Steinberg B, et al. Hemicondylar Hamate Replacement

Arthroplasty for Proximal Interphalangeal Joint Fracture/Dislocations. 54th Annual Meeting of

the American Society for Surgery of the Hand 1999; Boston, MA:(Abstract).

Reference 5: Foucher G, Merle M, Maneaud M, Michon J. Microsurgical free partial toe transfer

in hand reconstruction: a report of 12 cases. Plast Reconstr Surg 1980;65:616-27.

Reference 6: Tsai TM, Wang WZ. Vascularized joint transfers: indications and results. Hand Clin

1992;8:525-36.

Paper 33: Trends in Elbow Ulnar Collateral Ligament Reconstruction in

Professional Baseball Pitchers Clinical Paper Session 05: Hand 1 - Friday, September 11, 11:53 AM - 12:00 PM

Historical Information,Prognosis/Outcomes,Elbow and Forearm

Level 3 Evidence

Alexander T. Wilson, BS

Tyler Pidgeon, MD

Manuel F. DaSilva, MD

Nathan Morrell, MD

Receipt of Intellectual Property Rights/Patent Holder: SwissOrtho (DaSilva)

Hypothesis

Ulnar collateral ligament (UCL) reconstruction is commonly performed on professional baseball

pitchers to address UCL insufficiency. Some pitchers have elected to undergo revision UCL

reconstruction to prolong their careers after suffering recurrent UCL insufficiency. With recent

improvements in surgical techniques and rehabilitation protocols we hypothesize that UCL

revision reconstruction rates in professional baseball players have decreased in recent years.

Methods

Data were collected on 271 professional baseball pitchers who underwent primary UCL

reconstruction from 1974 until 2014. Each player was evaluated retrospectively for occurrence

of revision UCL reconstructive surgery. Data on players who underwent revision UCL

reconstruction were compiled to determine 1) total surgical revision rate and 2) revision rate by

year. Yearly revision rates were analyzed for trends. Dates of primary and revision surgery, as

well as ages of the players at these times and at retirement, were recorded. Average career

length after primary UCL reconstruction was calculated and compared to that of players who

underwent revision surgery. Logistic regression analysis was performed to assess risk factors for

revision including handedness, pitching role, and age at the time of primary reconstruction.

Results

The annual rate of primary reconstructions amongst professional pitchers increased from 1974

to 2014, while the rate of revision UCL reconstructions has recently decreased. Of the 271

pitchers included in the study, 40 (14.8%) required at least one revision procedure during their

playing career. Three (1.1%) cases required a second UCL revision reconstruction. The average

time from primary surgery to revision was 5 years (Range: 1-13 years). The average length of

career following primary reconstruction for all players was 5 years (Range: 0-22 years). The

average length of career following revision UCL reconstruction was 3 years (Range: 0-8 years).

No risk factors for needing revision UCL reconstruction were found.

Summary Points

• The rate of primary UCL reconstructions amongst professional pitchers is increasing.

• The rate of revision UCL reconstructions appears to be decreasing.

• Explanations for the decreased revision rate may include improved surgical technique and

improved rehabilitation protocols.

• The average length of career following primary reconstruction is 5 years compared to only 3

years following revision.

Paper 33_Image01

Paper 33_Image02

Paper 34: Role of Laser Pointer in Budgeting Fluoroscopy Time and

Radiation Exposure Clinical Paper Session 06: Practice Management - Friday, September 11, 11:25 - 11:32 AM

Evaluation/Diagnosis,Prognosis/Outcomes,Hand and Wrist

Level 2 Evidence

Tom Hong, MD

Robert C. Matthias, Jr., MD

Paul C. Dell, MD

Thomas W. Wright, MD

Hypothesis

The use of a laser pointer on a mini C-arm fluoroscopic unit helps to decrease the number of

shots required, the time it takes to accomplish the task at hand, and decreases the radiation

exposure to the surgeon and patient.

Methods

25 surgeons were tasked with obtaining "perfect circle" views of two cannulated screws placed

into a cadaveric wrist while multiple parameters, including time to complete the task, number of

shots required to complete the task, radiation exposure as recorded on the mini C-arm

fluoroscopic unit, and the number of blank shots taken, were recorded.

A one-tailed paired Student’s t-test (P < 0.05) was used to determine difference between the

time to complete the task, the number of shots required to complete the task, radiation

exposure, and total exposure time as recorded on the mini c-arm fluoroscopy unit. A Z-test was

used to determine the difference in percentages of blank shots taken by the surgeon. A post-

hoc power analysis was performed and statistical analysis was also completed.

Results

An average +/- SD of 81.6 +/- 41.3 seconds were required to complete the assigned task when

laser guidance was used compared to 104.6 +/- 68.2 seconds without laser guidance. (P = 0.074)

An average of 17 +/- 11.3 shots with the use of laser guidance and 21.8 +/- 10.4 shots without

laser guidance. (P = 0.056) The total exposure time and total dose area product (DAP) with and

without laser guidance were 24.5 +/- 19.9 compared to 29.0 +/- 15.4 and 2.1 +/- 1.8 compared

to 2.4 +/- 3.5 respectively. (P = 0.18; P = 0.26, respectively) Lastly, the number of blank shots

was significantly reduced from 88% to 12% with the aide of laser guidance. (P < 0.001)

A post hoc power analysis to detect a difference in the number of shots taken was 69%, 62% to

detect the difference in time to accomplish the task, 33% to detect the difference in total

exposure time, 22% for difference in DAP and 100% for difference in number of blank shots

taken.

Summary

The use of a laser pointer on a mini C-arm fluoroscopic unit helps to decrease the number of

shots required, the time it takes to accomplish the task set at hand, and decreases the incidence

of blank shots taken.

Paper 34_Image01

Paper 34_Image02

Reference 1: Athwal GS, Bueno Jr RA, Wolfe SW. Radiation exposure in hand surgery: mini versus

stand c-arm. J Hand Surg. 2005; 30:1317.

Reference 2: Singer G. Commentary: radiation exposure in hand surgery. J Hand Surg. 2005;

30:1317.

Reference 3: Singer G, Herron B, Herron D. Exposure from the large c-arm versus the mini c-arm

using hand/wrist and elbow phantoms. J Hand Surg. 2011; 36A:628-631

Reference 4: Badman NL, Rill L, Butkovich B, Arreola M, Vander Griend RA. Radiation exposure

with use of mini c-arm for routine orthpoaedic imaging. J Bone and Joint Surg Am. 2005; 87A: 13-

17.

Reference 5: Singer G. Radiation exposure to the hands from mini c-arm fluoroscopy. J Hand

Surg. 2005; 30A:795-797.

Reference 6: Hendee WR. History, current status, and trends of radiation protection standards.

Med Phys. 1993; 20:1303-1314.

Reference 7: Mastrangelo G, Fedeli U, Fadda E, Giovanazzi A, Scoizzato L, Saia B. Increased

cancer risk among surgeons in an orthopaedic hospital. Occup Med. 2005; 55: 498-500.

Reference 8: Cohen J (1988). Statistical power analysis for the behavioral sciences (2nd ed).

Hillsdale, NJ: Lawrence Earlbaum Associates.

Reference 9: Giodano CJ, Weikert, Watson JT. Lee DH. Hand and body radiation exposure with

the use of mini C-arm fluoroscopy. J Hand Surg Am. 2011; 36 (4) 632-638.

Reference 10: Vosbikian MM, Ilyas AM, Watson DD, Leinberry CF. Radiation exposure to hand

surgeons' hands: a practical comparison of large and mini C-arm fluoroscopy. J Hand Surg Am.

2014; 39: 1805-1809.

Paper 35: Online Patient Ratings of Hand Surgeons Clinical Paper Session 06: Practice Management - Friday, September 11, 11:32 - 11:39 AM

Evaluation/Diagnosis,Treatment,Patient Education,Hand and Wrist

N/A - Not a clinical study

Samir K. Trehan, MD

Christopher DeFrancesco, BS

Joseph Nguyen, BS

Aaron Daluiski, MD

Hypothesis

The primary aim of this study was to evaluate online patient ratings (OPRs) of hand surgeons. We

hypothesized that (1) the majority of hand surgeons would be rated online, (2) surgeons with

greater online presence would have higher OPRs, and (3) positive comments posted on rating

websites would more likely reflect surgeon-dependent factors, while negative comments would

more likely reflect surgeon-independent factors.

Methods

250 US hand surgeons were randomly selected from the ASSH online member directory. We

reviewed surgeon profiles on three of the most commonly visited OPR websites:

HealthGrades.com, Vitals.com and RateMDs.com [1]. Written comments were categorized into 6

groups: professional competence, communication, cost, overall assessment, staff and office

practice [2]. Surgeon-specific data were also collected from Google, Facebook and Twitter.

Independent sample t tests were used to compare OPRs between surgeons who had a website,

Facebook or Twitter page. One way ANOVA was used to analyze the mean number of written

comments between groups. Analyses were conducted with SPSS version 22.0.

Results

250 hand surgeons from 43 states were included in this study. 245 hand surgeons (98%) had at

least one OPR among the three websites. The number and magnitude of OPRs are presented in

Figure 1. When Google searching hand surgeons, the mean number of top 10 results dedicated

to OPR websites was 3.4.

220 hand surgeons (88%) had a professional website. Links to professional Facebook and Twitter

pages were listed on 113 (45%) and 50 (20%) surgeon websites, respectively. Surgeons with an

increased online presence (i.e. website, Facebook or Twitter pages) had significantly higher OPRs

on RateMDs.com (P < 0.01, 0.02, 0.02, respectively) and Vitals.com (P < 0.01, 0.80, 0.08,

respectively).

Positive online comments were found to be more likely associated with surgeon-dependent

factors (i.e. clinical outcomes), while negative comments more likely reflected surgeon-

independent factors (e.g. wait time, office staff, cost) (Figure 2).

Summary Points

• OPR websites are increasingly utilized by patients to inform decision-making, despite

potential concerns regarding validity [3-6].

• OPR websites feature prominently on Google and 98% of hand surgeons are reviewed online.

• This is the first study to evaluate hand surgeon OPRs, assess factors associated with positive

OPRs in orthopedic surgeons, and/or correlate physician online presence with OPRs.

• This is the first study to distinguish between physician-dependent and physician-independent

factors with respect to positive and negative written OPRs, respectively. This finding

highlights a fundamental difference in how patients and physicians assess care quality.

Paper 35_Image01

Paper 35_Image02

Reference 1: Kadry B, Chu LF, Kadry B, Gammas D, Macario A. Analysis of 4999 online physician

ratings indicates that most patients give physicians a favorable rating. J Med Internet Res.

2011;13(4):e95.

Reference 2: Emmert M, Meier F, Heider AK, Durr C, Sander U. What do patients say about their

physicians? an analysis of 3000 narrative comments posted on a german physician rating

website. Health Policy. 2014.

Reference 3: Hanauer DA, Zheng K, Singer DC, Gebremariam A, Davis MM. Public awareness,

perception, and use of online physician rating sites. JAMA. 2014;311(7):734-735.

Reference 4: Bakhsh W, Mesfin A. Online ratings of orthopedic surgeons: Analysis of 2185

reviews. Am J Orthop (Belle Mead NJ). 2014;43(8):359-363.

Reference 5: Rozental TD, George TM, Chacko AT. Social networking among upper extremity

patients. J Hand Surg Am. 2010;35(5):819-823.e1.

Reference 6: Curry E, Li X, Nguyen J, Matzkin E. Prevalence of internet and social media usage in

orthopedic surgery. Orthop Rev (Pavia). 2014;6(3):5483.

Paper 36: A Prospective Comparison of Large vs Mini C-Arm Fluoroscopy

and Resultant Eye Radiation Exposure Clinical Paper Session 06: Practice Management - Friday, September 11, 11:39 - 11:46 AM

Hand and Wrist

Level 2 Evidence

Mark L. Wang, MD, PhD

C. Edward Hoffler, II, MD, PhD

Asif M. Ilyas, MD

William H. Kirkpatrick, MD

Pedro K. Beredjiklian, MD

Charles F. Leinberry, MD

Hypothesis

The WHO recognizes cataract as the most prevalent eye disease in the world, and the association

of eye radiation exposure with the premature development of cataracts has been reported. The

current concept in the pathogenesis of radiation-induced cataract formation suggests elevated

radiation levels lead to the generation of reactive oxygen species and increased DNA damage at

the lens epithelium, resulting in cataractous lens. During routine Hand Surgery, fluoroscopic

radiation exposure is a potential occupational health hazard, given operator proximity and the

relative lack of eye shielding. The purpose of this study is to 1) perform a prospective

comparison of Large versus mini C-Arm Fluoroscopy and resultant eye radiation exposure, and 2)

test the hypothesis that mini C-Arm use yields lower radiation loads, which do not exceed the

critical eye radiation dosages associated with cataractogenesis.

Methods

Over a six month period, eye radiation exposure was measured in a Board-Certified Hand

Surgeon (CFL) utilizing both Large and mini C-Arm fluoroscopy during routine surgical

procedures. Eye dosimeters were secured to surgical loupes at the level of the orbit. Specific

dosimeters were designated for Large and mini-C-Arm use. Accumulated radiation dosage was

analyzed and compared to control badges on a monthly basis, and background exposure was

eliminated (Landauer). For each procedure, radiation output was logged, including the dose

rate, total accumulated dosage, and total exposure time.

Results

During the collection period, 38 cases used Large C-Arm fluoroscopy, and 11 cases used the mini

C-Arm. Common procedures included ORIF distal radius fractures, removal of hardware, closed

reduction and percutaneous pinning of metacarpal and phalangeal fractures. Average monthly

mini C-arm radiation output: dose rate: 4.68±2.09 mGy/sec, total accumulated dosage:

10.58±4.86 mGy, and total exposure time: 38.62±6.83 sec. Average monthly Large C-arm

radiation output: dose rate: 2.94±1.90 mGy/sec, total accumulated dosage: 5.44±4.27 mGy, and

total exposure time: 42.56±7.99 sec (Fig. 1). For both Large and mini C-Arm Fluoroscopy,

average monthly eye radiation exposure was undetectable (<30 mrem). These values were

significantly less than the previously reported maximum radiation dosage to the eye (1,250

mrem/month).

Summary Points

• Routine use of protective lead lining eyewear among Hand surgeons remains rare.

• No significant differences in eye radiation exposure were noted between Large or mini C-Arm

use, suggesting that accumulated eye radiation dosage does not approach previously

reported levels of critical radiation loads.

• Further investigation into C-arm radiation exposure may validate the safety associated with

its routine use during Hand Surgery.

Paper 36_Image01

Paper 37: Care Transfers for Patients with Upper Extremity Trauma:

Does Insurance Matter? Clinical Paper Session 06: Practice Management - Friday, September 11, 11:46 - 11:53 AM

Evaluation/Diagnosis,Treatment,Prognosis/Outcomes,Hand and Wrist,General Principles

Level 2 Evidence

Elham Mahmoudi, PhD

Lee Squitieri, MD, MS

Brianna Maroukis, BA

Kevin C. Chung, MD, MS

Jennifer F. Waljee, MD, MS

Hypothesis

Despite federal legislation, wide variation persists in the referral patterns of upper extremity

trauma patients. We sought to understand the differences in transfer rates for patients with

upper extremity trauma by hospital trauma center designation, and hypothesized that uninsured

and underinsured patients are more likely to be transferred to another facility compared with

privately insured patients.

Methods

Trauma centers are designated by local authorities and verified by the American College of

Surgeons. Using the 2012 National Trauma Data Bank, we examined the probability of a patient

with isolated upper extremity trauma to be transferred from one center to another. We used

multivariable logistic regression to compare risk-adjusted transfer rates for patients with upper

extremity injuries by trauma center designation and clustered variance method to adjust for

intra-hospital correlation.

Results

In 2012, 6,295 adult patients ages 18-64 with isolated upper extremity trauma presented to 477

hospitals. Overall, transfer rates were significantly higher among level III trauma centers (26%)

compared with level I (2%) or level II (11%) trauma centers (P < 0.001). Adjusting for patient and

hospital characteristics, patients with public insurance were more likely to be transferred from

level III trauma centers to another center (OR=1.76, CI: 1.07-2.88) compared with being privately

insured.

Summary Points

• Underinsured patients with upper extremity trauma injuries were more likely than privately

insured patients to be transferred from level III trauma centers.

• Lack of transfer guidelines for upper extremity trauma, scarcity and unbalanced distribution

of hand and plastic surgeons in level III trauma centers and financial considerations of

smaller community hospitals may explain substantial hospital-level variation in upper

extremity trauma care in the U.S.

• Current regulations may not prevent unnecessary patient transfers based on insurance status

among level III trauma centers.

• Policy makers may need to provide compensation or incentive to overcome the financial

burden of providing care for underinsured patients among smaller and less financially secure

hospitals.

Paper 37_Image01

Paper 37_Image02

Paper 38: Time Is Money: An Investigation of ASSH Members' Collections

from Medicare 2012 Database Clinical Paper Session 06: Practice Management - Friday, September 11, 11:53 AM - 12:00 PM

Evaluation/Diagnosis,General Principles

Level 3 Evidence

Patrick M. Kane, MD

Michael Gaspar, MD

Jillian Bonaroti, BS

Grace Honick, BS

Sidney Jacoby, MD

A. Lee Osterman, MD

Hypothesis

No previous study has examined factors within a large population of hand surgeons that may

contribute to variability in Medicare reimbursement. We hypothesize that a significant variation

in Medicare reimbursement exists among hand surgeons based on factors including number of

years in practice and geographic location.

Methods

We queried data from all surgeons with active membership in the American Society for Surgery

of the Hand (ASSH) in 2012. Identifying data for active ASSH members were matched with

provider information from the Medicare database as produced by the United States Centers for

Medicare and Medicaid Services (CMS). Members with inconsistent or missing data between the

two databases were excluded. A total of 1,667 hand surgeons satisfied inclusion. For each

surgeon, we obtained total CMS reimbursement, as well as individual reimbursements for each

service provided. Surgeons were sub-categorized based on the number of years they had been

ASSH members and by their primary state of practice. Average reimbursements were compared

between sub-groups using ANOVA analysis.

Results

Mean and median total CMS reimbursements for all ASSH members were 68,139.63 and

49,236.84, respectively (range 262.73 to 919,128.92). Of the four states with at least 90 hand

surgeons, Florida had the highest reimbursement per surgeon ($131,781.00 per 93 surgeons)

followed by New York ($72,401.80 per 104), Texas ($60,857.34 per 94) and California

($60,345.85 per 162). There was no significant correlation between number of hand surgeons

per capita and mean reimbursement. When reimbursement was compared across groups based

on years as ASSH members, there was a significant difference between all three age groups with

the highest mean reimbursement among the 8-20 year group (mean 74,952.34, median

52,764.02) followed by the over-20-year group (mean 64,352.63, median 45,499.51) and the 0-7

year group (mean 60,501.16, median 46,471.20).

Summary

We believe this to be the first study to examine factors exclusively among a large cohort of U.S.

hand surgeons that may contribute to variability in reimbursement from Medicare.

The non-linear relationship between hand surgeons’ time in practice and their total

reimbursement from Medicare suggests that higher reimbursements parallel surgeons’ prime

period of surgical volume rather than a predilection for or against treating the Medicare

population.

The geographic variations in reimbursement do not correlate with state population or hand

surgeons per capita. This may suggest that these geographic variations are more closely tied to

their respective patient demographics, as opposed to a “supply and demand” model of surgeons,

as suggested in other studies.

Reference 1: Belatti D a, Pugely AJ, Phisitkul P, Amendola A, Callaghan JJ. Total joint arthroplasty:

trends in medicare reimbursement and implant prices. J Arthroplasty. 2014;29(8):1539-1544.

doi:10.1016/j.arth.2014.03.015

Reference 2: Chung KC, Shauver MJ, Yin H. The relationship between ASSH membership and the

treatment of distal radius fracture in the United States Medicare population. J Hand Surg Am.

2011;36(8):1288-1293. doi:10.1016/j.jhsa.2011.05.028.

Reference 3: Fowler JR, Buterbaugh G a. Patient perception of physician reimbursement for

common hand surgical procedures. Orthopedics. 2013;36(9):e1149-e1154.

Reference 4: Gordon CR, Pryor L, Afifi AM, et al. Hand surgery volume and the US economy: is

there a statistical correlation? Ann Plast Surg. 2010;65(5):471-474.

doi:10.1097/SAP.0b013e3181d377ac.

Reference 5: Shauver MJ, Clapham PJ, Chung KC. An economic analysis of outcomes and

complications of treating distal radius fractures in the elderly. J Hand Surg Am.

2011;36(12):1912-1918.e1-e3. doi:10.1016/j.jhsa.2011.09.039.

Reference 6: Tucker J a, Scott CC, Thomas CS, O’Connor MI. Patient perception of Medicare

reimbursement to orthopedic surgeons for THA and TKA. J Arthroplasty. 2013;28(8 Suppl):144-

147. doi:10.1016/j.arth.2013.05.037.

Reference 7: Zhong L, Chung KC, Baser O, Fox D a, Yuce H, Waljee JF. Variation in Rheumatoid

Hand and Wrist Surgery among Medicare Beneficiaries: A Population-based Cohort Study. J

Rheumatol. 2015. doi:10.3899/jrheum.140658.

Reference 8: Belatti D a, Phisitkul P. Trends in orthopedics: an analysis of Medicare claims, 2000-

2010. Orthopedics. 2013;36(3):e366-e372. doi:10.3928/01477447-20130222-28.

Reference 9: Calfee RP, Shah CM, Canham CD, Wong AHW, Gelberman RH, Goldfarb C a. The

influence of insurance status on access to and utilization of a tertiary hand surgery referral

center. J Bone Joint Surg Am. 2012;94(23):2177-2184

Paper 39: A Biomechanical Comparison of Suture Button

Suspensionplasty versus Ligament Reconstruction with Tendon

Interposition for First Carpometacarpal Arthritis Clinical Paper Session 07: CMC Joint - Friday, September 11, 1:45 - 1:52 PM

Surgical Technique,Basic Science,Hand and Wrist

N/A - Not a clinical study

Ian R. Smithson, MD

Andres F. Cabezas, ME

Roger B Gaskins, MD

Thomas K. Stoops, MD

Brandon G. Santoni, PhD

Alfred V. Hess, MD

Contracted Research: Arthrex (Smithson)

Contracted Research: Arthrex (Hess)

Hypothesis

In treating carpometacarpal (CMC) osteoarthritis, it is currently unclear whether ligament

reconstruction and tendon interposition (LRTI) or suture button suspensionplasty is more

effective at restoring native biomechanical range of motion (ROM). Our goal was to test if

suspensionplasty is equivalent to LRTI utilizing a custom CMC joint simulator in an in-vitro

cadaveric model.

Methods

A novel robotic linear actuator simulator system was devised to generate CMC circumduction via

tendon excursion in cadaveric arms under load control. Six tendons (Flexor Pollicis Longus,

Abductor Pollicis Brevis, Abductor Pollicis Longus, Extensor Pollicis Brevis, Extensor Pollicis

Longus, Adductor Pollicis) were sutured to the actuator system at their proximal muscle origins,

utilizing minimal exposure of the tissue to promote hydration and native force vectors of the

tendons. Intrinsic tendon physiologic vectors were maintained by redirecting the attached suture

through eyelets secured to bony landmarks (the scaphoid tubercle and third metacarpal for the

Flexor Pollicis Longus and Adductor Pollicis, respectively). The actuators pulled on individual

tendons to a maximum tensile force of 20N, in addition to controlled releasing of each tendon in

a specific and repeatable sequence that allowed mobilization of the joint. Motion of the joint in

the flexion/extension, abduction/adduction, and circumduction planes was quantified using

opto-electric tracking. The metacarpophalangeal and interphalangeal joint were pinned with a

Kirschner wire while the thumb was fully extended in order to prevent joint articulation distal to

the CMC. Motion was analyzed for seven matched pairs of cadaveric specimens (n = 14), with

each pair receiving a LRTI and suspensionplasty intervention. Circumduction data was calculated

using the closed area of motion data points, projected on the fitted plane using custom Matlab

software. Data was statistically compared between both interventions using non-parametric

analysis (Mann-Whitney U) with significance set at P = 0.05.

Results

Results are presented on Table 1. There was no statistical difference between interventions for

all motion planes (P = 0.277 for all cases). The standard deviation for suspensionplasty

circumduction was much lower, indicating that this particular intervention had a more reliable

outcome.

Summary Points

• CMC circumduction in a cadaveric model was accomplished using tendon excursion and

robotic actuation with force feedback.

• Matched pair-comparison of an LRTI and suspensionplasty found that there was no statistical

difference between the kinematics of both interventions.

• Suture button circumduction motion was found to have a much lower standard deviation,

and thus a more reliable outcome.

Paper 39_Image01

Paper 39_Image02

Reference 1: Koff MF, et al. Joint kinematics after thumb carpometacarpal joint reconstruction:

an in vitro comparison of various constructs. J Hand Surgery, 2007;32(5):688-96.

Reference 2: Smutz WP, et al. Mechanical advantage of the thumb muscles. J Biomechanics,

1998; 31(6):565-70.

Reference 3: Cooney WP et al. Biomechanical analysis of static forces in the thumb during hand

function. J Bone Joint Surgery, 1977 ; 59 (1): 27 -36

Paper 40: A Prospective Assessment of Osteoporosis Using Digital Hand

X-rays Clinical Paper Session 07: CMC Joint - Friday, September 11, 1:52 - 1:59 PM

Evaluation/Diagnosis,Hand and Wrist,Diseases and Disorders,General Principles

Level 2 Evidence

Andrew J. Miller, MD

Christopher M. Jones, MD

Frederic E. Liss, MD

Jack Abboudi, MD

William H. Kirkpatrick, MD

Pedro Beredjiklian, MD

Hypothesis

We hypothesize digital X-rays, similar to the analog counterparts, have poor accuracy and

reliability in determining bone mineral density relative to DEXA scan.

Methods

We prospectively evaluated female patients older than 65 years who presented to our hand

clinic and had digital hand and wrist X-rays as part of their evaluation. Patients who had a

fracture and those who had not had a DEXA scan within the past two years were excluded from

the study. The remaining 34 patients form the basis of this study. Five fellowship-trained hand

surgeons, blinded to DEXA scores, evaluated the x-rays and classified them as osteoporotic,

osteopenic, or normal bone mineral density. The surgeons viewed the images on a standard

PACS terminal and were permitted use of the digital manipulation tools to replicate the common

clinical scenario. Four weeks after the initial assessment, the X-rays were again randomized and a

second assessment was performed. Accuracy relative to DEXA score was tabulated, and

interobserver and intraobserver agreement were also calculated.

Results

The observers performed a total of 340 assessments. The assessments relative to DEXA scores

were correct in 169 of the assessments (49%). Only one x-ray was correctly diagnosed by all

physicians over both assessments while two x-rays were never correctly diagnosed. Analysis of

the incorrect assessments revealed that observers tended to underestimate or overestimate

bone mineral density at an approximately similar rate (49% and 51% respectively). When the

observations were inaccurate, reviewers were off two grades (normal vs. osteoporosis and vice

versa) in 17% of the evaluations and 1 grade (normal vs. osteopenia, osteopenia vs. osteoporosis

and vice versa) in 83% of the evaluations. A mean weighted kappa coefficient of agreement

between observers was 0.29 (range 0.02-0.41) indicating fair agreement. The mean weighted

kappa coefficient for intraobserver agreement between the first and second assessment for all

five physicians was 0.46 (range 0.19-0.78) indicating moderate agreement.

Summary Points

• Abnormally low bone mineral density is a common occurrence in patients treated for upper

extremity disorders.

• There is poor accuracy and only fair agreement in diagnosing osteoporosis compared to

DEXA using visual assessments of digital hand and wrist x-rays.

• Digital hand x-rays have significant limitations as a tool for evaluating bone mineral density.

Reference 1: Olschewski, Eli, et al. "Assessment of osteoporosis using standard radiographs of

the wrist." Journal of Trauma and Acute Care Surgery 51.5 (2001): 912-916.

Paper 41: The Relationship Between the Bony Morphology of First

Metacarpal Base and the Stability of the Thumb Carpometacarpal Joint

in a Normal Female Population Clinical Paper Session 07: CMC Joint - Friday, September 11, 1:59 - 2:06 PM

Evaluation/Diagnosis,Treatment,Prognosis/Outcomes,Hand and Wrist,Diseases and Disorders

Level 1 Evidence

Jeonghwan Kim, MD

Hyun Sik Gong, MD

Jihyeung Kim, MD

Min Bom Kim, MD

Young Ho Lee, MD

Goo Hyun Baek, MD

Hypothesis

Instability of the thumb carpometacarpal joint (CMCJ) is considered as a major cause or an early

stage of CMCJ osteoarthritis. We evaluated the effect of the bony morphology of first

metacarpal base on the stability of thumb CMCJ.

Methods

We evaluated 108 female hands without generalized ligament laxity or CMCJ osteoarthritis. We

evaluated bony morphology of the first metacarpal base using the first metacarpal slope (MS)

measured in true lateral radiographs of the first metacarpal, and evaluated radiologic instability

of the thumb CMCJ using the subluxation ratio (SR) measured in CMCJ stress view radiographs.

After dividing the subjects into 4 subsets according to age or MS, we compared the CMCJ

instability (SR) between those in the upper and lower quartile groups. We also performed

correlation analyses among age, MS, and SR.

Results

The mean age was 57 years. The mean MS was 82.3 degrees (standard deviation (SD), 4.2

degrees; range, 71.2 to 89.8 degrees), and the mean SR was 0.27 (SD, 0.13; range, 0 to 0.57

degrees). There was statistically significant difference in the mean SR between those in the

upper and lower quartiles of MS (0.24 vs. 0.32, P = 0.013), meaning those with smaller MS are

more likely to have radiologic instability of the CMCJ. The mean SR did not differ between those

in the upper and lower quartile of age (P = 0.79). There was no statistically significant

relationship among age, MS, and SR in Pearson’s correlation test.

Summary

This study found that radiologic instability of the thumb CMCJ was larger in women with smaller

metacarpal slopes than in women with larger metacarpal slopes. However, there was no

relationship between the age and the metacarpal slope or radiologic instability of the CMCJ.

These finding suggest that age does not affect the first metacarpal morphology or radiologic

instability of the CMCJ, but that the first metacarpal base morphology may affect the joint’s

radiologic instability, which may be associated with the development and progression of thumb

CMCJ osteoarthritis.

Reference 1: Pellegrini VD, Jr. Osteoarthritis at the base of the thumb. Orthop Clin North Am.

1992;23(1):83-102.

Reference 2: Bettinger PC, Linscheid RL, Berger RA, Cooney WP, An K-N. Trapezial tilt: A

radiographic correlation with advanced trapeziometacarpal joint arthritis. J Hand Surg.

2001;26(4):692-697.

Reference 3: Kurosawa S, Tsuchiya I, Takagishi K. Trapezial-metacarpal joint arthritis:

radiographic correlation between first metacarpal articular tilt and dorsal subluxation. J Hand

Surg. 2013;38(2):302-308.

Reference 4: Halilaj E, Moore DC, Laidlaw DH, Got CJ, Weiss AP, Ladd AL, Crisco JJ. The

morphology of the thumb carpometacarpal joint does not differ between men and women, but

changes with aging and early osteoarthritis. J Biomech. 2014;27(11):2709-2714.

Reference 5: Jónsson H, Elíasson GJ, Jónsson A, Eiríksdóttir G, Sigurdsson S, Aspelund T, Harris

TB, Gudnason V. High hand joint mobility is associated with radiological CMC1 osteoarthritis: the

AGES-Reykjavik study. Osteoarthritis Cartilage. 2009;17(5):592-595.

Paper 42: Suture Suspension Arthroplasty for Thumb Carpometacarpal

Arthritis Reconstruction: Long-term Outcome Clinical Paper Session 07: CMC Joint - Friday, September 11, 2:06 - 2:13 PM

Treatment,Surgical Technique,Hand and Wrist

Level 4 Evidence

Jeanne L. DelSignore, MD

Kimberly Lynn Zambito-Accardi, MD

Sarah E. Ballatori, MBS

Hypothesis

A simple reconstructive method for treating advanced arthritis of the thumb carpometacarpal

(CMC) joint with suture suspension arthroplasty (SSA) is a reliable, low morbidity procedure,

providing a simpler alternative with similar long-term outcomes, compared to trapeziectomy

procedures, with or without ligament reconstruction.

Methods

SSA technique for thumb CMC arthritis reconstruction consists of trapeziectomy via a single volar

incision and a four-strand intra-articular suture (0 gauge non-absorbable) suspension sling,

creating a “hammock” between the distal-most insertions of the abductor pollicis longus and the

flexor carpi radialis. This construct is pulled firmly, tethering the base of the thumb towards the

base of the index metacarpal, correcting the subluxation deformity and maintaining arthroplasty

space. All procedures were performed by the senior author, averaging 22 minutes operative

time, followed by 14 days of post-operative immobilization, then short opponens splinting for

four weeks and rehabilitation protocol (1), progressing to unrestricted use by 12 weeks. Long-

term evaluation of 117 thumbs (average 89.4 months) with strength measurement and

QuickDASH questionnaire, were analyzed with a paired t test. Final Xrays were obtained.

Results

117 out of 153 thumbs in 110patients (76% recall) were available for long-term follow up

averaging 89.4 months (80-104 months). 96 patients were female, 21 male. Statistically

significant (P < 0.05) improvement in pain relief, patient satisfaction, grip, key and tip pinch

strength, and functional improvement was noted in the majority of patients. Average

QuickDASH score (0.3) at final follow up indicated good to excellent satisfaction and functional

use in the majority of patients. Xray evidence of subsidence averaged 30% (0-90%). One patient

(0.8%) required revision surgery. Flexor carpi radialis rupture occurred in 7 (6%) thumbs after a

sudden stress activity around 4-6 weeks post op, requiring no additional treatment.

Summary Points

• Suture suspension arthroplasty for thumb CMC arthritis reconstruction is a simple, reliable

method. Patient advantages include lower morbidity as a result of a single incision without

tendon sacrificing, and avoidance of potential complications related to multiple incisions,

tendon harvesting, drill hole formation, hardware implantation, pin fixation, or prolonged

immobilization. Most patients are able to resume normal, unrestricted use at 12 weeks post-

operative.

• This method is cost-effective, utilizing less operative time, and does not require additional

cost of implants or anchors.

• Long-term results of suture suspension arthroplasty show similar outcomes as described with

other methods of trapeziectomy, with or without ligament reconstruction (2), resulting in a

very high degree of patient satisfaction, with a simple, minimally invasive, and cost-effective

option.

Paper 42_Image01

Paper 42_Image02

Reference 1: DelSignore JL, Accardi KZ. Suture Suspension Arthroplasty technique for basal joint

arthritis reconstruction. Tech Hand Upper Extrem Surg. 2009 Dec;13(4):166-72

Reference 2: Vermeulen, GM, Slijper, H, Feitz, R, Hovius SE, Moojen TM, Selles RW. Surgical

Management of primary thumb carpometacarpal osteoarthritis: a systematic review. J Hand

Surg(Am). 2011; 36A: 157-169

Paper 43: The Effect of Medical Therapy on Surgery for Rheumatoid

Deformities of the Upper Extremity Clinical Paper Session 07: CMC Joint - Friday, September 11, 2:13 - 2:20 PM

Treatment,Hand and Wrist,Elbow and Forearm,Diseases and Disorders

Level 3 Evidence

Jennifer F. Waljee, MD, MS

Lin Zhong, MD, MPH

Onur Baser, PhD

David A. Fox, MD

Kevin C. Chung, MD, MS

Elham Mahmoudi, PhD

Hypothesis

The medical management of rheumatoid arthritis has dramatically changed with the approval of

biologic disease-modifying anti-rheumatic drugs (DMARDs). Today, early initiation of DMARDs is

considered standard of care and a quality indicator by many professional societies. Among

rheumatologists, surgical intervention is often considered a treatment failure. In contrast,

surgeons fear that surgical referrals are delayed, potentially losing the opportunity to achieve a

functional and aesthetically pleasing reconstruction for advanced deformities. This study

examines the effect DMARDs (biologic and non-biologic) on the rates of RA-related procedures

among older adults. We hypothesized that rates of surgery are lower among patients who

receive biologic DMARDs.

Methods

We examined all fee-for-service claims drawn from the Medicare Beneficiary Summary files

between 2006 to 2012, including Part A, Part B, and Part D prescription drug events. We used

National Drug Codes to identify the receipt of biologic and non-biologic DMARDs. We applied

Current Procedural Terminology and ICD-9 codes to identify RA-related upper extremity

procedures for the shoulder, elbow, wrist and hand. We used hierarchical logistic regression to

examine the effect of patient-level factors, including the receipt of DMARDs and annual number

of rheumatologist visits, and regional factors, including provider density, on rates of upper

extremity reconstruction for RA (defined as number of RA patients who received the surgery per

10,000 RA patients per year).

Results

In this cohort of 250,453 Medicare Beneficiaries with RA, 2.4% underwent upper extremity

procedures, with wide variation across hospital referral regions (0.1% - 2.57%; national average

rate=0.9%). (Figure 1) After controlling for other patient and regional-level factors, patients who

received biologic DMARDs by infusion (OR=1.63; 95%CI: 1.39-1.93) or injection (OR=1.66; 95%CI:

1.51-1.83) were more likely to undergo upper extremity reconstruction compared with patients

who received non-biologic DMARDs or no DMARD therapy (Table 1). Additionally, patients who

visited rheumatologists more than 3 times per year were more likely and were maintained on

biologics were twice as likely to undergo surgery compared with patients maintained on non-

biologic DMARDs or without DMARDs and fewer rheumatologist visits (OR=2.12; 95%CI: 2.01-

2.33).

Summary Points

• Among older patients, biologic DMARDs do not reduce the need for upper extremity

reconstruction.

• Given the substantial cost and immunosuppression risk associated with biologic DMARDs,

comparative evidence is needed to discern which patients will derive benefit from medical or

surgical intervention, and surgeons should continue to play an integral role in the

multidisciplinary care of RA patients.

Paper 43_Image01

Paper 43_Image02

Paper 44: Outcomes of Acute versus Subacute Scapholunate Ligament

Repair Clinical Paper Session 08: Schaphoid Lunate - Saturday, September 12, 8:45 - 8:52 AM

Evaluation/Diagnosis,Treatment,Prognosis/Outcomes,Hand and Wrist

Level 3 Evidence

Raymond Chen, BS

Ryan Patrick Calfee, MD

Jeffrey Stepan, MD, MSc

Daniel A. Osei, MD, MSc

Hypothesis

It is currently unknown whether time from injury affects outcomes following repair of dorsal

scapholunate ligament (SLL) tears. We tested the null hypothesis that the outcomes of SLL repair

are similar when performed within 6 weeks of injury (acute repair) versus when repaired from 6

to 12 weeks following injury (subacute repair).

Methods

This case-control study examined 22 patients (12 acute repair, 10 sub-acute repair) who

underwent dorsal SLL repair for isolated complete tears of the SLL, with or without

supplementary capsulodesis. Patients who underwent SLL repair for complete rupture of the

dorsal SLL between 1996 and 2012 were identified from an electronic billing database.

Demographic data (age, sex, BMI, occupation, tobacco use) was recorded and radiographic

measurements (SL angle and SL gap) were determined from preoperative radiographs. All

patients returned to clinic for a study-related visit including radiographic examination of the

injured wrist (PA, lateral, supinated PA grip view), physical examination (wrist range of motion,

strength testing) and standardized questionnaires (Michigan Hand Questionnaire, VAS-function

and pain, SF-12). Analyses were performed on all categorical and continuous data to compare

acute and subacute repair groups (P < 0.05).

Results

The median length of follow-up for the acute and sub-acute groups were 5.5 and 6.1 years,

respectively (Table 1). There was no significant difference in any of the variables between the

two groups. The groups were near identical with regard to final SL angle (acute: 66°, subacute:

65°), final SL gap (3.0 mm, 2.9 mm), and proportion of cases that progressed to scapholunate-

advanced collapse (2/12, 2/10). Patient-rated outcomes were not different between patient

groups (Table 2). Wrist motion (P = 0.20) and forearm motion (P = 0.21) were also comparable

for the acute and subacute repairs. Both acute and subacute repairs demonstrated well-

preserved grip strength (98% of unaffected versus 90%) (P = 0.29).

Summary Points

• At a median follow-up of 5.5 and 6.1 years, respectively, no statistically significant or clinically

relevant differences were found when comparing radiographic findings, patient rated

outcomes and wrist motion following acute and subacute SLL repair.

• Acute and subacute repairs of the SLL demonstrate similar rates of progression to end-stage

arthritis.

• Whether treated within 6 weeks or 12 weeks of injury, SLL repair may produce a similar

outcome when reparable ligamentous tissue exists.

Paper 44_Image01

Paper 44_Image02

Reference 1: Lavernia CJ, Cohen MS, Taleisnik J. Treatment of scapholunate dissociation by

ligamentous repair and capsulodesis. J Hand Surg Am. 1992;17:354–359.

Reference 2: Pomerance J. Outcome after repair of the scapholunate interosseous ligament and

dorsal capsulodesis for dynamic scapholunate instability due to trauma. J Hand Surg Am.

2006;31:1380–1386

Reference 3: Gajendran VK, Peterson B, Slater RR, Jr, et al. Long-term outcomes of dorsal

intercarpal ligament capsulodesis for chronic scapholunate dissociation. J Hand Surg Am.

2007;32:1323–1333.

Reference 4: Rohman EM, Agel J, Putnam MD, Adams JE. Scapholunate Interosseous Ligament

Injuries: A Retrospective Review of Treatment and Outcomes in 82 Wrists. J Hand Surg Am.

2014;39(10):2020-2026.

Paper 45: Reconstruction of the Scapholunate Interosseous Ligament

Using Bone-capitohamate Ligament-bone Clinical Paper Session 08: Schaphoid Lunate - Saturday, September 12, 8:52 - 8:59 AM

Treatment,Surgical Technique,Hand and Wrist

Level 4 Evidence

Toshiyasu Nakamura, MD, PhD

Yukihiko Obara, MD

Takuji Iwamoto, MD, PhD

Kensuke Ochi, MD,PhD

Kazuki Sato, MD, PhD

Hypothesis

The biomechanical property of the capitohamate (CH) ligament is equivalent to the SL ligament.

We reconstructed torn SL ligament using the bone-CH ligament-bone substitute.

Methods

Indications of this procedure are unrepairable complete disruption of the SL ligament (Fig 1A).

Scapholunate joint was reduced by manual or joystick maneuver, then temporary fixed with 2 K-

wires and the scaphocapitate interval was fixed with 1-2 K-wires. The dorsal portion of the SL

ligament was refreshed and the 5 mm×10 mm×5 mm (width, length, depth) cubic gutter was

made at the exact position of the dorsal portion of the SL ligament by a chisel. Proximal half of

the CH ligament with capitate bone and hamate bone (bone-CH ligament-bone) was harvested

as same size as the gutter made at the SL ligament, then grafted, fixed firmly with 1.2 mm

diameter titanium screws to the scaphoid and lunate to reconstruct the SL ligament (Fig 1B and

C). Since 2008, 15 wrists of 14 patients with an age of 38 years (range 25 to 75) underwent this

procedure with at least 1-year follow. There were 14 male and 1 female, 11 rights, 2 left and 1

bilateral wrists. Thirteen wrists indicated dissociation of SL joint gap more than 3 mm and two

indicated complete SL ligament disruption with severe DISI deformity. K-wires were removed 8

weeks after the surgery and active ROM exercise began. We evaluated pain (VAS), wrist motion

(angle), radiographic characteristics, such as SL gap (mm), SL angle, and modified Mayo wrist

score.

Results

VAS was improved to postoperative 77 from preoperative 12. We obtained average wrist

extension/flexion of 74/60 degrees. There was no ossification of reconstructed SL. SL gap was

improved average 4.8 mm to 2.1 mm and SL angle was changed from 67 to 55 degrees (Fig. 2).

Modified Mayo wrist score was improved to 82 points postoperatively from preoperative 47.

Clinical outcome was 8 excellent, 6 good and 1 fair with modified Mayo-wrist score.

Summary

We obtained excellent radiographic and clinical results of complete disruption of the SL ligament

by reconstruction using bone-CH ligament-bone substitute.

Paper 45_Image01

Paper 45_Image02

Reference 1: Cuenod P et al. J Hand Surg Am 2002; 27: 985-90.

Reference 2: Ritt MJ et al. J Hand Surg Br 1996; 21:451-4.

Reference 3: Ritt MJ et al. J Hand Surg Am 1996; 21:1022-8.

Reference 4: Soong M et al. J Hand Surg Am 2013; 38: 504-8.

Reference 5: Weiss AP. J Hand Surg Am 1998; 23: 205-15.

Reference 6: Garcia-Elias M et al. J Hand Surg Am 2006; 31: 125-34.

Paper 46: Biomechanical Analysis of Articulating Intercarpal Screw

Fixation After Scapholunate Ligament Division Clinical Paper Session 08: Schaphoid Lunate - Saturday, September 12, 8:59 - 9:06 AM

Anatomy,Basic Science,Hand and Wrist

N/A - Not a clinical study

Matthew E. Hiro, MD

Muturi Muriuki, PhD

Corey J. Schiffman, BS

Robert M. Havey, MS

Leonard Voronov, MD, PhD

Randy R. Bindra, MD, FRCS

Consulting Fee: Acumed, Integra (Binda)

Hypothesis

A biomechanical study was performed to determine the efficacy of an articulating intercarpal

screw for restoring normal scapholunate kinematics following sectioning of scapholunate

interosseous ligament (SLIL). We hypothesized that the screw would resist scapholunate (SL)

gapping while permitting normal rotational motion of the scaphoid and lunate during simulated

wrist motion in a cadaver model.

Methods

Optoelectronic motion sensors were placed on the scaphoid, lunate, distal radius and 3rd

metacarpal of 10 young cadaver wrists. The wrist tendons were loaded with 100N. Cyclic testing

of the wrist was performed in flexion/extension (FE), radial/ulnar deviation (RUD) and dart-

throwing motion (DTM). Kinematic data was analyzed to determine differential movement of

the scaphoid and lunate with 1) SLIL intact, 2) after sectioning the SLIL, 3) after sectioning the

SLIL and cycling the wrist through 1000 cycles of flexion/extension, and 4) after SL reduction and

placement of the articulating intercarpal screw. Scaphoid and lunate motion for each testing

state were compared using repeated measures ANOVA with statistical significance set at P <

0.05.

Results

After cutting the SLIL, changes of scaphoid and lunate motion were observed. During FE the

scaphoid moved into radial deviation (P = 0.02) and the lunate moved into flexion (P = 0.01).

During wrist RUD, the scaphoid moved into ulnar deviation (P = 0.016) and the lunate moved

into extension (P = 0.012). During DTM, the scaphoid moved into ulnar deviation (P = 0.03), and

the lunate moved into extension (P = 0.04) and ulnar deviation (P = 0.018).

After cycling the wrist through 1000 cycles, further changes in motion were observed. During FE,

the scaphoid moved into further radial deviation (P = 0.02) and during DTM the scaphoid and

lunate both moved into further ulnar deviation (P = 0.046 and 0.042 respectively).

Placement of intercarpal screw across the SL joint corrected the motion changes that were

observed after SLIL sectioning and motion through 1000 cycles. There was no significant

difference in the motion of the scaphoid or lunate during FE, RUD, DTM with the screw in place

compared to motion with an intact ligament.

Transecting the SLIL and cycling the wrist through 1000 cycles of FE did not produce an SL gap

during FE (P = 0.364), RUD (P = 0.290), or DTM (P = 0.524).

Summary Points

• Sectioning the SLIL and repetitive cycling of the wrist created significant changes in motion of

the scaphoid and the lunate during wrist range of motion.

• Placement of an articulating intercarpal screw corrected the changes in scaphoid and lunate

motion while permitting independent intercarpal motion.

Paper 46_Image01

Paper 46_Image02

Reference 1: Kitay A, Wolfe SW. Scapholunate instability: current concepts in diagnosis and

management. The Journal of hand surgery. Oct 2012;37(10):2175-2196.

Reference 2: Short WH, Werner FW, Green JK, Masaoka S. Biomechanical evaluation of the

ligamentous stabilizers of the scaphoid and lunate: Part II. The Journal of hand surgery. Jan

2005;30(1):24-34.

Reference 3: Herbert TJ. Acute rotary dislocation of the scaphoid: a new technique of repair

using Herbert screw fixation across the scapho-lunate joint. World journal of surgery. Jul-Aug

1991;15(4):463-469.

Reference 4: Filan SL, Herbert TJ. HERBERT SCREW FIXATION FOR THE TREATMENT OF

SCAPHOLUNATE LIGAMENT RUPTURE. Hand Surgery. 1998;03(01):47-55.

Reference 5: Cognet JM, Levadoux M, Martinache X. The use of screws in the treatment of

scapholunate instability. The Journal of hand surgery, European volume. Oct 2011;36(8):690-

693.

Reference 6: Opreanu RC, Baulch M, Katranji A. Reduction and maintenance of scapholunate

dissociation using the TwinFix screw. Eplasty. 2009;9:e7.

Paper 47: Wrist Biomechanics In Yoga Clinical Paper Session 08: Schaphoid Lunate - Saturday, September 12, 9:06 - 9:13 AM

Patient Education,Hand and Wrist

Level 4 Evidence

Christopher Klifto, MD

Anthony Sapienza, MD

Smita Rao, PT, PhD

Martin Posner, MD

Hypothesis

In a survey of yoga professionals, the wrist accounted for 11.5% of reported injuries. The

purpose of this study was to evaluate how modifications may decrease strain and prevent injury

in three common yoga positions- downward dog (DD), chaturanga (Ch), and side plank (SP).

Methods

The participants were 43 healthy volunteers, 23 females and 20 males. Mean age was 27 years.

Peak pressure, maximum force and load distribution were measured in standard and modified

positions in DD, Ch, and SP using a pressure-measuring device. Wrist extension was also

measured in these same positions. Modification to the DD position consisted of placing the

palms on an elevated platform. Ch and SP were modified by permitting the participants to have

their knees on the floor rather than balance on their toes. Modified positions shifted the center

of gravity further toward the lower torso, decreasing both load forces on the wrist and degree of

wrist extension. A two-way ANOVA was performed to assess the effect of standard and modified

positions on peak pressures.

Results

Peak pressures decreased from 379.4 to 308 kPa and 483.1 to 401.9 kPa in the modified Ch and

SP positions, respectively (P < 0.001). The modifications in DD did not significantly affect the

peak pressure (P = 0.713). Similarly, maximum force was decreased in modified Ch and SP

positions, with Ch decreasing from 290.0 to 244.2 N and SP from 433.0 and 360.1 N (P < . 001).

The modifications in DD did not significantly affect maximum force (P = 0.518). Analysis of load

distribution mapping showed that peak pressure and maximum force were highest in the thenar

area in the palms in DD and SP positions. In Ch, peak pressure and maximum force were highest

in the hypothenar area. The angle of wrist extension increased in Ch and SP from 70.3 to 70.7

and 82.3 and 83.3. Wrist extension decreased in the DD position from 57.5 to 52.0.

Summary Points

• Modified SP and CH yoga positions resulted in a significant decrease in peak pressure and

maximum forces by shifting the center of gravity toward the lower torso.

• Modifications to the DD pose resulted in a significant decrease in wrist extension angle

potentially adding protective benefits.

Paper 47_Image01

Paper 47_Image02

Reference 1: Fishman LM, Saltonstall E, S G. Yoga therapy in practice, understanding and

preventing yoga injuries. International Journal of Yoga Therapy. (18):1-10

Reference 2: Suprak DN, Dawes J, MD S. The effect of position on the percentage of body mass

supported during traditional and modified push-up variants. J Strength Cond Res. 2011

Feb;25(2):497-503

Paper 48: Buying Time: Long-term Results of Wrist Denervation and

Need for Revision Surgery Clinical Paper Session 08: Schaphoid Lunate - Saturday, September 12, 9:13 - 9:20 AM

Evaluation/Diagnosis,Treatment,Prognosis/Outcomes,Hand and Wrist,Nerve,Diseases and

Disorders

Level 4 Evidence

Maureen A. O'Shaughnessy, MD

Sanjeev Kakar, MD, MBA

Richard Berger, MD

Royalty: Skeletal Dynamics (Kakar)

Consulting Fee: Arthrex, Skeletal Dynamics (Kakar)

Hypothesis

Wrist denervation has been shown to be a good option for patients with chronic wrist pain

related to articular degeneration or chronic instability. Removal of the sensory innervation to the

wrist joint provides relief of pain; however denervation does not address the underlying

pathology. Patients continue to undergo degenerative changes and may need revision

procedures. This study reviews the 20 year long term outcomes of patients treated with partial

wrist (anterior and posterior interosseous nerve) denervation focusing on need for and time to

salvage procedure.

Methods

We conducted an IRB approved retrospective study over a 20 year period of all patients

undergoing wrist denervation by the lead authors between 1994 and 2014. At latest follow up,

data including range of motion, grip strength, radiographic degeneration and need for revision

surgery were recorded.

Results

The series includes 106 patients (68 male, 38 female) with an average age at surgery of 52 (range

14 to 80). Average follow up was 78 months (range 3 to 212). The main diagnoses in this series

were SLAC degenerative arthritis (43%) and radiocarpal arthritis (40%). Average flexion to

extension arc was 93 degrees on the affected extremity (76% of the contralateral) and average

grip strength was 83% of unaffected extremity.

Seventy one percent of patients (75/106) had satisfactory outcomes and did not require revision

procedures at average follow up of 78 months (range 3 to 212). Twenty nine percent (31/106) of

patients underwent revision surgery including four corner fusion (11), total wrist fusion (6),

proximal row carpectomy (4), radioscapholunate fusion (3), total wrist arthroplasty (1), Sauve-

Kapandji (1), ulnar shortening procedure (1), Darrach (1), radial styloidectomy (1) and ulnar head

hemiresection interposition arthroplasty (1). Time to salvage surgery was on average 25 months

after denervation (range 2 to 165).

Summary Points

• Partial wrist denervation is a reliable motion preserving procedure for patients with chronic

wrist pain. In this series, 71% of patients experienced pain relief and did not require further

salvage procedures at an average of 78 months of follow up.

• Twenty nine percent of patients ultimately underwent salvage procedure. On average, the

patients experienced pain relief for 25 months (range 2 to 165) prior to ultimately

undergoing a salvage operation.

• The significance of these results better enable surgeons to give time estimates and

expectations regarding pain control following wrist denervation in the patient with chronic

wrist pain.

Paper 48_Image01

Paper 48_Image02

Paper 49: Hydrophilic Polymers Immediately Restore Axonal Continuity

as Assessed by Retrograde Tracer Clinical Paper Session 09: Basic Nerve - Saturday, September 12, 8:45 - 8:52 AM

Basic Science,Hand and Wrist,Elbow and Forearm,Shoulder and Arm,Nerve

N/A - Not a clinical study

David C. Riley, BS

Hypothesis

Polyethylene glycol (PEG) immediately restores axonal continuity using an in-vivo rat sciatic

nerve injury model.

Methods

Female Spraque-Dawley rats were anesthetized with inhaled 2% isoflurane. The left sciatic nerve

was exposed by making a clean 25 mm transection through the biceps femoris. Pre-injury

compound action potentials (CAPs) were recorded. The nerve was transected and repaired using

standard microsurgical techniques. Polyethylene glycol (PEG) was delivered into the neurorraphy

using a novel application device. Post-repair compound action potentials were recorded

immediately following repair. The sciatic nerve was then cut 4-5 mm distal the repair site. The

proximal stump was exposed to 5 µL of 2% fast blue tracer for 1 hour. The biceps femoris was

sutured using horizontal mattress sutures and the skin re-approximated using a running

subcuticular suture. Animals were sacrificed on post-operative day 7 by perfusion fixation. Thirty

evenly spaced cross-sections of the lumbar spinal cord were taken from L2-L4. Experimental

animals were treated with Plasmalyte A, 1% methylene blue, 50% by weight solution of

polyethylene glycol (PEG), and Lactated Ringers; control animals did not receive PEG.

Results

We found that PEG rapidly restores axonal continuity as assessed by compound action potential

conduction and intracellular retrograde tracer across the injury site. In our study, we found that

83.33% (5/6) of PEG fused animals had restored CAP function immediately following repair while

0% (0/6) of control animals had any signs of CAP recovery. Additionally, PEG treated animals

were associated with a statistically significant increase in the number of fluorescently labeled

motor neurons from L2-L4 of the spinal cord compared to negative control animals. Finally, we

found a significant decrease in the number of fluorescently labeled cells for PEG vs positive

control which indicates that not all axons are being fused in PEG treated animals.

Summary Points

• We believe PEG fusion techniques may drastically improve the long-term recovery of more

proximal nerve injuries where poor outcomes are more common.

• The ability to record through conduction action potentials following repair in PEG treated

animals suggest that axonal continuity is immediately restored following application of PEG.

• The increased number of fluorescently labeled motor neurons in PEG vs negative control

animals suggests that restored axonal continuity following PEG fusions is maintained for days

following surgery.

• The decreased number of fluorescently labeled motor neurons in PEG vs positive control

animals suggests that the efficacy of PEG fusion procedures could be increased.

Paper 49_Image01

Paper 49_Image02

Reference 1: Riley D.C., Bittner G.D., Mikesh M.A., Cardwell N.L., Pollins A.C., Ghergherehchi C.L,

Sunkesula S.R., Ha T.N., Hall B.T., Poon A.P.,Pyarali M, Boyer R.B., Mazal A.T., Munoz N, Trevino

R.C., Schallert T., ThayerW.P. PEG-fused Allografts Produce Rapid Behavioral Recovery after

Ablating Sciatic Nerve Segments. Journal of Neuroscience Research. 2014

Reference 2: Novikova, L., L. Novikov, and J.O. Kellerth, Persistent neuronal labeling by

retrograde fluorescent tracers: a comparison between Fast Blue, Fluoro-Gold and various

dextran conjugates. J Neurosci Methods, 1997. 74(1): p. 9-15.

Reference 3: Spaeth, C.S., et al., Cellular mechanisms of plasmalemmal sealing and axonal repair

by polyethylene glycol and methylene blue. Journal of neuroscience research, 2012. 90(5): p.

955-66.

Reference 4: Bittner, G.D., Keating, C. P., Kane, J. R., Britt, J. M., Spaeth, C. S., Fan, J. D., Zuzek, A.,

Wilcott, R. W., Thayer, W. P., Winograd, J. M., Gonzalez-Lima, F., Schallert, T., Rapid, effective,

and long-lasting behavioral recovery produced by microsutures, methylene blue, and

polyethylene glycol after completely cutting rat sciatic nerves. Journal of neuroscience research,

2012. 90(5): p. 967-80.

Paper 50: Motor Nerve Regeneration Using an Optimized Nerve Allograft

in a Rat Model - An In vitro and In vivo Analysis Clinical Paper Session 09: Basic Nerve - Saturday, September 12, 8:52 - 8:59 AM

Treatment,Basic Science,Nerve

N/A - Not a clinical study

Caroline A. Hundepool, MD

Liselotte F. Bulstra, MD

Dimitra Kotsougiani, MD

Steven Hovius, MD, PhD

Allen Bishop, MD

Alexander Y. Shin, MD

Hypothesis

In previous animal studies commercially available processed nerve allografts have been inferior

to autograft nerve for motor recovery. The goal of this study is to create an optimized nerve

allograft (in vitro) and subsequently challenge it to the nerve autograft regarding motor nerve

regeneration (in vivo).

Methods

For the in vitro experiment 50 rat nerves were processed. Based on previous research, standard

decellularization protocols were used with different modifications and the addition of an highly

potent enzymatic step Elastase. Subsequently, the nerve segments were stored at either 4 or -

80°C for the duration of two weeks. Both processed and fresh control nerves were analyzed with

confocal microscopy using immunohistochemical stainings on the basal lamina (laminin ?-1),

Schwann cells (S100 protein) and immunogenicity (major histocompatibility complex class I).

Morphology of the ultrastructure and amount of cellular debris was analyzed on cross sections

of the nerves stained with toluidine blue and analyzed under electronmicroscopy. The superior

method of this in vitro project was used for implementation in vivo to test the motor functional

outcome of the nerve allograft in a rat. In the in vivo project, 60 rats sustained an 1 cm sciatic

nerve reconstruction with either autograft(I), non-frozen allograft(II), or frozen allograft (III).

Twelve and 16 weeks post-operatively motor functional outcome was determined with ankle

angle, electrophysiology, isometric tetanic force, muscle mass and histomorphometry.

Results

Nerve ultrastructure was preserved with all decellularization protocols. Storage at -80°C severely

altered nerve ultrastructure after any decellularization method. Elastase was found to

significantly reduce the immunogenicity (MHC-I) and the amount of Schwann cells (S100), while

maintaining good structural properties. When tested in vivo, significant differences were found

between the three groups with regard to motor function at both 12 and 16 weeks. Cold storage

of the processed allograft shows better results than the frozen stored allograft and reached the

level of the nerve autograft.

Summary Points

• Elastase, when added to nerve processing, reduced immunogenicity, diminished cellular

debris and removed Schwann cells better while maintaining ultrastructure.

• Storage at -80°C after the decellularization process heavily damaged nerve ultrastructure

compared to cold storage.

• The in vivo study, the optimized processed nerve allograft showed comparable to the golden

standard, the nerve autograft, at both 12 and 16 weeks postoperatively.

Paper 51: Laminin Rich and Immunologically Neutral Epineural Sheath

Conduit Supported with Bone Marrow Stromal Cells to Restore Long

Nerve Defects Clinical Paper Session 09: Basic Nerve - Saturday, September 12, 8:59 - 9:06 AM

Basic Science,Nerve

N/A - Not a clinical study

Maria Siemionow, MD, PhD, DSc

Maria Madajka, PhD

Safak Uygur, MD

Can Oztürk, MD

Jacek Szopinski, MD, PhD

Joanna Cwykiel, MS

Hypothesis

Several alternative approaches to autologous nerve grafting have been developed. Nevertheless,

current regenerative medicine-based techniques are severely limited and do not provide

satisfactory results. Currently used allograft conduits require immunosuppression and

demonstrate poor motor recovery. The aim of this study was to test the feasibility of Epineural

Sheath Conduit (ESC) Supported with Bone Marrow-derived Stromal Cells (BMSC) on restoration

of 6 cm long nerve defect in sheep model.

Methods

Sheep model was used due to morphometrical resemblance of sheep peripheral nerves to

human nerves and ability for long nerve defects creation. ESC was created from the median

sheep nerve by removing all fascicles. Sheep BMSC were purified by the buffy coat method and

cultured for 14 days. Next, cells were fluorescently labeled with PKH-26 dye and injected into the

empty ESC (70-80 x 106 cells). Restoration of 6cm median nerve defect was performed in 6

experimental groups (n = 6): Group 1: autograft controls, Group 2: autogenic ESC filled with

saline control, Group 3: autogenic ESC filled with autogenic BMSC, and Group 4: Allogenic ESC

filled with autogenic BMSC. At 3 and 6 months follow up, nerve conduction velocity (NCV) and

somatosensory evoked potential (SSEP) measurements and nerve samples were collected for

immunohistochemistry.

Results

All animals recovered from the surgery without complications. The shape and integrity of the

conduit was preserved in all groups. The NCV and SSEP assessments confirmed presence of

neurosensory responses in both saline and BMSC-filled conduit groups. Smaller diameter

fascicles were observed in BMSC filled conduits (Group 3 and 4) in comparison to saline filled

conduit (Group 2). Immunofluorescent staining at 3 months in saline filled conduit showed

presence of fascicle-like structure in the proximal, middle, and distal parts of the conduit.

Toluidine blue staining revealed the presence of myelinated axons in all of the groups. Migratory

potential of BMSCs in lymphoid organs was analyzed by fluorescent staining. No presence of

BMSCs was detected in liver, lymph nodes, spleen and thymus 6 months after SCEC

transplantation.

Summary

The feasibility of creation and application of ESC to restore 6 cm nerve defects in sheep model

was confirmed. Immunohistochemical and neurosensory assessment confirmed regenerative

properties of the ESC. ESC is a novel promising bio-construct of naturally occurring epineural

sheath and BMSCs and has potential for successful regeneration of long nerve defects. In the

future it can be included into the armamentarium of regenerative medicine.

Paper 52: Neuroprotective Potential of Erythropoietin as an Adjuvant to

Decompression for Chronic Compression Neuropathy Clinical Paper Session 09: Basic Nerve - Saturday, September 12, 9:06 - 9:13 AM

Treatment,Therapy/Rehabilitation,Prognosis/Outcomes,Hand and Wrist,Nerve

Level 1 Evidence

John C. Elfar, MD

Erica Lash, BA

Ron M.G. Menorca, BS

Ranjan Gupta, MD, PhD

Mark Noble, PhD

David Speach, MD

Hypothesis

We hypothesized that Erythropoietin (EPO) would accelerate neuronal recovery after surgical

decompression in a murine model of chronic nerve compression. Moreover, we hypothesized

that the positive effect of EPO treatment would correlate to the myelination status of the nerve,

in a model where demyelination is a direct result of compression injury.

Methods

A 3-mm biologically-inert tube was used to induce compression neuropathy for 10 weeks in mice

which then underwent surgical decompression. One group of mice (n=5) received erythropoietin

throughout the experiment (EPO/EPO), while a second group received saline throughout the

experiment (saline/saline), and a third group received saline during compression and

erythropoietin after decompression (saline/EPO) and a control group underwent sham surgery.

Electrophysiological and immunohistochemical evaluations were utilized to assess the recovery

of the injured nerves. Nerve conduction velocity (NCV) and myelin density were compared within

the experimental sham surgery control groups using appropriate parametric statistics (Student t-

test and one-way ANOVA).

Results

During compression, electrodiagnostic evaluation revealed a progressive decline in NCV. This

decline was attenuated in the group receiving EPO. In the saline-treated compression groups,

the NCV progressively decreased from a baseline of 50.82 ± 3.34 m/s to 34.46 ± 3.1 m/s at 10

weeks of compression (P = 0.02). In the EPO-treated compression group, the decrease in NCV

was diminished, from a baseline of 53.14 ± 7.66 m/s to 38.36 ± 3.39 m/s at 10 weeks of

compression (P = 0.10). After decompression, all experimental groups showed a progressive

increase in NCV with mice receiving EPO treatment as an adjuvant to decompression showing an

accelerated rate of recovery (P = 0.02). The average myelin density was calculated from nerves

harvested three weeks post-decompression. Untreated compressed animals (saline/saline)

showed statistically significant decreases in myelination as compared to the sham surgery group

(P = 0.003). Erythropoietin treatment, whether continual (EPO/EPO) or only after decompression

(saline/EPO), significantly improved myelin content to a level indistinguishable from the sham

surgery group (P = 0.99 and P = 1.00, respectively).

Summary

Erythropoietin treatment as an adjuvant to surgical decompression facilitates the recovery of

nerves in a standard murine model of compression neuropathy. Erythropoietin may also

demonstrate a neuroprotective effect during chronic nerve compression, in the absence of

surgical intervention, although additional study is needed. The clinical use of erythropoietin, as

an adjuvant to surgical decompression, may have therapeutic potential in the treatment of

chronic nerve compression injuries.

Paper 52_Image01

Paper 52_Image02

Reference 1: Campana WM, Myers RR. Erythropoietin and erythropoietin receptors in the

peripheral nervous system: changes after nerve injury. FASEB J. 2001;15(10):1804-1806.

Reference 2: Elfar JC, Jacobson J a, Puzas JE, Rosier RN, Zuscik MJ. Erythropoietin accelerates

functional recovery after peripheral nerve injury. J. Bone Joint Surg. Am. 2008;90(8):1644-1653.

Reference 3: Campana WM, Myers RR. Exogenous erythropoietin protects against dorsal root

ganglion apoptosis and pain following peripheral nerve injury. Eur. J. Neurosci. 2003;18(6):1497-

1506.

Reference 4: Gupta R. Chronic Nerve Compression alters Schwann Cell Myelin Architecture in a

murine model. Muscle Nerve 2013;45(2):231-241.

Reference 5: Gupta R, Truong L, Bear D, Chafik D, Modafferi E, Hung CT. Shear stress alters the

expression of myelin-associated glycoprotein (MAG) and myelin basic protein (MBP) in Schwann

cells. J. Orthop. Res. 2005;23(5):1232-1239.

Reference 6: Bianchi R, Buyukakilli B, Brines M, et al. Erythropoietin both protects from and

reverses experimental diabetic neuropathy. Proc. Natl. Acad. Sci. U. S. A. 2004;101(3):823-828.

Reference 7: Sirén A-L, Fasshauer T, Bartels C, Ehrenreich H. Therapeutic potential of

erythropoietin and its structural or functional variants in the nervous system. Neurotherapeutics

2009;6(1):108-127.

Paper 53: Acceleration of Schwann Cell Growth Co-cultured with

Amniotic Membrane and Amniotic Fluid Stem Cells Clinical Paper Session 09: Basic Nerve - Saturday, September 12, 9:13 - 9:20 AM

Basic Science,Nerve

N/A - Not a clinical study

Xue Ma, MD, PhD

Hypothesis

Schwann cells are key players in the setting of peripheral nerve injury and improve clinical

outcomes by accelerating nerve regeneration across nerve gaps. However, the relatively slow

growth rate and large amount of Schwann cells required for effective neurite outgrowth limit the

in clinical use in a feasible time period. Amniotic fluid derived stem (AFS) cells have

demonstrated multi-potency with neurogenic potential and have been suggested to produce

angiogenic and neurogenic growth factors in their undifferentiated form in vitro. Thus, we

hypothesize that co-culturing amniotic membrane and amniotic fluid stem cells will accelerate

the proliferation of Schwann cells in vitro.

Methods

Primary rat Schwann cells (rSC, isolated from sciatic nerves of 2 month old Sprague Dawley rats,

(P2-4)) and human NF1 Schwann-like cells (CRL-2884, ATCC®, Manassas, VA (P3-5)) were

cultured at 5000/well in 96 well plates and divided into eight test groups: I. rSC control II. rSC co-

cultured with live amniotic membrane III. rSC co-cultured with dehydrated amniotic membrane

IV. rSC co-cultured with ground amniotic membrane and amniotic fluid stem cells. V. human

Schwann cells (hSC) control VI. hSC co-cultured with live amniotic membrane VII. hSC co-cultured

with dehydrated amniotic membrane VIII. hSC co-cultured with ground amniotic membrane and

amniotic fluid stem cells. Cell Counting Kit-8 assays were performed on day 1, 7 and 14 to

determine cell proliferation and viability with the co-culturing. Six technical replicates and three

independent experiments were performed for each group. All data were expressed as mean ±

SEM and differences between the experimental and control groups were assessed by two-tailed

Student’s t-test. Results with P < 0.05 were considered statistically significant.

Results

Both rat and human Schwann cells were viable with each co-culturing at the end of 14 days. All

treatment groups (II, III, IV, VI, VII, VIII) showed a significant increase in proliferation compared to

the control groups (I and V) at 7 and 14 days. (fold change with co-culturing groups at 7 days:

Group II: 3.22 ± 0.26; Group III: 3.22 ± 0.20; Group IV: 2.01 ± 0.15; Group VI: 3.84 ± 0.28; Group

VII:1.51± 0.38; Group VIII: 1.94 ± 0.21, P < 0.01 in all groups compared to control).Results were

similar with 14 days of treatment.

Summary

Co-culture with amniotic membrane and amniotic fluid stem cells supported and facilitated

Schwann cell growth. Similar co culture may have the potential to improve the regeneration of

peripheral nerve and nerve bed following injury.

Reference 1: De Coppi P,Soker S, Atala A et al. Isolation of amniotic stem cell lines with potential

for therapy.Nat Biotechnol. 2007;25(1):100-6.

Reference 2: Bum Soo Kim, So Young Chun et al. Human amniotic fluid stem cell injection

therapy for urethral sphincter regeneration in an animal model. BMC Medicine 2012, 10:94

Reference 3: Rodrigues MC et al.Peripheral nerve repair with cultured schwann cells: getting

closer to the clinics.ScientificWorldJournal. 2012;413091

Paper 54: Comparative Morbidity of Cubital Tunnel Surgeries: A

Prospective Cohort Study Clinical Paper Session 10: Neuropathy - Saturday, September 12, 10:05 - 10:12 AM

Treatment,Surgical Technique,Elbow and Forearm,Nerve

Level 2 Evidence

Robert Staples, MD

Daniel London, MD, MSc

Daniel A. Osei, MD, MSc

Charles A. Goldfarb, MD

Andre Guthrie, BS

Ryan Patrick Calfee, MD, MSc

Hypothesis

Contemporary studies analyzing final neurologic recovery after cubital tunnel syndrome surgery

have not demonstrated the superiority of any one surgical approach. Assuming similar ultimate

outcome, differences in the relative risks and the morbidity between potential procedures plays

a pivotal role when recommending a surgery. The purpose of this study was to compare the

morbidity of common cubital tunnel surgeries. Our working hypothesis was that in situ

decompression would impart less surgical morbidity (surgical site pain, narcotic usage, functional

impairment) when compared to transposition or epicondylectomy.

Methods

This prospective cohort study enrolled 102 adult patients indicated for cubital tunnel surgery at a

tertiary institution. In situ decompressions (n=29), ulnar nerve transpositions (n=56), and medial

epicondylectomies (n=17) were performed. No significant preoperative differences in age, sex,

or the presence of pain existed between each surgical group (Table 1). Data were collected by

independent clinicians at 3 postoperative intervals: 2 weeks, 6 weeks, and >8 weeks.

Postoperative data quantified surgical morbidity: Visual Analog Scale (0-10) surgical site pain (at

rest, moving, placing on surface), narcotic consumption (morphine equivalents), olecranon

paresthesia, and wound complications (hematoma, drainage, infection). Patient-rated disability

was quantified with the Levine-Katz functional score. Statistical analyses compared morbidity

data between surgical groups.

Results

Surgical site tenderness was the least after in situ release although statistical significance was

only noted at 2 weeks. The frequency of narcotic use by patients decreased for all surgical

groups at each subsequent followup. In situ decompression resulted in fewer patients using

narcotics and fewer morphine equivalents consumed by users at all time points to a degree that

was judged clinically relevant but not statistically significant. Olecranon paresthesias were

frequent in all surgical groups but had only resolved by the final follow up interval in the in situ

decompression group (Table 1). Three hematomas occurred following transposition (5%) with 1

requiring operative debridement. No other wound complications occurred. Levine Katz

functional scores indicated initial disability that increased following transposition, although this

improved similarly to in situ decompression by the final follow up (Figure 1).

Summary Points

• Ulnar nerve transposition and medial epicondylectomy are associated with greater narcotic

requirements, surgical site tenderness, and olecranon paresthesia during early recovery than

in situ decompression.

• In the 3rd month after surgery, differences in patient-rated function following in situ

decompression and ulnar nerve transposition have normalized.

Paper 54_Image01

Paper 54_Image02

Reference 1: Charles YP, Coulet B, Rouzaud JC, Daures JP, Chammas M. Comparative Clinical

Outcomes of Submuscular and Subcutaneous Transposition of the Ulnar Nerve for Cubital Tunnel

Syndrome. J. Hand Surg.-Am. Vol. May-Jun 2009;34A(5):866-874.

Reference 2: Zlowodzki M, Chan S, Bhandari M, Kalliainen L, Schubert W. Anterior transposition

compared with simple decompression for treatment of cubital tunnel syndrome. J. Bone Joint

Surg.-Am. Vol. Dec 2007;89A(12):2591-2598.

Reference 3: Brauer CA, Graham B. The surgical treatment of cubital tunnel syndrome: A

decision analysis. J. Hand Surg.-Eur. Vol. Dec 2007;32E(6):654-662.

Reference 4: Bartels RH, Menovsky T, Van Overbeeke JJ, Verhagen WI. Surgical management of

ulnar nerve compression at the elbow: an analysis of the literature. Journal of neurosurgery.

1998 Nov;89(5):722-7.

Reference 5: Elhassan B, Steinmann SP. Entrapment neuropathy of the ulnar nerve. The Journal

of the American Academy of Orthopaedic Surgeons. 2007 Nov;15(11):672-81.

Reference 6: Nabhan A, Ahlhelm F, Kelm J, Reith W, Schwerdtfeger K, Steudel WI. Simple

Decompression or Subcutaneous Anterior Transposition of the Ulnar Nerve for Cubital tunnel

Syndrome. The Journal of Hand Surgery: British & European Volume. 2005;30(5):521-4.

Reference 7: Soltani AM, Best MJ, Francis CS, Allan BJ, Panthaki ZJ. Trends in the surgical

treatment of cubital tunnel syndrome: an analysis of the national survey of ambulatory surgery

database. J Hand Surg Am. 2013 Aug;38(8):1551-6.

Reference 8: Watts AC, Bain GI. Patient-Rated Outcome of Ulnar Nerve Decompression: A

Comparison of Endoscopic and Open In Situ Decompression. The Journal of Hand Surgery.

2009;34(8):1492-8.

Reference 9: Gervasio O, Gambardella G, Zaccone C, Branca D. Simple decompression versus

anterior submuscular transposition of the ulnar nerve in severe cubital tunnel syndrome: A

prospective randomized study. Neurosurgery. 2005;56(1):108-17.

Reference 10: Bartels RH, Verhagen WI, van der Wilt GJ, Meulstee J, van Rossum LG, Grotenhuis

JA. Prospective randomized controlled study comparing simple decompression versus anterior

subcutaneous transposition for idiopathic neuropathy of the ulnar nerve at the elbow: Part 1.

Neurosurgery. 2005 Mar;56(3):522-30

Paper 55: Clinical Diagnosis of Coincident Carpal and Cubital Tunnel

Syndromes Clinical Paper Session 10: Neuropathy - Saturday, September 12, 10:12 - 10:19 AM

Evaluation/Diagnosis,Prognosis/Outcomes,Nerve,Diseases and Disorders

Level 3 Evidence

Justin J. Koh, MA

Prosper Benhaim, MD

Kodi K. Azari, MD, FACS

Hypothesis

Patients with coincident cubital tunnel syndrome can be diagnosed among patients presenting

with carpal tunnel syndrome based on demographic factors, presenting symptoms, physical

exam findings, and nerve conduction study results.

Methods

A retrospective chart review of 515 patients was performed from patients treated for carpal

tunnel release and cubital tunnel release by two university based hand surgeons. These patients

were divided into cohorts as patients with isolated carpal tunnel syndrome (n=337) and patients

with coincident carpal and cubital tunnel syndromes (n=178). These patients were characterized

according to demographic factors, past medical history, physical exam findings, and nerve

conduction study results. Univariate and multivariate logistic regression were used to select

significant predictors of coincident nerve compression. The “K-B score” was constructed by

converting the regression coefficients of independently predictive factors in the multiple

regression model to integers for diagnosis of coincident nerve compression, after which a

simplified 5 point model was chosen. A receiver operating characteristic curve was generated

for each iteration of the K-B score, after which sensitivities, specificities, positive, and negative

predictive values were calculated for each potential score threshold to identify the best cutoff

value.

Results

Loss of intrinsic hand strength, ulnar sensation loss, positive elbow flexion test, positive cubital

tunnel Tinel’s sign, and abnormal ulnar nerve NCS result were selected. The cutoff value for the

K-B score was 2 points, with a sensitivity of 86.6% and a specificity of 86.5% in the

developmental cohort. Area under the receiver operating characteristic curve was 0.9217.

Summary Points

• Given the limited sensitivity and relatively high false negative rate of the NCS at the cubital

tunnel, physical exam findings should weigh heavily in a diagnosis of coincident cubital tunnel

syndrome in carpal tunnel syndrome patients.

• Patients with a K-B score of 2 or greater should be carefully evaluated for coincident

compression neuropathy.

• In this developmental cohort, the K-B score was a robust method for detecting coincident

cubital tunnel syndrome in carpal tunnel syndrome patients. The variables involved are

routinely used to assess compression neuropathy at the cubital tunnel.

• Importantly, all component factors of the K-B score (i.e. loss of intrinsic hand strength, ulnar

sensory loss, positive elbow flexion test, positive cubital tunnel Tinel’s sign, and abnormal

ulnar nerve NCS result) were determined to be of equivalent clinical weight in assessing

patients with potential coincident compression neuropathy.

Paper 55_Image01

Paper 55_Image02

Reference 1: Beekman R, Van der plas JP, Uidehaag BM, Schellens RL, Visser LH. Clinical,

electrodiagnostic, and sonographic studies in ulnar neuropathy at the elbow. Muscle Nerve.

2004; 30(2):202-8.

Reference 2: Bland, JD. Carpal Tunnel Syndrome. Curr Opin Neurol. 2005; 18(5):581-5.

Reference 3: Nakajima M, Ono N, Kojima T, Kusunose K. Ulnar entrapment neuropathy along the

medial intermuscular septum in the midarm. Muscle Nerve. 2009;39(5): 707-10.

Reference 4: Beekman R, Schreuder AH, Rozeman CA, Koehler PJ, Uidehaag BM. The diagnostic

value of provocative clinical tests in ulnar neuropathy at the elbow is marginal. J Neurol

Neurosurg Psychiatr. 2009; 80(12):1369-74

Reference 5: Novak CB. Lee GW, Mackinnon SE, Lay L. Provocative testing for cubital tunnel

syndrome. J Hand Surg Am. 1994; 19(5):817-20.

Paper 56: The Efficacy of In-Situ Cubital Tunnel Release in Management

of Elbow Ulnar Compression Neuropathy in McGowen Grade 3 Clinical Paper Session 10: Neuropathy - Saturday, September 12, 10:19 - 10:26 AM

Evaluation/Diagnosis,Treatment,Surgical Technique,Prognosis/Outcomes,Elbow and

Forearm,Nerve

Level 3 Evidence

Ali Izadpanah, MD, MSc

Robert Spinner, MD

Sanjeev Kakar, MD, MBA

Royalty: Skeletal Dynamics (Kakar)

Consulting Fee: Arthrex, Skeletal Dynamics (Kakar)

Contracted Research: Arthrex (Kakar)

Hypothesis

Cubital Tunnel syndrome is the second most common compression neuropathy of the upper

extremity with an incidence of 24.7 in 100,000. Numerous surgical modalities have been

proposed for management of this entity in the face of failure after conservative management.

However, up to this date, there has been no data demonstrating one method being superior to

another for management of this common compression neuropathy leading to considerable pain

and disability in patients. Thus, we sought to determine the efficacy and complication profile of

in-situ release compared to subcutaneous and submuscular or intramuscular ulnar nerve

transposition in McGowen grade 3 (constant numbness and evident weakness).

Methods

A retrospective chart review of 100 consecutive patients with McGowen grade 3, undergoing

surgical decompression from May 2008 to May 2009 was performed. All patients had a minimum

of one-year follow up. Patients’ demographics such as age, sex, and associated comorbidities

were collected. Electromyogram and nerve conduction studies were reviewed. Postoperative

course, any evidence of recurrence or incomplete relief of symptoms and data regarding the

perioperative complication profile were collected. Statistical analysis and comparison between

in-situ release versus subcutaneous and submuscular transposition was performed using SPSS

22.0.

Results

There were a total of 38 (38%) females and 62 males (62%) with a mean age of 52±17.1 years old

(16 years to 94 years). Twelve patients underwent submuscular or intramuscular transposition,

48 patients underwent subcutaneous transposition and 40 patients underwent in-situ release.

The average duration of symptoms for our patients was 12.1±5.8 months (3 months to 60

months. There were two patients with wound healing complications (dehiscence), one in

submuscular transposition and one in intra-muscular transposition. Five patients had recurrence

or incomplete relief of symptoms. Out of these five, two had undergone in-situ release, two had

undergone subcutaneous release and one had a submuscular release. A Chi-square analysis was

performed which demonstrated no statistical significance in recurrence rate requiring revisional

surgery between in-situ compared to subcutaneous or submuscular release (P = 0.4).

Summary

In conclusion, our results demonstrate that in surgical management of McGowen grade 3, the in-

situ release had similar success rate as subcutaneous or submuscular transposition with lower

complication rate (none versus 2%). Thus, in-situ release could be an alternative in management

of patients with McGowen grade 3 ulnar nerve compression neuropathy at the elbow with a

similar success rate as the submuscular and intramuscular transpositions with a lower

complication rate.

Paper 57: Does BMI, Age, Gender, or Diabetes Affect Cross-Sectional

Area of the Median Nerve in Asymptomatic Patients? Clinical Paper Session 10: Neuropathy - Saturday, September 12, 10:26 - 10:33 AM

Evaluation/Diagnosis,Anatomy,Hand and Wrist,Nerve,Diseases and Disorders

Level 2 Evidence

Tiffany J. Pan, MD

RJ White, BS

Caiyan Zhang, MS

Joseph Imbriglia, MD

William C. Hagberg, MD

John R. Fowler, MD

Hypothesis

BMI, age, gender, and diabetic status affect the baseline cross-sectional area (CSA) of the median

nerve at the wrist of asymptomatic individuals.

Methods

Consecutive patients without a history of carpal tunnel release were recruited. CTS-6 was

completed in all patients; those with a score of 0 were included. Ultrasound examination was

performed on both wrists and CSA of the median nerve at the carpal tunnel inlet recorded.

Trends and differences in median nerve CSA and CTS-6 score were analyzed with regard to hand

dominance, age, gender, BMI, and presence or absence of diabetes. Within each group, wrists

were separated into subgroups based on hand dominance. Statistical analysis was performed

using correlations and independent T-tests.

Results

A significant difference was seen between patients with BMI <30 (dominant side mean = 6.5

mm2, non-dominant side mean = 6.1 mm2) and those =30 (dominant side mean = 7.6 mm2,

non-dominant side mean = 7.2 mm2). CSA correlated with BMI (dominant side r=0.30, non-

dominant side r=0.35) and age (dominant side r=0.27, non-dominant side r=0.24). Side to side

difference reached marginal significance (P = 0.049). Mean CSA was significantly higher in the

non-dominant hand of diabetics (mean = 8.0 mm2) compared to non-diabetics (mean = 6.3

mm2, P = 0.002) but not in the dominant hand (mean = 7.9 mm2 in diabetics, mean = 6.7 mm2

in non-diabetics, P = 0.13). CSA was not significantly different with respect to gender. Females

trended toward a smaller mean CSA than males for both the dominant (mean = 6.5 mm2 for

females, 7.1 mm2 for males, P = 0.1) and non-dominant hands (mean = 6.4 mm2 for females, 6.5

mm2 for males, P = 0.69), though the differences did not reach statistical significance. (Table 1)

Summary Points

• Patients who are obese have a significantly larger median nerve CSA at baseline, even in

completely asymptomatic individuals.

• Median nerve CSA shows a positive correlation with both BMI and age.

• In a side to side comparison, CSA was larger for the dominant wrist compared to the non-

dominant wrist.

• Diabetics had a significantly larger median nerve CSA in the non-dominant hand but not the

dominant hand.

• Females trended toward a smaller mean CSA than males, but this did not reach statistical

significance.

Paper 57_Image01

Paper 58: Relationship Between the Idiopathic Anterior Interosseous

Nerve Palsy and “Hourglass-like Fascicular Constriction” Clinical Paper Session 10: Neuropathy - Saturday, September 12, 10:33 - 10:40 AM

Prognosis/Outcomes

Level 2 Evidence

Toru Sunagawa, MD, PhD

Yuko Nakashima, MD, PhD

Rikuo Shinomiya, MD, PhD

Mitsuo Ochi, MD, PhD

Hypothesis

An hourglass-like fascicular constriction, which is a focal fascicular lesion observed at one or a

few places in one or a few fascicles of a peripheral nerve trunk, and usually affects the anterior

interosseous nerve (AIN) or posterior interosseous nerve, is improved with the relief of

symptom.

Methods

Seven consecutive patients who were diagnosed with idiopathic AIN palsy based on clinical

findings and had hourglass-like fascicular constrictions in the AIN revealed by the

ultrasonographic examination were included. We used the high-resolution device with a 14-6

MHz linear probe, and observed nerve fascicles in the median nerve trunk in a transverse and

longitudinal fashions around the site of tenderness at the elbow joint level confirming the

presence of fascicular constriction.

The age at the time of diagnosis ranged from 19 to 56 years old. The duration between onset of

symptoms and ultrasonographic examination ranged from 7 days to 8 months, and the duration

between examination and operation ranged from 3 days to 1 month.

All but one case took interfascicular neurolysis, and we followed up all cases clinically and

ultrasonographically every one month. At the time of examination, we calculated constriction

ratio, which was obtained by the division of the involved fascicular diameter at the constriction

by that at the proximal non-constricted site.

Results

The number of constrictions ranged from one to eight, and all constrictions revealed

ultrasonographically were confirmed intraoperatively. In the five cases with the operative

treatment, recovery from paralysis began from 3 weeks to four months after surgery, and was

completed (M0 to M4 or M5) five to seven months after surgery. Postoperative ultrasonography

revealed the constrictions subsided. The other one treated operatively got little recovery (M0 to

M2) at 10 months after surgery, and the severe constriction still remained. In the one

conservative treated case, the paralysis began to recover at 9 months and recovered completely

(M0 to M5) at 14 months after the onset. On the ultrasonographic examination, its constriction

incompletely subsided.

Summary

The hourglass-like fascicular constriction subsided with the relief of the paralysis both in the

operatively and conservatively treated cases. The cause of constricitons is still unknown,

however, it may play a significant role on this type of paralysis.

Paper 58_Image01

Paper 58_Image02

Reference 1: Nakashima Y, et al. High-resolution ultrasonographic evaluation of "hourglass-like

fascicular constriction" in peripheral nerves: a preliminary report. Ultrasound in Med Biol.

2014;40: 1718-1721

Reference 2: Nagano A. Spontaneous anterior interosseous nerve palsy. J Bone Joint Surg Br

2003;85:313-318.

Paper 59: Emergency Hand Care: To Treat, Consult or Transfer Clinical Paper Session 11: Trauma - Saturday, September 12, 10:05 - 10:12 AM

Evaluation/Diagnosis,Treatment

Level 5 Evidence

Brian C. Drolet, MD

Scott David Lifchez, MD

Sidney Jacoby, MD

A. Lee Osterman, MD

Edward Akelman, MD

Scott Levin, MD

Hypothesis

Unnecessary inter-facility transfers for evaluation by a hand surgeon create significant human

and economic burden for patients, providers, and the healthcare system. However, emergency

hand care standards to guide treatment, consultation or transfer to a tertiary care center are

lacking. Diagnosis-specific guidelines for emergency providers may improve both the quality and

cost of care for upper extremity (UE) emergencies.

Methods

We created a framework to group common UE emergency diagnoses based on ASSH standards

and other published guidelines from the literature. Based on this framework, we designed a

survey to evaluate the level of training – emergency medicine (EM), general orthopedic or plastic

surgery, or hand fellowship – most appropriate to provide definitive, point-of-care service for

each of the diagnostic groupings. As both educational leaders and key partners for developing

consensus standards, EM and hand fellowship program directors (PDs) were chosen as the study

population.

Results

We received 79 responses from hand fellowship PDs (89.7% return rate) and 151 responses from

EM PDs (49.3% return rate). EM physicians were less likely than hand surgeons to report that

specialized training was necessary to care for most of the diagnoses evaluated. (Table 1) Despite

these differences, we identified consensus (>50% agreement with non-overlapping 99%

confidence intervals) for the level of training that PDs felt was most appropriate to care for

nearly all of the diagnosis groups in our framework. (Table 2)

Summary Points

• This survey demonstrates variable levels of consensus (56.1% - 100%) between EM and hand

surgery PDs regarding the level of training necessary to care for common urgent or emergent

UE diagnoses. The program directors reported:

o Emergency medicine physicians, with outpatient hand surgery follow up available,

should provide point-of-care service for uncomplicated cellulitis, simple abscesses,

paronychia or felon, simple lacerations without deep tissue involvement, non-

displaced distal radius or ulna fractures, and reducible hand fractures.

o General orthopedic or plastic surgery coverage should care for osteomyelitis, septic

wrist, open fractures of the hand or wrist, and compartment syndrome.

o Specialty hand coverage should be available for necrotizing infections, flexor

tenosynovitis, crush injuries and complex lacerations, complicated dislocations, and

high pressure injection injuries.

• This diagnostic framework may improve triage in emergency hand care, specifically regarding

the need for specialty consultation. Using these guidelines, unnecessary inter-facility

transfers may avoided by identification of patients who do not require a provider with more

specialized training, and therefore are not appropriate for transfer.

Paper 59_Image01

Paper 59_Image02

Reference 1: Hartzell TL, Kuo P, Eberlin KR, Winograd JM, Day CS. The overutilization of resources

in patients with acute upper extremity trauma and infection. J Hand Surg Am 2013;38:766-73.

Reference 2: Melkun ET, Ford C, Brundage SI, Spain DA, Chang J. Demographic and Financial

Analysis of EMTALA Hand Patient Transfers. Hand 2010;5:72-76.

Reference 3: Friebe I, Isaacs J, Mallu S, Kurdin A, Mounasamy V, Dhindsa H. Evaluation of

appropriateness of patient transfers for hand and microsurgery to a level I trauma center. Hand

2013;8:417-421.

Reference 4: Patterson JM, Boyer MI, Ricci WM, Goldfarb CA. Hand trauma: a prospective

evaluation of patients transferred to a level I trauma center. Am J Orthop 2010;39:196-200

Paper 60: Defining a Functional Baseline Index when Comparing

Outcomes in Hand Transplants, Users of Multi-articulating Electric Hands

and Toe-to-Hand Transfers Clinical Paper Session 11: Trauma - Saturday, September 12, 10:12 - 10:19 AM

Treatment,Surgical Technique,Therapy/Rehabilitation,Prognosis/Outcomes,Hand and Wrist

Level 3 Evidence

Diane J Atkins, OTR, FISPO

Neil F. Jones, MD

Hypothesis

To date there has never been a national or international study designed to compare the

functional outcomes of individuals who have been recipients of hand transplants, amputees fit

with electric multi-articulating hands, and those with toe-to-hand transfers. Can a Functional

Baseline Index score be defined and what does it tell us about the objective and subjective

outcomes these individuals experience?

Methods

The subject population included 3 study groups- 5 individuals with unilateral and bilateral hand

transplants, 14 unilateral and bilateral prosthetic users of electric multi-articulating hands and

digits, and 6 individuals with unilateral and bilateral toe-to-hand transfers. Each subject in the

study was evaluated with the following validated and standardized tests: Box and Blocks Test

(BBT), Nine Hole Peg (NHP), Southampton Hand Assessment Procedure (SHAP) and the

Disabilities of the Arm, Shoulder and Hand (DASH). Because of the differences in the subject

group size and overall sample size, the data was calculated by Cohen’s d- effect size, to represent

group differences.

Results

When evaluating the subjective, patient perception of disability, calculated by the DASH, subjects

who utilized electric multi-articulating hands and digits perceived themselves “less disabled”

when compared to hand transplant subjects (d=.96). The individual with bilateral multiple toe-

to-hand transfers however, considered himself to be the “least disabled” as recorded by the

DASH. Subjects who utilized electric multi-articulating hands and digits scored slightly higher (d

=.12) in their overall “index of function” recorded by the SHAP. Bilateral hand transplant subjects

scored slightly better in manual dexterity, based upon their Box and Blocks Test score, and

bilateral prosthetic users scored better in fine motor dexterity based upon the Nine Hole Peg

scores.

Summary Points

• As dramatic advances are being made in the field of reconstructive, microvascular and hand

transplantation, the field of electric multi-articulating hand and digit technology has

experienced significant success as well.

• An ability to quantify the “success” of these individuals needs to be defined through a

Functional Baseline Index score that will enable hand procedure subjects to be compared to

the functional score of those fit with advanced prosthetic components.

• Early results reveal that the outcomes of hand transplants, 2 years or more post-procedure,

demonstrate similar outcomes of prosthetic users of advanced hand technology, as it relates

to activities of daily living, fine motor and manual dexterity.

Paper 61: Reliability of the “Ten Test” for Assessment of Sensation in

Hand Trauma Clinical Paper Session 11: Trauma - Saturday, September 12, 10:19 - 10:26 AM

Evaluation/Diagnosis,Hand and Wrist,Nerve

N/A - Not a clinical study

Michael Berger, MD, PhD

William Regan, BSc

Alex Seal, MD, FRCSC

Sean Bristol, MD, FRCSC

Hypothesis

The purpose of this study was to determine reliability parameters (inter-rater reliability,

response stability and responsiveness) of the "Ten Test" (TT), a clinical measure of discriminative

sensation whereby the magnitude of abnormal sensation is normalized to an area of normal

sensation on a 10-point Likert scale, in a sample of hand trauma patients. A secondary purpose

was to compare the reliability of TT to that of the Weinstein Enhanced Sensory Test (WEST), a

semi-quantitative monofilament test that is commonly used in this setting. We hypothesized that

TT would display good reliability and that reliability parameters would be similar to those of

WEST.

Methods

Patients (n=29, mean age=37±12) with self-reported abnormal hand sensation, presenting to an

outpatient hand trauma clinic within seven days of injury, underwent TT and WEST by two

separate raters on the same day. The order of test and rater were randomized to reduce

systematic error. Levels of WEST were transformed into a 5-point ordinal scale corresponding to

the coloured monofilaments, which represent progressively impaired sensation. Bland-Altman

plots were constructed to provide a visual representation of agreement. Inter-rater reliability,

response stability and responsiveness of each test were determined by the intraclass correlation

coefficient (ICC: 2, 1), standard error of measurement (SEM) with 95% confidence intervals (CI)

and minimal clinical difference score (MCD), respectively.

Results

Inspection of the Bland-Altman plots revealed greater inter-rater agreement for TT than for

WEST (Figure 1). TT displayed excellent inter-rater reliability (ICC=0.95, 95% CI 0.89-0.97)

compared to good reliability for WEST (ICC=0.78, 95% CI 0.58-0.89). The range of true scores

expected with 95% confidence based on the SEM (i.e. response stability), was ±1.05 for TT and

±1.10 for WEST. MCD scores reflecting test responsiveness were 1.50 and 1.60 for TT and WEST,

respectively.

Summary Points

• TT displayed excellent inter-rater reliability, response stability and responsiveness in a

sample of patients presenting to an outpatient hand trauma clinic.

• Reliability parameters were stronger for TT compared to WEST.

• The range of scores expected on repeated measurements of WEST encompassed a wide

range of sensory impairment (±1.10). For a patient with a score of 3, the true score would lie

between 2-4, reflecting a range of sensory impairment from mild-to-severe.

• These results provide support for the utility of TT in this population. Considering the ease of

implementation and excellent reliability of TT, it may be a practical alternative to

monofilament testing.

Paper 61_Image01

Reference 1: Patel MR, Bassini L. A comparison of five tests for determining hand sensibility. J

Reconstr Microsurg 1999;(15):523-526.

Reference 2: Strauch B, Lang A, Ferder M, Keyes-Ford M, Freeman K, Newstein D. The ten test.

Plast Reconstr Surg 1997;(99):1074-1078.

Reference 3: Sun HH, Oswald TM, Sachanandani NS, Borschel GH. The 'Ten Test': application and

limitations in assessing sensory function in the paediatric hand. J Plast Reconstr Aesthet Surg

2010;(63):1849-1852.

Reference 4: Rosen B, Dahlin LB, Lundborg G. Assessment of functional outcome after nerve

repair in a longitudinal cohort. Scand J Plast Reconstr Surg Hand Surg 2000;(34):71-78.

Paper 62: The Role of the Dorsal Wrist Capsuloligamentous Structures

on Volar Radiocarpal Instability After Distal Radius Fractures With Volar

Lunate Facet Fragments Clinical Paper Session 11: Trauma - Saturday, September 12, 10:26 - 10:33 AM

Basic Science,Hand and Wrist

N/A - Not a clinical study

Christopher Bui, MD

Hypothesis

The hypotheses of this study was that in distal radius fractures with displaced volar lunate facet

fragments, disruption of the dorsal radiocarpal (DRC) and the dorsal intercarpal (DIC) ligaments

will significantly increase volar lunate translation and that cyclic grip loading will further increase

translation.

Methods

6 matched pair cadaveric specimens from the mid-forearm to hand were tested on a custom

dynamic hand testing system. In group 1, testing was performed on the intact wrist, the wrist

with a volar lunate facet fracture, and the fractured wrist after 500 cycles of grip. In group 2, in

addition to the intact and fractured wrist, the fractured wrist with the DRC and DIC cut, and the

fractured wrist with the dorsal ligaments cut after 500 cycles of grip were tested.

Results

Volar-dorsal, proximal-distal, radial-ulnar, and total displacement of the lunate was calculated

from 45° wrist flexion to 45° wrist extension in 22.5° increments with the wrist flexors/extensors

loaded. Statistical comparisons were performed using repeated measures ANOVA with a Tukey

post-hoc test with a P-value 0.189 or radial-ulnar translation (P > 0.128) with the fracture alone.

Grip cycling further increased proximal translation at 22.5° of extension (P = 0.013) and neutral

wrist positions (P = 0.045) but had no additional effect on other translations (P > 0.056).

In the wrist extension positions, significant increases (P 0.328) or radial-ulnar (P > 0.15)

translations after the dorsal ligaments were cut. Grip cycling significantly increased (P < 0.048)

resulting displacements after dorsal ligament cutting.

Summary Points

• Volar radiocarpal instability after distal radius fractures with displaced volar lunate facet

fragments is exacerbated by injury to the DRC and DIC ligaments.

• These findings suggest that patients with volar radiocarpal subluxation are likely to have

disruption of the dorsal capsuloligamentous structures.

• Radiocarpal instability further worsened with grip cycling only after the dorsal

capsuloligamentous structures were cut suggesting that unrecognized dorsal sided injury

may be a contributing factor to why fixation of volar lunate facet fragments remains

problematic.

Paper 62_Image01

Paper 62_Image02

Reference 1: Beck J, Harness N, Spencer H. Volar Plate Fixation Failure for Volar Shearing Distal

radius Fractures With Small Lunate Facet Fragments. J Hand Surg Am. 2014 Apr;39(4):670-8

Reference 2: Andermahr J, Lozano-calderon S, Trafton T, Crisco J, Ring D. The Volar Extension of

the Lunate Facet of the Distal Radius: A Quantitative Anatomic Study. J Hand Surg Am. 2006;

31(6):892-895

Reference 3: Kitay A, Mudgal C. Volar carpal Subluxation Following Lunate Facet Fracture. J Hand

Surg Am. 2014 Jun 4. pii: S0363-5023(14)00503-6.

Reference 4: Harness N, Jupiter J, Orbay J, Raskin K, Fernandez D. Loss of Fixation of the Volar

Lunate Facet Fragment in Fractures of the Distal Part of the Radius. J Bone Joint Surg Am. 2004

Sep;86-A(9):1900-8

Reference 5: Apergis E, Darmanis S, Theodoratos G, Maris J. Beware of the Ulno-palmar Distal

Radius Fragment. J Hand Surg Br. 2002 Apr;27(2):139-45

Reference 6: Mandziak D, Watts A, Bain G. Ligament Contribution to Patterns of Articular

Fractures of the Distal Radius. J Hand Surg Am. 2011 Oct;36(10):1621-5.

Paper 63: Biomechanical Analysis of Reconstruction Methods for

Peripheral Triangular Fibrocartilage Complex Tears Clinical Paper Session 11: Trauma - Saturday, September 12, 10:33 - 10:40 AM

Treatment,Surgical Technique,Basic Science,Hand and Wrist

N/A - Not a clinical study

Amar Arun Patel, MD

Ali Alhandi, MD

Ted Milne, BS

Anna Makowski, HTL

Loren Latta, PhD

Elizabeth A. Ouellette, MD, MBA

Hypothesis

Peripheral triangular fibrocartilage complex (TFCC) tears may be treated with several methods

that have a high variability in outcomes. We believe that a combination of extensor

capsulorrhaphy using the Herbert Sling (HS) and all-inside arthroscopic suture repair (SR)

provides greater ulnocarpal joint (UCJ) and distal radioulnar joint (DRUJ) stability when

compared to either procedure in isolation.

Methods

Twelve fresh-frozen, age-matched specimens intact from the proximal humerus to the fingertips

were used for this study. Non-destructive testing was performed for each arm to assess the

native UCJ and DRUJ stability. Each specimen was secured to a mechanical testing machine, and

an actuator was then sinusoidally cycled dorsally and volarly until a neutral zone was displayed.

The slope of the load-displacement curve at the maximal dorsal displacement was defined as

“stiffness”.

An ulnar-sided, peripheral TFCC injury (Palmer 1b) was created in each specimen using an

arthroscope, and mechanical testing was repeated. Six specimens were treated with SR, six were

treated with HS, and testing was repeated. The six specimens treated with SR were then treated

with HS, and testing was repeated again. Paired Student’s t-tests were used for statistical

analysis within cohorts.

Results

All three reconstructions demonstrated improvements in UCJ and DRUJ stability. When

combining all cohorts, there was a decrease in UCJ (P = 0.020) and DRUJ stiffness (P = 0.079)

after the creation of a peripheral TFCC injury, and after repair there was a significant increase in

UCJ (P = 0.0077) and DRUJ (P = 0.0056) stiffness. With regards to the UCJ stiffness, HS recovered

47% (P = 0.030), SR recovered 32% (P = 0.32), and SR+HS recovered 124% (P = 0.040) (Fig. 1).

When comparing DRUJ stiffness, HS recovered 133% (P = 0.021), SR recovered 48% (P = 0.36)

and SR+HS recovered 88% (P = 0.16) (Fig. 2).

Summary Points

• All repair constructs increase both DRUJ and UCJ stability after the creation of a peripheral

TFCC tear; however, SR demonstrates the least improvement with the most inconsistency in

recovery.

• The addition of HS after SR provides greater improvement in both DRUJ and UCJ stability

when compared to SR alone.

• Consideration should be made for HS as an adjunct procedure in cases where stability cannot

be fully restored with just SR.

Paper 63_Image01

Paper 63_Image02

Reference 1: Dy CJ, Ouellette EA, Makowski AL. Extensor retinaculum capsulorrhaphy for

ulnocarpal and distal radioulnar instability: the Herbert sling. Tech Hand Up Extrem Surg. 2009

Mar;13(1):19-22.

Reference 2: Panjabi M, Abumi K, Duranceau J, Oxland T. Spinal stability and intersegmental

muscle forces. A biomechanical model. Spine (Phila Pa 1976). 1989 Feb;14(2):194-200.

Reference 3: Dy CJ, Ouellette EA, Makowski AL, Milne E, Latta LL. Peripheral triangular

fibrocartilage complex tears cause ulnocarpal instability: a biomechanical pilot study. Clin Orthop

Relat Res. 2012 Oct;470(10):2771-5.

Reference 4: Lawler E, Adams BD.Reconstruction for DRUJ instability. Hand (N Y). 2007

Sep;2(3):123-6.

Reference 5: Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist: anatomy

and function. J Hand Surg [Am]. 1981;6:153Y162.

Paper 64: Achieving the Optimal Epinephrine Effect with Local

Anesthesia in Hand Surgery Clinical Paper Session 12: Hand 2 - Saturday, September 12, 2:15 - 2:22 PM

Surgical Technique,Historical Information,Basic Science,Hand and Wrist,General Principles

Level 2 Evidence

Daniel Mckee, MD

Donald H. Lalonde, MD

Achilles Thoma, MD

Lisa Dickson, MD

Stuart Martin, MD

Hypothesis

In hand surgery, the optimal epinephrine effect from local anesthesia - producing maximal

vasoconstriction and prime visualization- is achieved by waiting significantly longer than the

traditionally quoted 7 minutes from the time of injection.¹ ² ³

Methods

In this prospective comparative study, healthy patients undergoing unilateral carpal tunnel

surgery waited either 7 minutes versus 33 minutes - between the time of injection of 1%

lidocaine with 1:100,000 epinephrine, and the time of incision. A standardized incision was made

through dermis and into the subcutaneous tissue followed by exactly 60 seconds of measuring

the quantity of blood loss using sterile micropipettes (Fig 1).

Results

There was a statistically significant reduction in the mean quantity of bleeding in the group that

waited a mean of 33 minutes after injection and before incision compared to the group that

waited only 7 minutes ( 95% Confidence intervals of 0.06 +- 0.03 ml/cm of incision, compared to

0.17 +- 0.08 ml/cm respectively) (P = 0.03).

Summary Points

• No studies to date have measured micro quantities of intraoperative bleeding in order to

directly quantify the effects of local anesthetic and epinephrine on vasoconstriction in

humans; previous studies have instead used indirect measurements such as laser doppler

and near-infrared spectroscopy (4,5).

• Waiting roughly 33 minutes for the optimal epinephrine effect will result in less

intraoperative bleeding than the traditionally quoted 7 minutes for all hand surgery

procedures using wide awake local anesthesia & no tourniquet (WALANT). Achieving the

optimal epinephrine effect is crucial in order to obtain hemostasis and visualization in

WALANT hand surgery (60. The benefits of WALANT hand surgery include: intraoperative

active movement examinations, as well as a reduction in the cost, waste, and complications

which are associated with the main operating room and general anesthesia (7,8).

Paper 64_Image01

Reference 1: Kryger Z, Sisco Z. Local Anesthetics. In: Kryger ZB, Yagmour T, eds. Practical plastic

surgery. 1st ed. Austin, Texas: Landes Bioscience; 2007:29–32.

Reference 2: Knize DM. Forehead lift. In: Thorne CH, Beasley RW, Aston SJ, Bartlett SP, Gurtner

GC, Spear SL, eds. Grabb and Smith’s Plastic Surgery. 6th ed. Philadelphia: Wolters Kluwer

Health/ Lippincott Williams & Wilkins; 2007:509–517

Reference 3: Larrabee WF Jr, Lanier BJ, Miekle D. Effect of epinephrine on local cutaneous blood

flow. Head Neck 1987;9:287–289.

Reference 4: O’Malley TP, Postma GN, Holtel M, Girod DA. Effect of local epinephrine on

cutaneous bloodflow in the human neck. Laryngoscope 1995;105:140–143.

Reference 5: Mckee D, Lalonde D, Thoma A, Glennie D, Hayward J. Optimal time delay between

epinephrine injection and incision to minimize bleeding. Plast Recontr Surg.2013;131:811-814.

Reference 6: Lalonde DH. Reconstruction of the hand with wide awake surgery. Clin Plast Surg.

2011;38:761–769.

Reference 7: Leblanc M, Lalonde D, Thoma A, Bell M, Wells B, Allen M, Chang P, Mckee D,

Lalonde J. Is main operating room sterility really necessary in carpal tunnel surgery? A

multicenter prospective study of minor procedure room field sterility surgery. Hand. 2011;6:60-

63.

Reference 8: Higgins A, Lalonde DH, Bell M, McKee D, Lalonde JF. Avoiding flexor tendon repair

rupture with intraoperative total active movement examination. Plast Reconstr Surg. 2010;126:

941–945

Reference 9: Lalonde D, Martin A. Tumescent local anesthesia for hand surgery: improved

results, cost, effectiveness, and wide-awake patient satisfaction. Arch Plast Surg. 2014;41:312-

316.

Paper 65: Dennervated SBRN versus Sural Nerve Grafting: A Case-control

Analysis of 75 Patients Clinical Paper Session 12: Hand 2 - Saturday, September 12, 2:22 - 2:29 PM

Treatment,Surgical Technique,Prognosis/Outcomes,Shoulder and Arm,Congenital and Pediatric

Problems,Nerve,General Principles

Level 3 Evidence

Eric Wagner, MD

Nina Suh, MD

Michelle Kircher, BS

Robert Spinner, MD

Allen Bishop, MD, PhD

Alexander Y. Shin, MD

Salary: Mayo Clinic (Shin)

Royalty: Trimed (Shin)

Contracted Research: Bacterin International (Shin)

Other (Please describe): editor Techniques Hand Upper Extremity (Shin)

Hypothesis

The purpose of our study was to perform a case-control analysis of two sources of nerve graft;

the denervated superficial branch of the radial nerve (SBRN) in patients with ipsilateral brachial

plexus injuries and the normal sural nerve in nerve grafting to restore function in the upper

extremity.

Methods

Over a 10-year period, 25 patients underwent SBRN nerve grafting with a dennervated ipsilateral

nerve for brachial plexus injuries, which were T matched 2:1 with 50 patients who underwent

sural nerve grafting by age, gender, and BMI (Comparisons are summarized in Table 1).

Results

The average follow-up for the use of ipsilateral dennervated SBRN patients was 2.5 years (1-7)

and for the sural patients was 2.8 years (1-9). In the dennervated SBRN group, only 3 (12%) of

patients experienced grade III or higher muscle function. All 3 of these patients underwent a

grafting of the spinal accessory to triceps motor branch. This is in contrast to 20 (36%) of the

patients who underwent sural nerve grafting achieving grade III or higher muscle recovery (P <

0.01), including C5, C6, or upper trunk to axillary (n=5) and musculocutaneous (n=7); or spinal

accessory to axillary (n=1), musculocutaneous (n=2), and triceps motor branch (n=5). Only 12%

of the dennervated SBRN group had EMG signs of muscle recovery compared to 61% of the sural

nerve group (P < 0.01). Smoking had a negative impact on muscle recovery, decreasing the rate

of grade III or higher recovery in the dennervated SBRN group (P < 0.01) and the sural group (P =

0.01). No other factors had an impact on muscle recovery. Overall, patients in both groups had

significant improvements in their preoperative to postoperative pain and DASH scores (P < 0.04).

Summary Points

• Use of ipsilateral dennervevated SBRN nerve grafts in patietns with brachial plexus injures

has significantly poorer outcomes when compared to sural nerve grafts in the treatment of

brachial plexus injuries in a matched series.

• The use of this deinnervated nerve should be saved for situations when no other nerves

grafts are available and should be avoided when sural nerve grafts are available.

• Patients also should be counseled on the risks of smoking when choosing to undergo brachial

plexus reconstruction.

Paper 65_Image01

Paper 66: Benign Hand Tumors Have a Clear Indication for Surgery

According to the Patient-rated Outcome Measures Clinical Paper Session 12: Hand 2 - Saturday, September 12, 2:29 - 2:36 PM

Treatment,Prognosis/Outcomes

Level 3 Evidence

Michiro Yamamoto, MD

Takanobu Nishizuka, MD

Katsuyuki Iwatsuki, MD, PhD

Shigeru Kurimoto, MD

Hitoshi Hirata, MD

Hypothesis

The purpose of this study was to report the patient-rated outcome measures (PROMs) using the

Hand20 questionnaire (Suzuki et al. JBJS 2010) before and after surgery of the benign upper limb

tumor. We hypothesized that benign upper limb tumors have a clear indication for surgery

according to the PROMs.

Methods

This study included 301 consecutive patients with histories of benign bone and soft tissue

tumors of the upper limb, who had undergone surgery. There were 130 male and 171 female

patients with a mean age of 45 years (range, 11–87 years). The diagnoses included 72 ganglions,

37 vascular tumors, 31 giant cell tumors of tendon sheath (GCTTS), 24 schwannomas, 21

lipomas, 21 enchondromas, 17 glomus tumors, 16 fibromas, 15 exostoses, 12 epidermoid cysts,

6 vascular leiomyomas, 6 granulomas, and 23 others.

The tumors were located on the finger in 147 cases, hand in 51 cases, wrist in 61 cases, forearm

in 18 cases, elbow in 16 cases, and upper arm and axilla in 8 cases.

Tumor size was classified into 3 groups: smaller than 1 cm (45 cases), between 1 and 3 cm (157

cases), and larger than 3 cm (99 cases).

We have prospectively assessed PROMs using Hand20 questionnaire before and after surgery.

The mean period from surgery to assessment was 21 months (range, 6–78 months).

Results

The mean Hand20 and pain scores significantly improved in patients with ganglions, vascular

tumors, GCTTS, schwannomas, enchondromas and lipoma. The mean pain scores in patients

with glomus tumors improved significantly, but the mean Hand20 scores improved without

significance. In patients with fibromas, exostoses, epidermoid cysts, granulomas, and vascular

leiomyomas, both the mean Hand20 and pain scores improved without statistical

significance.(Figure 1 and 2)

As to the size of the tumors, the mean Hand20 and pain scores significantly improved in all 3

groups.

The mean Hand20 scores were significantly improved in patients with tumors located in the

finger, thumb, hand, and wrist. However, the mean Hand20 scores were improved without

statistical significance in patients with tumors located in the forearm, elbow, upper arm, and

axilla.

Summary

Upper limb tumors are frequently encountered by hand surgeons. Surgery is indicated not only

to sample the tumor tissue for definitive diagnosis, but also to improve the function and

aesthetic outcome of the hand. According to the results of PROM, benign hand tumors located

within the distal upper limb have a clear indication for surgery.

Paper 66_Image01

Paper 66_Image02

Reference 1: Suzuki M, Kurimoto S, Shinohara T, et al. Development and validation of an

illustrated questionnaire to evaluate disabilities of the upper limb. J Bone Joint Surg Br. 2010, 92:

963-9.

Paper 67: av integrin is a Crucial Regulator in the Development of

Dupuytren Contracture Clinical Paper Session 12: Hand 2 - Saturday, September 12, 2:36 - 2:43 PM

Basic Science

N/A - Not a clinical study

Yuichiro Matsui, MD, PhD

Shigeyuki Kon, PhD

Tadanao Funakoshi, MD, PhD

Tomoe Miyashita, Undergrad

Tadashi Matsuda, PhD

Norimasa Iwasaki, MD, PhD

Hypothesis

Although Dupuytren contracture is characterized by myofibroblast development and increased

cytokines including transforming growth factor-ß1 (TGF-ß1) in the palmar fascia, the relationship

between TGF-ß1 and av integrin, which is considered to be related to fibrosis, has not been

clearly elucidated. We hypothesized that av integrin would play an important role in the

development of Dupuytren contracture.

Methods

Seven male patients whose mean age at the time of surgery was 70.7 years (range, 68 to 73)

underwent partial fasciectomy as treatment for Dupuytren contracture. The nodule and cord

were isolated from the palmar fascial tissues of the patients. Normal palmar fascia was obtained

from seven control patients with carpal tunnel syndrome undergoing carpal tunnel release.

These included two male and five female patients whose mean age at the time of surgery was

67.0 years (range, 36 to 88). Histologic and immunohistochemical analyses were performed to

investigate the expression patterns of the myofibroblast and integrins. The expression of TGF-ß1

and av-, a4-, ß6-, ß8-integrins were assessed by real-time PCR reaction. Statistical comparisons

were performed using paired t-tests (P < 0.05).

Results

The spreading and proliferation of fibroblasts were found in nodules, while few fibroblasts were

detected in cords and normal palmar fascia. In immunohistochemical analysis, alpha-smooth-

muscle-actin (a-SMA)-positive cells were mainly observed in nodules, while few a-SMA-positive

cells were found in normal palmar fascia. Among the a-SMA and integrins, a-SMA and av integrin

were markedly induced and co-localized in nodules. Real-time PCR analysis confirmed that the

expression of TGF-ß1 and av integrin genes were significantly increased in nodules, as compared

to those in normal palmar fascia (P = 0.004 and P = 0.006, respectively) (Figure 1A and 1B).

Summary

Henderson et al. showed that av integrin controls a core molecular pathway that regulates

fibrosis in several organs. In fact, we found the expression of TGF-ß1 and av integrin were

significantly increased in nodules, as compared to those in normal fascia. The obtained results

indicate that av integrin is a critical intrinsic regulator of the growth of fibrous tissue in

Dupuytren contracture via regulating TGF-ß1 expression. av integrin will become a target

molecule for the injection treatment of Dupuytren contracture.

Paper 67_Image01

Paper 67_Image02

Reference 1: Henderson NC, Arnold TD, Katamura Y et al. Targeting of alphav integrin identifies a

core molecular pathway that regulates fibrosis in several organs. Nature medicine. 2013, 19:

1617-24.

Reference 2: Magro G, Lanzafame S, Micali G. Co-ordinate expression of alpha 5 beta 1 integrin

and fibronectin in Dupuytren's disease. Acta histochemica. 1995, 97: 229-33.

Reference 3: Kloen P. New insights in the development of Dupuytren's contracture: a review.

British journal of plastic surgery. 1999, 52: 629-35.

Reference 4: Balaguer T, David S, Ihrai T, Cardot N, Daideri G, Lebreton E. Histological staging and

Dupuytren's disease recurrence or extension after surgical treatment: a retrospective study of

124 patients. The Journal of hand surgery, European volume. 2009, 34: 493-6.

Reference 5: Hurst LC, Badalamente MA, Hentz VR et al. Injectable collagenase clostridium

histolyticum for Dupuytren's contracture. The New England journal of medicine. 2009, 361: 968-

79.

Paper 68: The Effect of Corticosteroid Concentration on Glycemic

Control in Patients with Diabetes Mellitus Clinical Paper Session 12: Hand 2 - Saturday, September 12, 2:43 - 2:50 PM

Treatment,Prognosis/Outcomes,Hand and Wrist

Level 2 Evidence

Amar Arun Patel, MD

Nikola Lekic, MD

Megan E. Fleming, MD

David Chen, MD

Patrick W. Owens, MD

Morad Askari, MD

Hypothesis

Corticosteroid injections have proven to be less effective in diabetic patients and may result in

transient elevations in blood glucose levels. We hypothesize that triamcinolone injected at a

concentration of 10 cc/ mg (T-10) is equally successful, safer, and more cost-effective than

triamcinolone 40 cc/mg (T-40).

Methods

All patients with type II diabetes mellitus and presenting to a university-based hand surgery clinic

were prospectively- enrolled in this study if they were candidates for a corticosteroid injection.

Either T-10 or T-40 was administered based on surgeon preference. Fasting glucose the morning

of injection, QuickDash scores prior to injection, and location of pain were recorded. Blood

glucose was recorded the evening of the injection, and the fasting glucose was recorded each

morning until it normalized back to the pre-injection levels. QuickDash and VAS scores were

recorded at 6 weeks. Statistical analysis was represented with means, standard deviations, and

student’s T-test for comparisons when needed.

Results

Patients in both cohorts on average had improvements in their QuickDash and VAS scores after

the injection, and there was no significant variation between cohorts. There was a significant

elevation in blood glucose regardless of injection type (P = 0.005). The T-10 group had an

average maximum glucose elevation of 53 (41%) points, which returned to baseline at 21 hours.

In contrast, T-40 had a maximum glucose of 50 (40%) points returning in 54 hours to baseline.

The difference in time to return to baseline trended towards statistical significance (P = 0.07). No

patients in either cohort had glucose elevations that required adjunct insulin treatment or

evaluation in the emergency room. T-10 was also 4 times cheaper ($2.40 versus $9.96 per cc)

than T-40 per injection administered.

Summary Points

• Both T-10 and T-40 are effective in relieving painful symptoms and improving patient

functionality after injection.

• A lower concentration of triamcinolone steroid is associated with a quicker return of blood

glucose to baseline.

• T-10 is a cheaper and more cost-effective alternative to T-40.

Paper 68_Image01

Reference 1: Blyth MJ, Ross DJ. Diabetes and trigger finger. J Hand Surg Br. 1996 Apr;21(2):244-

5.

Reference 2: Baumgarten KM, Gerlach D, Boyer MI. Corticosteroid injection in diabetic patients

with trigger finger. A prospective, randomized, controlled double-blinded study. J Bone Joint

Surg Am. 2007 Dec;89(12):2604-11.

Reference 3: Catalano LW 3rd, Glickel SZ, Barron OA, Harrison R, Marshall A, Purcelli-Lafer M.

Effect of local corticosteroid injection of the hand and wrist on blood glucose in patients with

diabetes mellitus. Orthopedics. 2012 Dec;35(12):e1754-8.

Reference 4: Wang AA, Hutchinson DT.The effect of corticosteroid injection for trigger finger on

blood glucose level in diabetic patients. J Hand Surg Am. 2006 Jul-Aug;31(6):979-81.

Paper 69: Unplanned Readmissions Following Outpatient Hand and

Elbow Surgery Clinical Paper Session 13: Elbow - Saturday, September 12, 2:15 - 2:22 PM

Prognosis/Outcomes,Hand and Wrist,Elbow and Forearm

Level 3 Evidence

Mohamed Noureldin, MD

Elizabeth B. Habermann, PhD

Daniel S. Ubl

Sanjeev Kakar, MD, MBA

Royalty: Skeletal Dynamics (Kakar)

Consulting Fee: Arthrex, Skeletal Dynamics (Kakar)

Contracted Research: Arthrex (Kakar)

Hypothesis

Readmission following surgery is a quality metric tracked by many institutions including

Government agencies. The incidence of readmission following outpatient hand and elbow

surgery is not reported. We utilized the American College of Surgeons National Surgical Quality

Improvement Program (ACS-NSQIP) database to determine the incidence of unplanned thirty-

day readmission and the associated perioperative characteristics of patients undergoing

outpatient hand and elbow surgery.

Methods

The ACS-NSQIP database was queried to identify patients undergoing outpatient hand and elbow

surgery between 2011 and 2013. The patients were identified using 407 hand-and-elbow-

specific CPT codes. NSQIP captures 30-day readmissions that take place at the index hospital as

well as any other hospital. Patients who underwent any other concomitant surgery were

excluded from the analysis. Patients who required an unplanned readmission were compared

with those who were not readmitted. Preoperative patient characteristics, intraoperative

variables, days from procedure to discharge, 30-day complication rates, and mortality were

compared between the cohorts. An a = 0.001 denoted statistical significance due to the large

sample size.

Results

A total of 18,174 outpatient hand and elbow surgeries were identified between 2011 and 2013

of which 202 patients (1.1%) required an unplanned readmission. Patients who required

readmission were significantly older (58 vs. 50 yr; P < 0.001) and experienced longer operative

time (80 vs. 64 mins; P < 0.001). Pre-operative comorbidities including diabetes, hypertension,

COPD,, renal dialysis, and steroid use were more prevalent in the readmitted cohort (P < 0.001).

Likewise, ASA class 3 and 4 were more prevalent in the readmitted cohort (P < 0.001). These

patients had greater incidences of postoperative morbidity and mortality (P < 0.001).

Summary

The incidence of unplanned readmission following outpatient hand and elbow surgery is low.

Nevertheless, patients who were readmitted experienced higher incidences of postoperative

complications and mortality.

These data may be helpful for risk stratification of these patients prior the surgery.

Further analysis is warranted to characterize the independent predictors of readmission

following outpatient hand and elbow surgery.

Paper 69_Image01

Paper 69_Image02

Paper 70: Non-surgical Functional Treatment for Displaced Olecranon

Fractures in the Elderly Clinical Paper Session 13: Elbow - Saturday, September 12, 2:22 - 2:29 PM

Treatment,Prognosis/Outcomes,Elbow and Forearm

Level 4 Evidence

Gerardo L. Gallucci, MD

Jorge G. Boretto, MD

Nicolas Piuzzi, MD

Pablo Slullitel, MD

Pablo De Carli, MD

Hypothesis

Olecranon fractures is most commonly found in elderly patients with multiple comorbidities, low

demands and a diminished bone quality, which sometimes makes fixation difficult. Although

good surgical outcomes have been reported in elderly patients, some authors presented

complications in up to 30% of the cases. Given the number of elderly patients sustaining theses

injuries, research is required to determine the role of non-operative treatment for displaced

fractures, since there is not much literature that compares surgical and non-surgical treatments.

The purpose of this study was to evaluate retrospectively the clinical and radiological outcomes

of a consecutive cohort of patients over 70 years old with displaced olecranon fractures

functionally treated.

Methods

During a 30-months period, we collected data on all patients with olecranon fractures who

presented in our service. Inclusion criteria were: patients with displaced fracture older than 70

years old, acceptance and completeness the proposed protocol of treatment and more than

one-year follow-up. An articular gap or a gap at the level of the posterior cortical of the

olecranon bigger than 5mm was considered a displaced fracture. Twenty-eight patients were

included. The elbow was immobilized with a long arm cast at 90° of elbow flexion for an average

of five days (4 to 7). Then, the cast was removed and a sling placed. Active mobilization was

indicated as tolerated. No patients were lost in this study. Twenty-seven were female. Average

age was 82 years (71 to 91). Twenty-two patients had osteoporosis. According to Mayo Clinic’s

Classification, 18 fractures were type IIA and 10 were IIB.

Results

At a mean follow-up of 16 months (range 12-26), the average flexo-extension was 140º-15° (92%

of the contralateral side). The average pain was 1 (0 to 8) and the average degree of satisfaction

was 9 (8 to 10), according to VAS. Elbow extension strength was M5 in 17 patients and M4 in

nine. Average MEPI score was 95. Twenty-two patients evolved into a non-union. No patient

required surgical treatment.

Summary Points

• Non- surgical functional treatment of displaced olecranon fractures in the elderly showed a

functional range of motion with a high rate of satisfaction.

• Although an important number of non-unions were present, most were well tolerated and it

was not necessary to operate on any of the patients.

Reference 1: Duckworth AD, Clement ND, Aitken SA, Court-Brown CM, McQueen MM. The

epidemiology of fractures of the proximal ulna. Injury 2012;43:343–346.

Reference 2: Umer S, Vioreanu M, Baker J, Fleming P. Olecranon fractures in the elderly: is

tension band wiring the right treatment? Injury Extra 2011;42:122.

Reference 3: Veras Del Monte L, Sirera Vercher M, Busquets Net R, et al. Conservative treatment

of displaced fractures of the olecranon in the elderly. Injury 1999;30:105–110.

Paper 71: Olecranon Osteotomy Facilitated Elbow Release (OFER): A

Simplified, Safe and Effective Approach for the Treatment of Elbow

Contracture Clinical Paper Session 13: Elbow - Saturday, September 12, 2:29 - 2:36 PM

Treatment,Surgical Technique,Prognosis/Outcomes,Elbow and Forearm

Level 4 Evidence

Scott Edwards, MD

Hypothesis

Is it possible to minimize the dissection necessary to completely release severe elbow

contractures in a less complicated manner than traditional open or arthroscopic techniques?

The purpose of this study is to evaluate the safety and efficacy of a new surgical technique which

releases elbow contractures through the exposure of an olecranon osteotomy.

Methods

21 consecutive patients with established elbow contractures and who had failed to respond to

nonoperative treatments underwent an osteotomy-facilitated elbow release (OFER). Average

preoperative arc of motion was 28 degrees (ranged from 0 degrees to 45 degrees). Minimum

follow up was 24 months. Average patient age was 35 years (range: 28 to 53yrs). Average time

between the initial injury or most recent surgery and OFER was 14 months (ranges: 6 to 22

months). Conditions resulting in contracture include supracondylar humerus fracture treated

with ORIF (14 patients), terrible triad fracture-dislocation (4 patients), spontaneous heterotopic

ossification following head injury (2 patients), and olecranon malunion (1 patient). Average

flexion-extension arc was 35° (range: 0-60°). All patients received rehabilitative services begin

within the first postoperative day. Following the OFER procedure, patients were evaluated in

terms of motion, pain, DASH scores, and complications. No patients were lost to follow up.

Results

Average operative time was 45 minutes and average incision length was 10 cm. At final follow

up, average flexion-extension arc increased 110°. Average pain was reported to be 1 out of 10

(range: 0-2). DASH scores demonstrated high functioning abilities compared to control

populations. All olecranon osteotomies healed. There were no nonunions, malunions, or

problems with joint instability. One patient developed ulnar neuritis four weeks after surgery

that spontaneously resolved.

Summary Points

• Osteotomy-facilitated elbow release (OFER) appears to be a safe and effective alternative to

more invasive open release or more technically demanding arthroscopic elbow releases.

• All intrinsic and extrinsic causes for the contracture, including extensive heterotopic bone,

may be addressed through this exposure.

• Results of the OFER are similar or better than those reported for more traditional open or

arthroscopic procedures.

• Anecdotal observations suggest that the OFER procedure may be faster, easier, safer and

results in less postoperative swelling and consequently facilitates rehabilitation over more

traditional techniques.

Paper 71_Image01

Paper 72: Phase 2a Study of Safety/Efficacy of Collagenase (CCH) in

Patients with Adhesive Capsulitis Clinical Paper Session 13: Elbow - Saturday, September 12, 2:36 - 2:43 PM

Treatment,Shoulder and Arm

Level 1 Evidence

Edward D. Wang, MD

Marie A. Badalamente, PhD

Sean MacKenzie, MD

Michael Skyhar, MD

Greg Kaufman, MD

James Tursi, MD

Contracted Research: Auxilium Pharmaceuticals (Wang, MacKenzie, Skyhar)

Royalty: Biospecific Technologies Corp. (Badalamente)

Consulting Fee: Cayenne Medical (Skyhar)

Salary: Auxilium Pharmaceuticals, Inc. (Kaufman, Tursi)

Fees for Non-CME Services Received Directly from a Commercial Interest or its Agent:

Auxilium Pharmaceuticals, Inc. (Kaufman)

Other (Please describe): Stock options, Auxilium Pharmaceuticals, Inc. (Tursi)

Hypothesis

This phase 2a, open-label, controlled, dose-ranging, multicenter study was designed to assess

the safety and efficacy of CCH compared to an exercise-only control group in patients with Stage

2(frozen)unilateral idiopathic adhesive capsulitis.

Methods

Four cohorts of 10 patients each received up to 3 ultrasound-guided extra-articular

injections,(Figure 1) directed on to the anterior capsule, midway between the tip of the coracoid

and the bicipital groove, of 0.29 mg or 0.58mg of CCH (in varying volumes: 0.5, 1, or 2 mL),

separated by 21 days. Cohort 5 (n=10) performed home shoulder exercises only. The primary

endpoint was change, in degrees, from baseline to Day 92 in AROM forward flexion compared to

the exercise-only cohort. Secondary endpoints were change in passive ROM forward flexion and

changes in AROM and PROM of 3 additional planes (abduction, external/internal rotation).

Function and pain were assessed. Adverse events (AEs) were assessed. Baseline and end of study

MRIs were obtained for all patients.

Results

50 patients (10 male, 40 female) at 11 sites throughout the US with a mean age of 54 years

(range, 41-74) were enrolled. The 0.58mg/1mL and 0.58mg/2mL dosing arms showed significant

improvement from baseline in AROM forward flexion vs. the exercise-only group (P = 0.0131 and

P = 0.0385, respectively). Trends with improvement in AROM were also seen in the other CCH

treated cohorts. PROM forward flexion was significantly improved in the 0.58mg/1mL and

0.58mg/2mL dosing arms compared to exercise only. The 0.58mg/1mL treatment group also

showed significant improvements in passive ROM abduction and external rotation compared to

exercise only. Passive ROM internal rotation was significantly increased in the 0.58mg/0.5mL

cohort compared to exercise only. Twenty-nine patients (72.5%) received 3 CCH injections, 5

patients received 2 injections, and 6 received 1 injection. Both the 0.58mg/1mL and 0.58mg/2mL

cohorts had significant improvement in pain and function from baseline vs. the exercise-only

group (P < 0.05). Treatment-related AEs with CCH were transient and confined to the local

injection site and ipsilateral arm/shoulder. AEs of injection site pain and injection site swelling

resolved in ~7 days without intervention. There were no serious AEs. Baseline and Day 92 MRI

evaluations indicated no clinically significant rotator cuff injuries or other safety findings.

Summary Points

• Extra-articular injection of CCH (1mL and 2mL) significantly improved ROM, shoulder

function, and pain compared to an exercise-only treatment regimen in patients with

adhesive capsulitis.

• The safety profile was consistent with prior studies(1,2) and CCH use in other indications.

Paper 72_Image01

Reference 1: 1Badalamente, M.A., Wang, E. Enzymatic Capsulotomy for Adhesive Capsulitis of

the Shoulder. AAOS, Annual Meeting, Chicago, March, 2006.

Reference 2: Badalamente MA, Wang ED, Hurst LC. Injectable Clostridial Collagenase: Striving

Towards Nonoperative Treatments for Fibroproliferative Disorders. 2009 Orthopaedic Research

and Education Foundation Clinical Research Award. Joint Session of the Orthopaedic Research

Society and AAOS, February 2009.

Paper 73: Prospective Evaluation of Opioid Utilization After Upper

Extremity Surgery: Determining Consumption Patterns and Developing

Prescribing Guidelines Clinical Paper Session 13: Elbow - Saturday, September 12, 2:43 - 2:50 PM

Evaluation/Diagnosis,Treatment,Surgical Technique,Prognosis/Outcomes,Hand and Wrist,Elbow

and Forearm,Shoulder and Arm,General Principles

Level 2 Evidence

Nayoung Kim, BS

Jonas L. Matzon, MD

Asif Ilyas, MD

Mitchel Maltenfort, PhD

Hypothesis

While adequate management of post-operative pain with oral analgesics is an important aspect

of surgery, it remains unclear how many pills are necessary to appropriately manage post-

operative pain. The purpose of our prospective study was two-fold: (1) to evaluate opioid

consumption after outpatient upper extremity surgery, and (2) to evaluate opioid utilization

patterns in order to develop prescribing guidelines.

Methods

Nine board-certified hand surgery fellowship-trained orthopaedic surgeons prospectively

collected data for six consecutive months on all patients undergoing outpatient upper extremity

surgery. Data included patient demographics, surgical details, anesthesia type, and opioid

prescription and consumption patterns. Linear regression was used for statistical analysis.

Results

A total of 1,466 patients with an average age of 55 years (range 5-93) were included. On

average, surgeons prescribed 25 pills (range 0-110), while patients consumed 8.1 pills (range 0-

90), resulting in a utilization rate of 32%. Only 6% of patients received disposal information. Soft

tissue procedures required less opioids (5.1 pills for 2.2 days) compared to fractures (12.2 pills

for 4.1 days) or joint procedures (14.6 pills for 5.0 days) (P < 0.01). Both hand and wrist surgeries

utilized an average of 7.6 pills, compared to 10.6 pills for forearm/elbow surgeries, and 22 pills

for arm/shoulder surgeries (P < 0.01). Patients undergoing surgery with only local anesthesia

consumed the least opioids (4.5 pills for 2 days), compared to patients anesthetized with

sedation (5.7 pills for 2.6 days), general (12.2 pills for 4.0 days), and regional (15 pills for 4.8

days) (P < 0.01). Based on morphine equivalents, procedure type, anatomical location, and

anesthesia type significantly influenced the amount of opioid used (P < 0.001). In contrast, age

and insurance, was found to not statistically affect opioid consumption.

Summary Points

• To the best of our knowledge this is the largest prospective evaluation of opioid consumption

to date and we found that patients in our series are being over-prescribed pain medications

post-operatively for hand & upper extremity surgery.

• Patients only utilized 32% of their prescribed pain medication, thereby leaving 68% of unused

prescribed narcotics available for potential diversion.

• Very few patients (6%) received safe disposal information for excess pain medication by their

prescriber, surgical facility, or pharmacy.

• Surgeons should consider prescribing less pain medications on average and base it upon the

procedure type, anatomic location, and mode of anesthesia.

Paper 74: Wrist Arthroplasty: A Complicated Matter Clinical Paper Session 14: Arthroplasty - Saturday, September 12, 3:35 - 3:42 PM

Evaluation/Diagnosis,Treatment,Patient Education,Prognosis/Outcomes,Hand and Wrist

Level 3 Evidence

Patrick M. Kane, MD

Michael Gaspar, MD

Jesse Lou, BA

Sidney Jacoby, MD

Hypothesis

Despite continued advances in implant design for partial and total wrist arthroplasty, these

surgeries present a high incidence of complications, many of which require revision surgery with

the potential of a complicated post-operative course. We hypothesize that the incidence of

complication is higher then the current reported literature. Follow up duration averaged 2.6

years with longest being 12.4 years.

Methods

A retrospective review of 105 wrist surgeries in 100 patients who underwent surgery with

prosthetic replacement of the distal radius, the proximal carpus or both at a single institution

(2005-2014) was performed. Patient factors including age, sex, BMI, handedness, underlying

disease and previous injury were recorded. Outcomes were focused particularly on post-

operative complications and need for revision surgery.

Results

Fourty-seven total wrist arthroplasties (TWA), 52 distal radius hemi-arthroplasties (DRH), and 6

proximal carpal hemiarthroplasties (CH) were performed. Majority (61.7%) of TWA were

performed for Rheumatoid Arthritis (RA) or other inflammatory arthropathies, whereas

degenerative or post-traumatic arthritis represented the underlying condition for majority of

both the DRH (76.9%), and CH (66.7%) groups. Overall complication rate was 50.1% (53/105).

Post-operative contracture accounted for the largest number of complications needing

additional surgery (20%) though the incidence was much higher in DRH than in TWA (42.3 vs.

16.7%). Component failure composed 15% of all complications, with TWA having the highest

incidence across the groups with 24%. Superficial infections occurred at 7.1 and 7.6% in TWA

and DRH, respectively. One superficial infection resulted in wound dehiscence that was

operatively debrided and closed. All other superficial infections resolved with a short course of

oral antibiotics. Deep infections occurred in 4.7 and 3.8% of TWA and DRH, respectively. They

were associated with a high number of medical co-morbidities and multiple prior surgeries. All

deep infections required removal of hardware, antibiotic spacer placement, and a prolonged

course of IV antibiotics prior to a definitive operation.

Summary Points

• Though total and partial wrist arthroplasty can provide significant pain relief for the

arthritic wrist, there remains a significant potential for complications and need for

further surgery.

• Patients should be counseled on the potential risks and post-operative course.

• It should be noted that the likelihood of failure of wrist arthroplasty tends to increase as

time from surgery increases.

• Certain patients should be screened with great caution, particularly those with multiple

medical co-morbidities, and those pre-disposed to wound issues such as those with low

BMI, or poor skin quality.

Reference 1: Nydick JA, Watt JF, Garcia MJ, Williams BD, Hess AV. Clinical outcomes of

arthrodesis and arthroplasty for the treatment of posttraumatic wrist arthritis. J Hand Surg Am

2013;38:899–903

Reference 2: Weiss AP, Kamal RN, Shultz P. Total wrist arthroplasty. J Am Acad Orthop Surg

2013;21:140–8.

Reference 3: Kistler U, Weiss AP, Simmen BR, Herren DB. Long-term results of silicone wrist

arthroplasty in patients with rheumatoid arthritis. J Hand Surg Am 2005;30:1282–7.

Reference 4: Weiss AP, Akelman E. Total wrist replacement. Med Health R I 2012:95:117–9.

Reference 5: Herzberg G. Prospective study of a new total wrist arthroplasty: short term results.

Chir Main 2011;30:20–5.

Reference 6: Stegeman M, Rijnberg WJ, van Loon CJ. Biaxial total wrist arthroplasty in

rheumatoid arthritis. Satisfactory functional results. Rheumatol Int 2005;25:191–4.

Paper 75: Intraoperative and Postoperative Fractures in Total Wrist

Arthroplasty: Risk Factors and Long-term Outcomes Clinical Paper Session 14: Arthroplasty - Saturday, September 12, 3:42 - 3:49 PM

Evaluation/Diagnosis,Treatment,Surgical Technique,Prognosis/Outcomes,Hand and

Wrist,Diseases and Disorders,General Principles

Level 2 Evidence

Eric R. Wagner, MD

Kapil Mehrotra, MD

Marco Rizzo, MD

Hypothesis

There is a paucity of literature evaluating periprosthetic fractures in total wrist arthroplasty. The

purpose of this study was to assess the factors that contributed to an increased risk for fracture

and the long-term outcomes after fracture stabilization.

Methods

At a single institution over a 40-year period from 1974-2013, 425 total wrist arthroplasties were

performed, with a minimum of 2-year follow-up for inclusion into this study. Demographics

included age (57 years), BMI (27), and female (72%). The mean OR time was 185 minutes, while

the mean tourniquet time was 135 minutes. The primary diagnosis for the TWA included 22 (5%)

osteoarthritis (OA), 375 (88%) inflammatory arthritis, and 28 (7%) post-traumatic arthritis. The

implants breakdown was: Remotions (n=31), Biax (n=159), Volz (n=33), Meuli (n=138), Universal

(n=7), and Swanson (n=57). 357 (84%) were cemented, while 36 (8%) required bone graft.

Results

Intraoperative periprosthetic fractures occurred in 9 (2%) wrists. The distal metacarpals where

fractured in 5, while the distal radius was fractured in 4. Univariate regression analysis

demonstrated that increasing age (P = 0.007), Biax implants (P = 0.07), and osteoarthritis (P =

0.07) in increased fracture risk, as summarized in Table 1. At a mean follow-up of 12 years (2-22),

1 (8%) patient who had an intraoperative fracture suffered a postoperative fracture, compared

to 12 (3%) patients without intraoperative fractures (P = 0.27). (P = 0.27). One patient who had

an intraoperative fracture underwent revision surgery for pain and limited motion. No other

patients suffered any complications. The 5 and 10 year survival after intraoperative fracture was

88%, 88%, compared to 84% and 74% without a fracture (P = 0.39).

There were 13 patients who suffered postoperative fractures overall. The 5, 10, and 20 year

survival free of postoperative fracture was 99%, 96%, and 94%, respectively. The implant

breakdown for these fractures was Swanson (n=5), Volz (n=0), Meuli (n=4), Biax (n=3), Remotion

(n=1), Universal (n=0). The risk of postoperative fracture was increased by increasing age (P =

0.07), while patients with Swanson (P = 0.02) and Volz (P = 0.14) implants had lower rates of

fracture.

Summary Points

• Intraoperative fractures occur in approximately 2% of total wrist arthroplasties. When

properly stabilized, these do not affect long-term outcomes.

• The implant design is an important factor in the risk of intraoperative and postoperative

fractures.

Paper 75_Image01

Paper 75_Image02

Paper 76: Cementless or Cemented Fixation in Proximal Interphalangeal

Joint Surface Replacement Arthroplasty? Clinical Paper Session 14: Arthroplasty - Saturday, September 12, 3:49 - 3:56 PM

Treatment,Prognosis/Outcomes,Hand and Wrist

Level 1 Evidence

Maiken Stilling, MD, PhD

Bo Munk, MD

Ole Rahbek, MD, PhD

Kjeld Soballe, MD, DMsC

Lone Romer, MD

Karsten Kroner, MD

Hypothesis

A surface replacement (SR) proximal interphalangeal (PIP) joint arthroplasty is a motion and

stability preserving reconstructive surgical option for the painful osteoarthritic PIP joint, but the

optimal fixation method is debated(1,2,3,4,5). We compared cementless with cemented fixation

of SR PIP joint arthroplasty, and hypothesized better implant stability and less bone stress

shielding with cementless fixation.

Methods

In a prospective, parallel-group, randomized patient-blinded clinical trial, we included 30 hands

in 30 patients (7 M) at a mean age of 56 years (34-69) with osteoarthritis in one of the 4 ulnar

fingers. Cemented (n=15) or cementless (n=15) fixation of SR PIP joint arthroplasty (PIP-SRA, SBI)

was used. Dorsal Chamay approach was used. Tantalum beads were inserted in the bone and

mounted on the components for marker-based radiostereometry (RSA). Patients were followed

6 times during 2 years. Outcome was evaluated by 1) implant migration (RSA), 2) periprosthetic

bone mineral density (BMD) changes, and 3) clinical assessment of pain (VAS), ROM, PVA,

grip/pinch strength, and complications.

Results

At 1 and 2 years, cementless fixation of the proximal component resulted in less rotation about

the long-axis of the prosthesis (P 0.08). At 2 years, 5/13 patients with cemented and 1/13

patients with cementless fixation reported pain during motion (VAS>4) (P = 0.16). ROM was

similar between groups at 2 years with mean 61° active flexion, mean -6° active extension, and

mean 4cm PVA. Only the cementless group improved grip and pinch strength significantly at 2

years follow-up. We saw one early wound infection, 7 patients (3 C and 4 CL) with swan neck

deformity, and 2 patients (1 in each group) were amputated because of poor function.

Summary Points

• Cementless fixation was superior for the proximal component with better rotation stability.

• Cementless fixation seems to have a more physiological bone stress-shielding with regain of

periprosthetic BMD at 2 years.

• Grip and pinch strength increased only in the cementless group, and there was a tendency

towards less pain at 2 years follow-up for cementless fixation.

Paper 76_Image01

Paper 76_Image02

Reference 1: Linscheid RL, Murray PM, Vidal MA, Beckenbaugh RD. Development of a surface

replacement arthroplasty for proximal interphalangeal joints. J Hand Surg [Am ] 1997; 22(2):286-

298

Reference 2: Daecke W, Veyel K, Wieloch P, Jung M, Lorenz H, Martini AK. Osseointegration and

mechanical stability of pyrocarbon and titanium hand implants in a load-bearing in vivo model

for small joint arthroplasty. J Hand Surg [Am ] 2006; 31(1):90-97.

Reference 3: Murray PM. Surface replacement arthroplasty of the proximal interphalangeal joint.

J Hand Surg Am 2007; 32(6):899-904

Reference 4: Jennings CD, Livingstone DP. Surface replacement arthroplasty of the proximal

interphalangeal joint using the PIP-SRA implant: results, complications, and revisions. J Hand Surg

Am 2008; 33(9):1565-11

Reference 5: Johnstone BR, Fitzgerald M, Smith KR, Currie LJ. Cemented versus uncemented

surface replacement arthroplasty of the proximal interphalangeal joint with a mean 5-year

follow-up. J Hand Surg Am 2008; 33(5):726-732

Paper 77: An Analysis of 583 Metacarpophalangeal Arthroplasties for the

Management of Inflammatory Arthritis Clinical Paper Session 14: Arthroplasty - Saturday, September 12, 3:56 - 4:03 PM

Treatment,Prognosis/Outcomes,Hand and Wrist,Diseases and Disorders,General Principles

Level 3 Evidence

Eric R. Wagner, MD

Matthew Houdek, MD

Steven L. Moran, MD

Marco Rizzo, MD

Consulting Fee: Intregra (Moran)

Hypothesis

Metacarpophalangeal (MCP) arthroplasty has shown promise in treating inflammatory arthritis,

however, there is a lack of studies comparing different implant designs and their effect on

function. The purpose of this study was to assess the outcomes of MCP joint arthroplasty in

inflammatory arthritis, with a comparison of the 3 most common types of implants.

Methods

Utilizing a single institution’s joint registry, we examined 583 MCP arthroplasties performed in

142 patients with inflammatory arthritis from 1998 to 2012. The mean age at surgery was 61

years and a BMI of 25.63% involving the dominant extremity.86% were females, 11% smokers,

and 12% had diabetes mellitus (DM). Implant types included pyrocarbon (n=155), silicone

(n=366), and SRA (n=61). Patient characteristics comparisons, with the exception of age, did not

differ significantly between implants. For pyrocarbon, SRA, and silicone groups age averaged (53,

54, 65), females (81%, 89%, 88%), smokers (12%, 0%, 11%), and DM (12%, 3%, 11%).

Results

There were 38 revision surgeries performed at a mean 2 years postoperatively. The 2, 5 and 10

year survival rates were 98%, 95%, and 87%, respectively. The 5-year survival rates for the

pyrocarbon, SRA, and silicone implants were 91%, 84%, and 99%, respectively (Figure 1, silicone

(blue), pyrocarbon (red), and SRA (green)). Patients receiving a SRA (HR 3.42, P < 0.001) and

pyrocarbon (HR 2.60, P = 0.005) had an increased risk of revision arthroplasty compared to

silicone implants. Intraoperative fractures and use of cement also increased implant failure risk

(Table 1). There were 15 intraoperative complications involving a periprosthetic fracture, while

postoperative complications included 19 dislocations, 2 heterotopic ossifications, 4

postoperative fractures and 9 infections. Pyrocarbon implants were associated with an increased

rate of dislocation (P < 0.001) and HO (P = 0.02). In those unrevised patients, at a mean 5 years

(2-10) follow-up, preoperative to postoperative pain levels significantly improved (P < 0.01). In

unrevised implants, there was no significant change in total arc of motion, grip or pinch strength

when compared to preoperative values. SRA implants were associated with a increased total arc

of motion (51o) compared to pyrocarbon (42o) and silicone (44o) (P = 0.005).

Summary Points

• MCP arthroplasty for inflammatory arthritis can be a successful motion sparing procedure

with reasonable medium term survival and low complications.

• Silicone prosthesis was associated with a higher survival rate than pyrocarbon or SRA.

• Patients experience predictable pain relief and maintenance of their motion.

Paper 77_Image01

Paper 77_Image02

Paper 78: Pyrocarbon in Metacarpophalangeal Arthroplasty: A

Longitudinal Analysis of 253 Cases Clinical Paper Session 14: Arthroplasty - Saturday, September 12, 4:03 - 4:10 PM

Treatment,Surgical Technique,Basic Science,Prognosis/Outcomes,Hand and Wrist,Diseases and

Disorders,General Principles

Level 2 Evidence

Eric R. Wagner, MD

John Weston, MD

Matthew T. Houdek, MD

Steven L. Moran, MD

Marco Rizzo, MD

Consulting Fee: Intregra (Moran)

Hypothesis

The objective of this study was to examine a large prospective group of patients who underwent

PIP arthroplasty utilizing a pyrocarbon prosthesis, attempting to identify those factors that have

a significant influence on the outcomes.

Methods

An analysis of 254 consecutive MCP arthroplasties in 110 patients was prospectively collected

using an institution’s total joints registry over a 14 year time period from 1998 to 2012.

Demographics included average age of 56 years, BMI 29.8 kg/m2, 65% females, 13% smokers,

11% with diabetes mellitus (DM), 4% laborers, and with 60% involving the dominant extremity.

Diagnoses included inflammatory arthritis (n=164), post-traumatic arthritis (n=37), and

osteoarthritis (n=53). Of the 164 fingers with inflammatory arthritis, 51 required prednisone and

93 required methotrexate perioperatively. 32 implants were augmented with bone graft.

Results

Of the 253 arthroplasties performed over the 14-year time-period (224 primaries, 30 revisions),

26 (10%) patients underwent revision surgery. Revision surgeries were performed for

dislocations (n=8), recurrent ulnar deviation or subluxation (n=5), pain with limited motion

(n=12), and proximal component loosening (n=1). The 2, 5 and 10-year survival rates were 96%,

89%, and 77%, respectively. The risk for revision surgery was increased in smokers (P < 0.05) and

those with inflammatory arthritis requiring either prednisone or methotrexate (P < 0.02).

Breaking down by indication, the 5-year survival for inflammatory arthritis (90%) (blue),

osteoarthritis (85%) (red), and post-traumatic arthritis (85%) (red) were not significantly

different. Intraoperative fractures and smokers also had an increased risk for revision surgery

(Table 1). Sixteen operations were complicated by intraoperative fractures. Postoperative

complications included infections (n=3), postoperative fractures (n=4), heterotopic ossification

(n=5), and PIP dislocations (n=13). Female patients, those with a history of a MCP dislocation,

and patients requiring methotrexate for their inflammatory arthritis had higher rates of

dislocations (P < 0.04). In those patients who did not undergo revision surgery, at a mean follow-

up of 4.8 years, patients had significant improvements in their preoperative to postoperative

pain levels (P < 0.01), as well as MCP arc of motion from 38o to 45o (P = 0.002), as well as

improvements in their pinch strengths (P < 0.001).

Summary Points

• MCP arthroplasty using a pyrocarbon implant demonstrates nearly a 90% 5-year survival rate

with a relatively low rate of complications.

• Smokers and patients requiring methotrexate and prednisone had a higher revision surgery

risk, while females and prior dislocations increased the rate of dislocations.

• Overall, patients experienced predictable pain relief and improvements in their range of

motion and pinch strength.

Paper 78_Image01

Paper 78_Image02

Paper 79: Simple vs. Complex Syndactyly of the Hand: A Nationwide

Comparison of Clinical Characteristics, Associated Congenital Anomalies,

and Postoperative Outcomes in 528 Patients Clinical Paper Session 15: Pediatrics - Saturday, September 12, 3:35 - 3:42 PM

Prognosis/Outcomes,Congenital and Pediatric Problems,Diseases and Disorders

Level 2 Evidence

Grant M. Kleiber, MD

Rajiv P. Parikh, MD

Hypothesis

Syndactyly has been linked with a constellation of other congenital conditions. However, our

understanding of these associations is limited by small sample size and single center

retrospective data. We hypothesize that a comparison of complex syndactyly and simple

syndactyly patients across a large multi-center database will demonstrate significant syndromic

associations with complex syndactyly.

Methods

The American College of Surgeons National Surgical Quality Improvement Program Pediatric

(NSQIP Peds) is a quality improvement database that prospectively collects data on

demographics, comorbidities, risk factors, and 30-day postoperative outcomes nationally across

56 institutions. Patients less than 18 years old who underwent syndactyly reconstruction were

identified from the NSQIP Peds 2012 and 2013 databases. Two cohorts were compared: patients

with simple syndactyly (CPT codes 26560 and 26561) and patients with complex syndactyly (CPT

code 26562). Additional congenital anomalies were categorized by ICD-9 codes. Patient

characteristics, intraoperative details, and 30-day postoperative outcomes were analyzed using

chi-squared and Wilcoxon rank-sum tests.

Results

528 patients were identified: 418 (79%) with simple syndactyly and 110 (21%) with complex

syndactyly. Average age at surgery for simple syndactyly was 2.8 years compared to 1.8 years for

complex syndactyly. Concomitant congenital anomalies were present in 59% (n = 309) of all

patients, 58% of patients with simple syndactyly, and 60% of patients with complex syndactyly.

Common associated non-limb congenital anomalies included malformations of the skull and

facial bones (4.2%), atrial septal defect (3.6%), cleft lip and palate (3.4%), Apert syndrome (2.8%),

and Down syndrome (2.3%). Additional congenital limb anomalies occurred in 14% of patients,

with Poland syndrome (2.5%), polydactyly of the hand (2.5%), cleft hand (2.1%), club foot (1.3%),

and brachydactyly (1.1%) being most common. Certain congenital anomalies were significantly

more likely to occur in association with complex syndactyly, including Apert syndrome (P <

0.001), Down syndrome (P = 0.001), polydactyly (P = 0.003), and plagiocephaly (P = 0.05).

Average operative time was significantly longer (P < 0.001) in complex syndactyly (176 minutes)

vs. simple syndactyly (123 minutes). Complex syndactyly reconstruction also resulted in a longer

hospital stay (P < 0.001). However, when comparing overall 30-day postoperative complications,

there was no statistically significant difference between the cohorts.

Summary Points

• There is a significant association between complex syndactyly and certain congenital

anomalies, including Apert syndrome and Down syndrome.

• The incidence of concomitant congenital anomalies in patients with syndactyly may be higher

than previously recognized.

• Complex syndactyly reconstruction requires longer operative times and hospital stays

compared to simple syndactyly; however, there is no difference in 30-day postoperative

complications.

Paper 80: Pathologic Arterial Changes in Neurovascularly Intact Gartland

III Pediatric Supracondylar Humerus Fractures Clinical Paper Session 15: Pediatrics - Saturday, September 12, 3:42 - 3:49 PM

Evaluation/Diagnosis,Elbow and Forearm,Congenital and Pediatric Problems

Level 2 Evidence

Christine A. Ho, MD

David A. Podeszwa, MD

Anthony I. Riccio, MD

Robert L. Wimberly, MD

Brandon Ramo, MD

Mary Yang, MD

Hypothesis

This pilot study was performed to describe changes in arterial flow in neurovascularly intact

Gartland III pediatric supracondylar humerus fractures (SCHFx) using Duplex ultrasonography.

We hypothesized that these patients would have arterial flow comparable to the uninjured side.

Methods

This is an IRB-approved prospective study from October 2012 through August 2013 of eleven

Gartland type III SCHFx that had no cortical continuity but did have a palpable radial pulse and

normal neurologic exam. Duplex ultrasonography was performed on injured and uninjured arms,

both pre-operatively and post-CRPP, and interpreted by a board-certified pediatric radiologist.

Ultrasound wrist/brachial indexes (WBI) were calculated using the higher value of the

radial/brachial or the ulnar/brachial index.

Results

Only 2 patients (Patients #1 and #2) had normal Duplexes with flow comparable in the brachial,

radial, and ulnar arteries of the affected arm, compared to the unaffected arm, both pre-

operatively and post-pinning.

Pre-operatively, 6 patients (Patients #3-8) had stenosis of the affected brachial artery at the level

of the fracture site (22-60% narrowing) with elevated peripheral systolic velocity (PSV) (1.52-2.98

times higher) when compared to the brachial artery proximal to the fracture. The brachial artery

in these patients demonstrated monophasic/biphasic flow, but flow of the radial and ulnar

arteries was preserved. Of these 6 patients, 2 had decreased WBI in the affected arm compared

to the unaffected arm, 3 had minimally lower WBI, and 1 had higher WBI. Postoperatively, for

these 6 patients, 1 patient had no change in Duplex post-CRPP, 1 patient had improved artery

narrowing but continued elevated PSV, 1 had both improved artery narrowing and PSV, and 3 did

not have a post-CRPP Duplex performed.

Patient #9 had brachial artery narrowing with decreased PSV in the distal arm and markedly

decreased WBI compared to the unaffected arm. Post-CRPP, there was improved brachial artery

narrowing but with elevated PSV and minimally improved flow to the wrist.

Patient #10 had brachial artery narrowing but normal PSV and intact ultrasound wrist/brachial

index, without much change post-CRPP.

Patient #11 had a pink pulseless hand after anesthesia induction. Duplex revealed narrowed

brachial artery with decreased PSV of brachial, radial, and ulnar arteries and decreased

ultrasound WBI with no significant improvement post-CRPP.

Summary Points

• Type III SCHFx patients with a normal neurovascular exam may have abnormal Duplex

ultrasonography with brachial artery stenosis and elevated PSV pre-operatively although

distal flow remains comparable to the contralateral side.

• This study establishes a baseline of pathologic changes in the Duplex examination.

Paper 81: When Does Pediatric Trigger Thumb Start and End? Clinical Paper Session 15: Pediatrics - Saturday, September 12, 3:49 - 3:56 PM

Prognosis/Outcomes,Congenital and Pediatric Problems

Level 2 Evidence

Jihyeung Kim, MD

Hyun Sik Gong, MD

Seung Hwan Rhee, MD

Young Ho Lee, MD

Goo Hyun Baek, MD

Hypothesis

Pediatric trigger thumb is a condition with flexion deformity of the interphalangeal joint in

children. It rarely presents at birth and usually develops spontaneously during childhood. And we

can also expect spontaneous resolution without any treatments such as splinting, exercise and

surgery. The objectives of this study were to investigate the ages at the time of disease

development and resolution, and to suggest a guideline of the conservative treatment.

Methods

We prospectively followed up 359 thumbs of 283 patients without any treatments such as

splinting, exercise and surgery. The dates of the initial visits ranged from January 1999 to

October 2012. The average duration of follow-up was 52.7 (range, 24-180) months. We

measured the degree of the flexion deformity of the thumb interphalangeal joint at every six-

month follow-up visit. We defined the resolution of the disease as having occurred when the

flexion deformity of the interphalangeal joint became 0° with the wrist and the

metacarpophalangeal joint of the thumb in neutral position.

Results

Among the unilateral cases, the average age of the symptom development was 23.9 months,

that of the initial visit was 28.1 months, and that at the time of resolution was 63.6 months.

Among the bilateral cases, the average age at the time of the symptom development was 26.5

months, that of the first visit was 31.9 months, and that at the time of resolution was 65.8

months. The duration of the disease showed negative correlation with the age at the time of

symptom development in both groups. The resolution rates were 62% in unilateral cases and

61% in bilateral cases. However, those were increased to 84% in unilateral cases and 82% in

bilateral cases among the patients with more than five year follow-up. Among the patients with

more than seven year follow-up, those were 90% in unilateral cases and 89% in bilateral cases.

Summary

Pediatric trigger thumb most commonly occurs around the age of the two years and resolves

between the age of the five and six years. If it develops at the younger age, it may take more

time until the resolution of the disease. Pediatric trigger thumb seems to be a developmental

disease and the developmental mismatch between the A1 pulley and the flexor pollicis longus

tendon can be one of the possible causes.

Paper 81_Image01

Paper 81_Image02

Reference 1: Baek GH, Kim JH, Chung MS, Kang SB, Lee YH, Gong HS. The natural history of

pediatric trigger thumb. J Bone Joint Surg Am. 2008 May;90(5):980-5.

Reference 2: Bae DS. Pediatric trigger thumb. J Hand Surg Am. 2008 Sep;33(7):1189-91.

Reference 3: Shah AS, Bae DS. Management of pediatric trigger thumb and trigger finger. J Am

Acad Orthop Surg. 2012 Apr;20(4):206-13.

Reference 4: Shiozawa R, Uchiyama S, Sugimoto Y, Ikegami S, Iwasaki N, Kato H. Comparison of

splinting versus nonsplinting in the treatment of pediatric trigger finger. J Hand Surg Am. 2012

Jun;37(6):1211-6.

Reference 5: Koh S, Horii E, Hattori T, Hiroishi M, Otsuka J. Pediatric trigger thumb with locked

interphalangeal joint: can observation or splinting be a treatment option? J Pediatr Orthop. 2012

Oct-Nov;32(7):724-6.

Reference 6: Verma M, Craig CL, DiPietro MA, Crawford J, VanderHave KL, Farley FA, Caird MS.

Serial ultrasound evaluation of pediatric trigger thumb. J Pediatr Orthop. 2013 Apr-

May;33(3):309-13.

Reference 7: Farr S, Grill F, Ganger R, Girsch W. Open surgery versus nonoperative treatments

for paediatric trigger thumb: a systematic review. J Hand Surg Eur Vol. 2014 Sep;39(7):719-26.

Reference 8: Baek GH, Lee HJ. The natural history of pediatric trigger thumb: a study with a

minimum of five years follow-up. Clin Orthop Surg. 2011 Jun;3(2):157-9.

Paper 82: Outcome of Repaired Digital Nerve Injuries in Children –

Influence of Age in a Retrospective Long Term Follow Up Clinical Paper Session 15: Pediatrics - Saturday, September 12, 3:56 - 4:03 PM

Prognosis/Outcomes,Congenital and Pediatric Problems,Nerve

Level 3 Evidence

Hans-Eric Rosberg, MD, PhD

Derya B. Hazer, MD

Lars B. Dahlin, MD

Hypothesis

Do children with a repaired digital nerve injury regain normal sensation and hand function and

does age correlate with outcome?

Methods

Eighty-two children, aged 1-16 years at the time of injury, were treated for a digital nerve injury

between 2002-2009 at our department. All children were invited for a follow up, including

clinical evaluation (Semmes-Weinstein monofilaments, grip strength, VAS for function and

cosmetic) and questionnaires (QuickDASH, CISS). Thirty-eight children (46%) accepted and

outcome was evaluated at a median of 40 months (range 12-131 months) after the injury. The

study population was divided into two groups – a young group (n=18) with age 0-10 years and an

older group (n=20) with age 11-16 years.

Results

Most children were boys, who were injured at home and by a cut. The level of digital nerve

injury was in 20/38 (53%) patients distal to the PIP-joint and the remaining patients had an injury

between the PIP-joint and the distal volar crease. The index finger was the most frequently

injured finger. The median Hand Injury Severity Score (HISS) was 37 (8-137).

All patients regained normal sensation based on monofilament test with limited affected hand

function, although some cold sensitivity remained. We found no significant difference between

younger and older children concerning HISS, Cold Sensitivity Severity Scale (CISS), QuickDASH,

VAS or grip power. No correlation between age and perception of touch (i.e. monofilament test)

was found.

Summary Points

• Children (0-16 years) have an excellent recovery after a digital nerve injury and repair.

• Age of the children did not affect outcome.

• The majority of children have some degree of cold sensitivity.

• No major hand disability was found irrespective of age.

Reference 1: Thorsen F, Rosberg HE, Steen Carlsson K, Dahlin LB. Digital nerve injuries:

epidemiology, results, costs, and impact on daily life. J Plast Surg Hand Surg. 2012, 46: 184-90.

Reference 2: Ljungberg E, Rosberg HE, Dahlin LB. Hand injuries in young children. J Hand Surg Br.

2003, 28: 376-80.

Reference 3: Vahvanen V, Gripenberg L, Nuutinen P. Peripheral nerve injuries of the hand in

children. A follow-up study of 38 patients. Scand J Plast Reconstr Surg. 1981, 15: 49-51.

Reference 4: Lohmeyer JA, Hulsemann W, Mann M et al. [Return of sensitivity after digital nerve

reconstruction in children: how does age affect outcome?]. Handchir Mikrochir Plast Chir. 2013,

45: 265-70.

Reference 5: Carlsson IK, Nilsson JA, Dahlin LB. Cut-off value for self-reported abnormal cold

sensitivity and predictors for abnormality and severity in hand injuries. J Hand Surg Eur Vol.

2010, 35: 409-16.

Reference 6: Campbell DA, Kay SP. The Hand Injury Severity Scoring System. J Hand Surg Br.

1996, 21: 295-8.

Reference 7: Bell-Krotoski JA. Sensibility testing with the Seemes-Weinstein monofilaments. In:

Mackin EJ, Callahan AD, Skirven TM, Schneider LH, Osterman AL (Eds.) Rehabilitation of the hand,

5th ed. St Louis, Mosby, 2002: 194-211.

Paper 83: Flexor Carpi Ulnaris Myotendinous Lengthening Improves

Function in Children with Spastic Hemiplegic Cerebral Palsy Clinical Paper Session 15: Pediatrics - Saturday, September 12, 4:03 - 4:10 PM

Treatment,Hand and Wrist,Congenital and Pediatric Problems

Level 3 Evidence

Matthew B. Burn, MD

Gloria R. Gogola, MD

Hypothesis

Children with spastic hemiplegic cerebral palsy with dynamic wrist flexion position during tasks,

but with volitional wrist extension in isolation are often treated with Botox, which may limit

muscle strength and growth. As the dynamic limitations in wrist movement are due to both

abnormal myofascial loads as well as to abnormal patterns of muscle activation, we hypothesize

that reducing the non-neural component via myotendinous lengthening of the flexor carpi

ulnaris can reduce wrist impairment while maintaining muscle strength.

Methods

We performed a respective cohort study of forty children with spastic hemiplegic cerebral palsy

(mean age 10.7 years, range 4.3-to-17 years old; 24 boys, 16 girls; MACS 1-4), with dynamic wrist

flexion contractures who had FCU fractional lengthening as part of their single event multi-level

surgery. We analyzed each child’s SHUEE (Shriners Hospital for Children Upper Extremity

Evaluation) for overall scores and wrist sub-scores, wrist active range of motion, Pediatric

Outcomes Data Collection Instrument (PODCI) scores, wrist flexion and extension strength, grip

and pinch strength, and gross motor dexterity (box & blocks test). These measurements were

obtained pre-operatively and at 1 year post-operatively. Statistical analysis was completed using

data analysis tool sets, such as two-tailed t-tests, in Microsoft Excel.

Results

At 1 year, there were significant improvements (P 0.05) was observed in the PODCI comfort/pain

subsection, SHUEE grasp and release score, wrist flexion strength, or pinch strength.

Summary

In children with spastic hemiplegic cerebral palsy with volitional wrist extension and dynamic

wrist flexion contractures that impair function, FCU fractional lengthening can:

• Improve spontaneous use

• Improve dynamic wrist posture

• Improve grip strength

• Improve dexterity

• Preserve wrist flexion strength