ABSTRACTS

Concurrent Scientific Paper Sessions

American Association for Hand Surgery ConcurrentScientific Paper Session A-1

The Use of Pyrolytic Carbon for the Treatmentof Complex Post Traumatic Arthritis and Acute JointLoss in the MCP and CMC Joint

Institution where the work was prepared: Mayo Clinic,Rochester, MN, USAFurkan Erol Karabekmez, MD; Ahmet Duymaz, MD;Steven L. Moran; Mayo Clinic

Introduction:Preservation of joint motion in cases of acute jointdestruction and post-traumatic arthritis are challengingproblems for surgeon. Previous options for preserving jointmotion have included silicone and soft tissue interpositionalarthroplasty. Pyrocarbon arthroplasty has been recentlyintroduced as another option. We wished to examine ourintermediate outcomes with the use of pyrocarbon completeand hemi-arthroplasty for the treatment of acute traumaticjoint loss and post-traumatic arthritis.

Material and Method:From May 2003 to August 2007, 6 MCP and 3 CMC jointpyrolytic carbon metacarpophalangeal implants were insertedin 6 patients. Two patients underwent complete MCParthroplasty, 3 patients underwent CMC hemiarthroplasty,and 1 patient underwent acute hemiarthroplasty of the smallfinger. Charts were reviewed for final range of motion (ROM),pinch and grip strength. Post-operative complications werenoted. Hand radiographs were reviewed for signs of implantloosening, migration and subsidence. Visual analog scale(VAS) scores were used to assess postoperatively pain.

Results:All patients were male manual laborers with an average age47 years. Follow-up averaged 36 months. None of the jointsrequired removal. There were no cases of post-operativesubsidence, loosening or implant facture. Pre-operativemotion in the two patients with post-traumatic MP arthritiswas 15 degrees, post-operative MP ROM was 65.8 degreeand this change was found to be significant (p<0.05). MeanCMC radial abduction angle and palmar abduction angle

were 38.3 and 40 degree respectively in CMC arthroplastycases. There was no statistical difference in radial or palmarabduction angles of CMC joints pre and post-operativelyand no significant difference was seen when compared tothe contra lateral normal hands. Statistically significantimprovement was found between grip strength of the CMCjoints pre and postoperatively (p<0. 05). Average post-operative VAS (scale 1–10) was 0 in cases of MCParthroplasty and 1 in cases of CMC arthroplasty. Allpatients returned to previous employment.

Conclusion:Pyrocarbon arthroplasty provides an excellent option forjoint preservation in cases of acute and post traumaticarthritis of the MCP and CMC joint. Joint replacementprovided pain relief while maintaining adequate ROM forpost-operative activities. All patients returned to previousemployment. Further study is required to assess long-termoutcome.

Biomechanical Comparison of Three FixationTechniques of Four Corner Arthrodesis: K wiresvs Circular plate (Spider Plate) vs Locked Circularplate (Xpode Plate)

Institution where the work was prepared: Mayo Clinic,Rochester, MN, USAAlexander Y. Shin, MD1, Jirachart Kraisarin, MD2;Lawrence J. Berglund, BS1; David G. Dennison 1; Kai-NanAn, PhD1; (1)Mayo Clinic, (2)Chang Mai University

Introduction:Four-corner arthrodesis is a common technique for salvageof degenerative wrist problems as well as carpal instability.Advocates of plate fixation state that rigid fixation allowsearly motion, which improves outcome of surgery. Despitethis claim, there have been no comparative studies theeffect of early motion on fixation type. The purpose of thisstudy is to compare biomechanical profile of Kwires versuslocked and unlocked dorsal circular plate in four-cornerarthrodesis in physiologic condition mimicking early activerange of motion.

HAND (2009) 4:195–237DOI 10.1007/s11552-009-9186-7

Materials and Methods:6 paired(12wrists) of fresh frozen cadaveric wrists underwentscaphoidectomy and four corner arthrodesis using K-wires(0.045” x 4), unlocked stainless steel dorsal circular plates(Spider plate, Kinetikos Medical Inc.) or locked polyethlyeth-lyketone circular plate (Xpode, Trimed Inc.) An electromag-netic motion sensor was placed in the capitate and lunate. Thespecimens were placed in a cyclical flexion-extension wristjoint simulator. Repetitive cyclic wrist flexion and extensionwas applied using both displacement and force control.Hardware failure or motion > 2 mm was considered a failureof fixation.

Results:The biomechanical profiles for 5000 cycles and the initial100 cycles are shown below(Figure). 67% in the K wiregroup catastrophically failed, and 67% of the Spider plategroup failed. There were no failures of the Xpode platefixation group. Mode of failure in K-wire group wereincluding pin breakage, bending, and loosening. For thespider group failure mechanism involved loosening screws.

Discussion:This study determined the immediate stability of each fixationtechnique for cyclical loading mimicking early motion. Spiderplate provide more rigid fixation in flexion and abruptlyincrease motion when more than 35 degree wrist extensionoccur. Xpode plate provided more stability in extension andwas able to withstand cyclical loading in this experiment, andcould tolerate simulated early range of motion without failure.

Outcome assessment of arthroscopic interpositionalarthroplasty of the trapeziometacarpal joint

Institution where the work was prepared: Brown HandCenter, Phoenix, AZ, USAMichael Fitzmaurice, MD; P. Stephen Mahoney, MD;Michael Brown, MD; Brown Hand Center

Osteoarthritis of the trapeziometacarpal joint is a commoncause of pain in the upper extremity. Small joint arthroscopy

allows performance of partial trapeziectomywith interpositionarthroplasty without the morbidity of an open procedure. Wedescribe the preliminary results of an outcome assessment ofinterposition arthroplasty with the artelon implant utilizing theDASH and Nelson scores. The DASH score is a generaloutcome assessment of function and symptoms in the upperextremity, however, the Nelson score is a new outcome tooldesigned specifically for trapeziometacarpal arthritis. TheDASH is scored from 0–100 with the higher numberindicating greater disability. The Nelson is also scored from0–100; however the lower number indicated greater disability.21 procedures on 19 patients (2 bilateral) have beenperformed. Evaluation was performed pre-operatively and at13 weeks post-operatively. Nearly all patients had full range ofmotion and were able to touch the small finger to the 5thmetacarpal head. Patients who were not retired were able toreturn to normal work activities. The average DASH score preand post-operatively was 46 and 22. The average Nelson scorepre and post-operatively was 49 and 75. There was asignificant improvement in both scores, however, the Nelsonscore is a shorter survey, easier for patients to complete andappears to be more specific to trapeziometacarpal arthritis.The outcome assessments for the arthroscopic partial trape-ziectomy with arthroplasty utilizing the artelon implantdemonstrate a significant improvement in both function andsymptoms without the morbidity associated with opentechniques.

Short-Term Outcomes of Trapeziometacarpal ArtelonImplant Compared with Abductor Pollicis LongusTendon Interposition Arthroplasty - A Case-ControlStudy

Institution where the work was prepared: Department ofOrthopedics, Hässleholm Hospital, Hässleholm, SwedenIsam Atroshi, MD, PhD; Ingrid Isaxon, PT; MagnusFlondell, MD; Maria Jörheim, MD; Peter Kalén, MD,PhD; Hässleholm Hospital

Background:Several implants have recently been introduced for thetreatment of trapeziometacarpal (TMC) osteoarthritis. TheArtelon implant is a biodegradable T-shaped devicedesigned to be placed in the TMC joint following minimaltrapezial resection to provide joint reconstruction andstabilization. This study aimed to compare short-termefficacy of the Artelon implant with that of trapeziectomyand Abductor Pollicis Longus (APL) tendon suspensioninterposition arthroplasty.

Methods:A case-control study was designed to include at least 3controls for each case. The inclusion criteria were primary

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TMC osteoarthritis that failed nonoperative treatment,surgery with the Artelon implant or trapeziectomy andAPL tendon suspension interposition arthroplasty, andpostoperative follow-up time of at least 6 months. TheArtelon group comprised 13 consecutive patients (10women), mean age 54 (range 44–75) years. The APLgroup comprised 40 patients (33 women), mean age 58(43–76) years, randomly selected with computer among 88consecutive eligible patients. The mean follow-up time forthe Artelon group was 13 (SD 4) months and for the APLgroup 12 (SD 3) months. All patients completed theQuickDASH questionnaire and a scale measuring thumbpain and related activity limitation, both scored from 0(best) to 100. Satisfaction with the results of surgery wasrecorded. The majority attended physical examinationperformed by a therapist who was blinded to the surgicalprocedure.

Results:No statistically significant differences between the groupswere found but a tendency for better results after APLarthroplasty. The median QuickDASH score for the Artelongroup was 25 and for the APL group 20 and the medianpain score was 38 and 28, respectively. In the Artelon group8 patients (61.5%) were satisfied and 5 (38.5%) wereneutral or dissatisfied compared with 32 (76%) and 7(18%), respectively, in the APL group. The mean gripstrength as a percentage of the contralateral hand was 82%in the Artelon group and 95% in the APL group and themean pinch strength was 61% in the Artelon and 86% inthe APL group. No statistically significant differences werefound between the groups with regard to thumb palmar orradial abduction. One patient in the Artelon group underwentrevision to APL arthroplasty.

Conclusions:The short-term outcomes of Artelon implant arthroplastyare at best similar to those of APL tendon suspensioninterposition arthroplasty. Considering the higher cost ofthe Artelon implant, these results may not justify its use inthe treatment of TMC osteoarthritis.

The Effect on Wrist Flexion Strength of ThumbCarmpometacarpal Joint Arthroplasty Using the EntireFlexor Carpi Radialis Tendon

Institution where the work was prepared: Curtis NationalHand Center, Baltimore, MD, USARebecca J. Saunders, PT/CHT; Michael S. Murphy, MD;Curtis National Hand Center at the Union MemorialHospital

Introduction:Thumb carpometacarpal joint arthroplasty with ligamentreconstruction and tendon interposition is a well establishedprocedure for painful arthrosis of the thumb carpometacarpaljoint. Many surgeons utilize the entire flexor carpi radialis(FCR) tendon for ligament reconstruction, while some preferpreserving part of the tendon's normal insertion onto thesecond metacarpal base.

Purpose:To determine if harvesting the full FCR tendon effectspostoperative wrist flexion strength.

Methods:A prospective study of 17 patients who underwent thumbcarpometacarpal joint arthroplasty with ligament recon-struction and tendon interposition was performed. Allpatients underwent isometric testing of wrist strength andmotion preoperatively, at three months postop, and at sixmonths postop utilizing the Dexter Hand Therapy Systemautomated testing device for strength testing. Testing andROM measurements were performed by one CHT.

Results:The data was analyzed using paired t tests. There was nostatistically significant difference in the wrist flexionstrength between preoperative and final postoperativevalues at 6 months. Average wrist flexion strength,measured in inch-pounds, was 36.7 preoperatively and37.8 at six months postop (P=0.71). There was also nosignificant difference in final wrist flexion range of motion.Average wrist flexion preop was 78.9 degrees and at6 months postop was 77.0 (p=0.51)

Conclusion:Utilizing the entire FCR tendon for thumb CMC arthroplastywith ligament reconstruction and tendon interposition doesnot adversely effect eventual wrist flexion strength or therange of wrist flexion.

Long-term Follow-up of Surface ReplacementArthroplasty of the PIP Joint

Institution where the work was prepared: Mayo Clinic,Rochester, MN, USAPeter M. Murray, MD; William P Cooney; Ronald LLinscheid; The Mayo Clinic

Introduction:We propose that surface replacement arthroplasty is adurable alternative for the treatment for osteoarthritis(OA) and rheumatoid arthritis (RA) of the proximalinterphalangeal (PIP) joint of the finger. The purpose of

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this study is to examine the long-term outcome of a surfacereplacement PIP joint prosthesis with a CrCo proximalcomponent and an ultrahigh-molecular-weight polyethylenedistal component.

Methods:51 prostheses were used in 36 patients (mean age, 58 years)over 32 years. There were 33 fingers with degenerativearthritis, 9 with post-traumatic osteoarthritis, and 9 withrheumatoid arthritis. The mean follow-up was 10.7 years(range, 2.6–31.8 years). 44 patients had a dorsal approach,5 a volar approach and 2 had a lateral approach. 35 patientshad cement and 16 had a press fit technique. At follow-uppatients were evaluated by physical examination, radiography,DASH, and SF36 assessments.

Results:Average total arc of motion at follow-up was 42 degreescompared to 43.7 degrees pre-operative. 45 of 51 jointswere in service at follow-up examination. The average post-operative visual analog pain score was 8/100. 26 of 36patients had reported pain pre-operative with 6 beingsevere. The average follow-up DASH score was 46.5,many patients had multiple disabilities. There were 28complications in 10 patients including 4 fusions and 2amputations. Complications included extensor and flexortenodesis, heterotopic bone formation, boutonnière defor-mity and swan-neck deformity. Additional radiographiccomplications of polyethylene wear and asymptomaticloosening occurred in 4 and 3 patients respectively.Infection did not occur.

Discussion:At long-term follow up, PIP arc of motion was less butsimilar to pre-operative motion. 90% of the prostheses werestill in service at follow-up and pain relief was excellent.Infection did not occur. We conclude that PIP joint surfacereplacement arthroplasty is a durable and pain relievingalternative for the arthritic PIP joint of the finger.

Flexor Tendon Tissue Engineering: Bioreactor CyclicStrain Increases Construct Strength

Institution where the work was prepared: Stanford Universityand Palo Alto VA, Palo Alto, CA, USASepideh Saber, BS1; Andrew Y. Zhang, MD1; Sae H. Ki,MD1; Derek Lindsey, MS2; Hung M. Pham, BS1; JamesChang, MD/FACS3; (1)Stanford University, (2)VA Palo AltoHealth Care System, (3)Stanford University Medical Center

Purpose:Mutilating injuries of the hand and upper extremity result intendon losses too great to be replaced by autologous grafts.

Our goal is to use tissue engineering techniques to produceadditional tendon material. In this study, we used a custombioreactor to apply cyclic mechanical loading onto tissueengineered tendon constructs to study ultimate tensilestress, elastic modulus, construct architecture, and cellorientation.

Methods:A custom LigaGen tissue bioreactor providing uniaxialtendon strain was used for this study. Tendon constructswere subjected to a stretch force of 1.25 N over a 5 daycourse. Constructs used were acellularized tendonsreseeded with tenocytes or left unseeded. Actual tendonstrain was measured linearly by comparing restingtendon length to tendon length under applied tension.Ultimate tensile stress and elastic modulus of the tendonconstructs were compared after different cycle parameters(1cycle/min vs. 2cycles/min in alternating 1 hour periodsof loading and rest) using a materials testing system(MTS 858, MTS Inc). Histologic appearances wereexamined for tendon architecture with specific emphasis oncollagen organization and cell orientation. Finally, pairwisecomparison of means across groups was assessed using thetwo-tailed unpaired Student T-test with the significance levelset at p<0.05.

Results:Seeded tendon constructs that were exposed to a 1 cycle/min load were found to have a significantly increasedultimate tensile stress and elastic modulus (UTS=84.73 N;ë=1054.77 MPa) compared to non-loaded controls (UTS=38.90 N, p=0.002; ë=699.98 MPa, p=0.03). Seededtendon constructs exposed a 2 cycle/min load also had asignificant yet less remarkable increase (UTS=73.95 N; ë=1045.21 MPa) compared to non-loaded controls (UTS=38.90 N, p=0.01; ë=699.98 MPa, p=0.02). Histologically,stressed tendons showed better alignment of collagenfibrils. Cyclic strain further caused the cells and their actincytoskeleton to reorient parallel to the direction of strain.This alignment was in stark contrast to the random cellorientation of unstressed constructs.

Relevance:This study shows that cyclic loading of tendon constructsincreases the strength of seeded constructs and changes theconstructs’ collagen architecture and cell orientation. Theuse of the bioreactor may therefore accelerate the in vitroproduction of strong, non-immunogenic tendon materialthat can potentially be used clinically to reconstructsignificant tendon losses. The ultimate goal of this projectis to produce tissue engineered tendon for clinical use inhand and upper extremity reconstruction.

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Barbed Suture Tenorrhaphy - An Ex-VivoBiomechanical Analysis

Institution where the work was prepared: Curtis NationalHand Center, Union Memorial Hospital, Baltimore, MD,USAPranay M. Parikh, MD1; James Patrick Higgins, MD2;Steven Paul Davison, MD, DDS1; (1)Georgetown University,(2)Union Memorial Hospital

Purpose:Use of a barbed suture for flexor tenorrhaphy could permitknotless repair with tendon barb adherence along thesuture’s entire length. The purpose of this study is toevaluate the tensile strength of a novel technique for flexortendon repair employing barbed suture.

Methods:Forty cadaveric FDP tendons were lacerated in Zone IIand randomized to a novel barbed 2–0 polypropylenerepair in a knotless 3-core or 6-core configuration, or toa traditional 4-core cruciate repair with either 4–0polypropylene, 4–0 braided polyester, or 4–0 fiberwire.For each repair, we recorded the cross-sectional area atthe repair site before and after tenorrhaphy. Tendonswere linearly distracted to failure, and load at failure andmode of failure recorded.

Results:The mean cross-sectional area ratio of 4 core cruciatecontrol repairs was 1.5+/−0.3, whereas those of 3-coreand 6-core barbed repairs were 1.2+/-0.2 (p=0.009) and1.2+/-0.1 (p=0.005), respectively. The mean load to failureof control repairs was 29+/−7 N, whereas those of 3-coreand 6-core barbed repairs were 36+/−7 N (p=0.32) and88+/-4N (p<0.001), respectively. Cruciate repairs failedby knot rupture or pullout in 24/24 tendons whereasbarbed repairs failed by suture breakage in 13/14 repairs(p<0.001).

Conclusions:In an ex-vivo model of flexor tendon repair, a 3-corebarbed suture technique achieved tensile strength com-parable to that of traditional 4-core cruciate repairs,while demonstrating significantly less repair site bunching.A 6-core barbed suture technique demonstrated markedlyincreased tensile strength compared to 4- core cruciatecontrols, as well as significantly less repair site bunching.Our data suggest that barbed suture repair may offer severaladvantages in flexor tenorrhaphy, and that further in-vivotesting is warranted.

Brunelli Pull-OutTechnique in Flexor Tendons Repairin Zones II and III: A Study on 65 Cases

Institution where the work was prepared: University ofMedicine Cluj, Spitalul Clinic de Recuperare, Cluj-Napoca,RomaniaAlexandru Georgescu, Prof, MD, PhD; Irina Capota, MD;Filip Ardelean, MD; IleanaMatei, MD; UMF Iuliu Hatieganu

Background and Aims:Reconstructing the continuity of long fingers flexor tendonsin zones II and III still raises problems from operative pointof view. One of the surgical methods with great success ratefor zone II lesions is the pull-over technique described byBrunelli. In this paper we will present the modificationsproposed by us for this technique, as well as theindication’s expansion for lesions in zone III.

Material and Method:The study refers to 65 cases involving flexor tendon lesionsin zone II and III, operated in our service since the year2000 until now. From these, 58 were zone II lesions and 7zone III lesions. Lacking the very long and highly curvedneedles used by Brunelli, we modified the initial techniqueby starting from the proximal towards the distal area andused 2 straight needles continuous threads. In addition andespecially for the zone III lesions, we incised the digitalskin until near the insertion area of flexor digitorumprofundus and the suture thread was passed through thetendon in one or more steps to reach the distal end of thetendon. In 42 cases we used non-absorbable sutures thatwere removed after 21 days, and in 23 cases absorbablesutures, that were only cut after 21 days. In 57 cases thesurgical procedure took place under regional anesthesia thatallowed the reinforcement of patient's psychological moti-vation, seeing the favorable results during surgery. Therecovery started from the first post-operative day withpassive fingers mobilization, and 48 hours after the surgerywe initiated the active against-resistance mobilization.

Results:The patients were followed for 3–24 months after thesurgery. We obtained a complete flexion in 32 patients; in 7patients we had a flexion deficit of 5–10 degrees, in 19patients we had a 10–20 degrees flexion deficit and in 7 caseswe had a 20–30 degrees flexion deficit (all of them havingzone III lesions). All the patients were able to resume sociallife and work in the same place after maximum 45 days. Wehad no rupture cases and tenolysis was necessary in only 5cases (patients with complex traumas).

In conclusion, we consider that the Brunelli’s technique is avery good method for zone II lesions and that the

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modifications proposed by us allow a broadening of itsindication’s field.

Flexor Tendon Tissue Engineering: the BiomechanicalAnalysis of Explanted Acellularized Tendon Constructs

Institution where the work was prepared: Stanford Hospitaland Clinics and the VA Palo Alto Healthy Care Palo Alto,CA, USAAndrew Y. Zhang, MD1; Sae H. Ki, MD1; Sepideh Saber,BS1; Derek Lindsey 2; Hung M. Pham, BS1; James Chang,MD3; (1)Stanford University, (2)VA Palo Alto Health CareSystem, (3)Stanford University Medical Center

Purpose:The demand for tendon grafts may exceed supply inmutilating hand injuries. Our tissue engineering model usesthe acellularized rabbit forepaw zone II flexor tendon as thescaffold. Cultured tenocytes and adipoderived stem cells(ASCs) are seeded onto acellularized tendon to create noveltendon constructs. Previous studies have established thatthese constructs are viable in vitro, and that the constructsalong with acellularized scaffold maintain comparabletensile strength to fresh tendons in vitro. The purpose ofthis study is to investigate the in vivo integrity of ourscaffold and tendon constructs.

Methods:The experimental cohort contains three groups including 1)acellularized tendon scaffolds, 2) constructs seeded withcultured tenocytes, 3) constructs seeded with ASCs. Theseconstructs were grafted to span a 2 cm gap in rabbit zone II3rd digit FDP tendons. Our controls included autologustendon graft over the same area in the adjacent 4th digit andintact fresh tendon in the 2nd digit. Macroscopic andhistological appearances along with mechanical testing forultimate tensile stress (UTS) were determined at 2 and4 weeks time points. Statistical analysis was performedusing the paired two-tailed student t test.

Results & Conclusions:All cohort groups have macroscopic appearances indistin-guishable from autologus graft and fresh tendon at all timepoints. There did not appear to be significant adhesionformation between the grafts and the tendon sheath.Histologically, collagen architecture was preserved in allexperiments groups. Minimal cell penetration into thecollagen architecture was noted, however it appears thatthere was more cell penetration as time elapsed.The UTS was not statistically different between our threeexperimental cohorts and controls. At 2 weeks timepoint, the average UTS for intact tendon was 60(N/mm2)compare to 52(N/mm2) for autologus graft (n=12; P=0.2),

61.2(N/mm2) for acellularized tendon (n=3, P=0.46),46(N/mm2) for Tenocyte seeded constructs (n=4, P=0.55),and 67(N/mm2) for ASC seeded constructs (n=7; P=0.12). At4 weeks, the average UTS for intact tendon was 53(N/mm2)compare to 42(N/mm2) for autologus graft (n=7; P=0.13),46(N/mm2) for acellularized tendon (n=3; P=0.5),41(N/mm2) for Tenocyte seeded constructs (n=3; P=0.29),and 42(N/mm2) for ASC seeded constructs (n=3; P=0.3).

Relevance:Our study suggests that tissue engineered grafts remainviable in the short-term in vivo. Surprisingly, acellularizedtendon alone retained strength and may be a suitablesubstitute for autologus grafting in the short term. Furtherwork will include longer follow up and analysis of repairstrength and construct gliding characteristic.

Biomechanical Comparison of Lasso Tendon Repairto Pulvertaft Weave and Side-to-Side Repairs

Institution where the work was prepared: University ofTexas Southwestern Medical Center, Dallas, TX, USASean Bidic; Anubodh Varshney, BS; Harry Orenstein;University of Texas Southwestern Medical Center

Introduction:Pulvertaft weaves, although reliable, require substantialtendon length for overlap. Side-to-side tendon repair areless reliable. A new technique for joining tendons, the lassorepair, has been developed. The hypothesis is that the lassohas similar biomechanical strength as the Pulvertaft weave,requires less tendon, and is simpler to perform.

Methods:Lasso repair involves making an axial stab incision 1.5 cmfrom the end of the passive tendon that allows the activetendon to be tightly weaved using a hemostat. A secondlongitudinal incision is made in the active tendon such thatthe active tendon can be weaved through itself. Horizontalmattress sutures are placed at both weave points; anadditional suture is placed in between the incisions.Pulvertaft weave repairs had three weaves and sutures andside-to-side repairs had three sutures embedded in the2.5 cm overlap. Repairs were conducted using porcinetrotter flexor tendons obtained at animal sacrifice. Lassoand Pulvertaft weave repairs were standardized with thefirst incision 1.5 cm from the end of one tendon. Side-to-side repairs were standardized to a 2.5 cm overlap. 4–0Mersilene suture with 5 knots per suture was used. Tenrepairs of each type were performed. Tendon length used ineach repair and width of the repair, and time to completethe repair were assessed. Repair failure for each repair wasmeasured using a tensile testing machine with a 5 kN load

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cell was used to test repairs to failure at a crosshead speedof 20 mm/minute. Load and extension plots and maximumload were digitally recorded using data acquisition software.

Results:The mean maximum load in the side-to-side, Pulvertaftweave, and lasso repair specimens was 88.58N, 159.67N,and 155.78N respectively. Maximum load is found to be thesame between lasso and Pulvertaft weave repair based onthe Student's t-test (p<0.05). Lasso repair used 7.1 mm lesstendon than the Pulvertaft weave and took less than half ofthe time to complete. Lasso repair is slightly thicker at itswidest point than the Pulvertaft weave, but the thickness isconcentrated to a small area, while in Pulvertaft weaverepairs the thickness is spread out throughout the specimen.

Conclusions:Our study supports the hypothesis that lasso tendon repair is asstrong as the Pulvertaft weave, takes less time to perform, andrequires less tendon. Side-to-side repair is shown to be aninferior technique due to its characteristically low maximumload.

Flexor Tendon Repair using Modified Lim and Tsai SixStrand Suture Technique

Institution where the work was prepared: Department OfSurgery, Singapore General Hospital, Singapore, SingaporeJayan Man Shrestha, MS, (General, Su; Shian Chao Tay,MD, MS; Singapore General Hospital

Introduction:Flexor tendon repair with 6 strand suture technique hasresulted in improved strength and increased resistance togapping. We used a modification of Lim and Tsai’stechnique for flexor tendon repair and assessed the clinicaloutcome.

Methods:A retrospective review of all complete flexor digitorumprofundus (FDP) and flexor pollicis longus (FPL) tendoninjuries in zones 1,2 and 3, with or without flexor digitorumsuperficialis (FDS) tendon injuries, from May 2002 to May2006 was conducted. Thirty-one patients with 38 fingersand thumbs were found. Functional outcome was assessedusing Strickland and Glosovac’s criteria for the finger, andWhite’s method for the thumb.

Results:Out of a total of 38 digits, 22 were rated as excellent (58%),9 good (24%), 7 fair (18%) ad 0 poor (0%). Twenty-five ofthese digits were injured in zone 2 and, 13 digits of thesedigits were rates as excellent (52%), 6 good (24%), 6 fair(24%) and 0 poor (0%). The rate of flexor tendon rupturewas 2.6%.

Conclusion:The modified Lim and Tsai technique for flexor tendonrepair is a useful 6-strand technique for flexor tendon repairwith a satisfactory outcome rate.

Biomechanical Comparison of FiberLoop versusLooped Supramid Extra versus Ethibond Suturein Zone II Flexor Tendon Repair Using a CyclicProtocol

Institution where the work was prepared: The ClevelandClinic, Cleveland, OH, USAJoy V. Sharma, MD, MS; Ryan Milks, BSE; Kathleen A.Derwin, PhD; Peter J. Evans, MD, PhD; Jeffery N.Lawton, MD; The Cleveland Clinic

The purpose of this study was to investigate differences ingap formation and failure load between FiberLoop, loopedSupramid Extra (LSME), and Ethibond suture in Zone IIflexor tendon repairs. In addition, the inherent properties ofthe sutures were tested in a simulated tendon construct.

Two sets of ten paired human cadaveric flexor digitorumprofundus tendons were used. The tendons were transectedin zone II, and randomly repaired with either 4–0 Fiber-Loop or 4–0 LSME in the first set of ten paired tendons.The second set of ten were randomly repaired with 4–0Ethibond or 4–0 FiberLoop. All repairs where performedusing an eight-strand cruciate repair technique followed bya running epitendinous 6–0 prolene suture. The repairedtendons were cycled 8000 times between 2N and 25N andthen pulled to failure. Suture markers were placed on bothsides of the repair site to analyze gap formation. In thesecond part of the study, an eight-strand cruciate repair wasperformed using a custom fixture simulating a tendon

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construct. Failure load, method of failure, and knot volumeswere recorded and statistically analyzed for the aforemen-tioned suture products.

In the first part of the study, no significant differences werefound in gap formation between suture types at 8000cycles. All mean gaps were less than 2 mm. FiberLooprepairs failed at significantly (p=0.002) higher loads (72.9±6.6 N) when compared to LSME (64.3±8.8N). However,no significant difference in failure loads was found in thepaired flexor tendons comparing FiberLoop and Ethibond.All repairs failed at the tendon suture interface. In thesecond part of the study, FiberLoop failed by knot slippageat low loads when four throws per knot were used. Whensix throws per knot were used FiberLoop (235±15.6 N)was significantly stronger than LSME (114.5±6.3 N) andEthibond (123.9±12.6 N) and majority of repairs failed bysuture breakage.

Our data suggests that all three suture products were able towithstand cyclical loading with less than 2 mm gapformation using an eight-strand cruciate repair technique.The second part of the study suggests that FiberLoop isinherently stronger than LSME and Ethibond but theincreased strength is realized only when an increasednumber of throws is used to secure the knot. In the clinicalsetting, suture breakage may be irrelevant as all repairfailures occurred at the suture tendon interface regardless ofsuture product.

Indications and Clinical Experience Using AdhesionBarrier Wrapping

Institution where the work was prepared: Miami HandCenter, Miami, FL, USAAlejandro Badia, MD, FACS; Badia Hand to ShoulderCenter

The development of postoperative adhesions has longcaused clinical problems for hand surgeons in a variety ofscenarios. Acute repairs of either tendons or nerves hasoften been associated with the development of exuberantscar tissue postoperatively that interferes with function. Ithas been a long sought after goal to try to minimizeadhesions using a variety of techniques in order to improveclinical outcome after these types of surgical interventions.Recurrance of adhesions is also a common problem aftereither tenolysis or neurolysis. The use of a bioresorbablepolylactide sheet to minimize adhesions to a protectedviscera has demonstrated good clinical benefit in generalsurgery and gynecologic surgery applications. It is com-prised of polylactic acid (PLA) which has a long clinicaltrack record of having minimal tissue reaction with no

known side effects. These same benefits have only recentlybeen introduced in the musculoskeletal arena. Clinicalindications will be outlined and a series of case examplespresented in order to illustrate this concept as applied tohand surgery. Follow-up on these patients has demonstratedno adverse foreign body or inflammatory response, and theclinical goals have been achieved in all cases: namely thatof minimizing adhesions as demonstrated by physical examat the application site. While this physical barrier does notsolve the elusive goal of reducing adhesions in zone IIflexor repairs due to its mechanical nature, it seemspromising for minimizing post-op adhesions in such criticalareas as the dorsum of the hand, forearm flexor/extensortendon applications, and a wide variety of peripheral nerveapplications. A future prospective randomized study assessingone specific clinical scenario will shed further light on itsefficacy.

American Association for Hand Surgery ConcurrentScientific Paper Session A-2

Intramedullary Fixation of Displaced Distal RadiusFractures

Institution where the work was prepared: Temple UniversityHospital, Philadelphia, PA, USAAsif M. Ilyas, MD; Joseph J. Thoder, MD; TempleUniversity Hospital

Purpose:Multiple treatment options exist for operative fixation ofdistal radius fractures. Recently, there has been increasedinterest in intramedullary fixation. We treated 10 dis-placed and unstable distal radius fractures with anintramedullary nail over a one year period. We presentour results with an average follow-up of 21 months(minimum 12 months).

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Methods: The implant use was limited to extra-articularand simple intra-articular distal radius fractures thatdisplayed instability or persistent malreduction afterattempted closed reduction and splinting. The patients werefollowed at set intervals for a minimum of 12 months.

Results:At an average follow-up of 21 months, the average volar tiltwas 3.8° dorsally angulated, radial inclination was 22.9°,radial height was 12.1 mm, and ulnar variance was−0.6 mm. All cases maintained reduction of the fracturebetween immediate post-operative and final radiographsexcept for two cases that incurred a loss of volar tilt by 15°and 20°, respectively. Range of motion included wristflexion of 67°, wrist extension of 71°, supination of 82°,pronation of 85°, radial deviation of 23°, and ulnardeviation of 38°. Grip strength of the operative limbrelative to the uninjured limb was 91%. According to theDASH form there was 8 excellent, 1 good, and 1 poorresult. The average DASH score was 8.12 (range, 0–57).There were two cases of transient superficial radial sensoryneuritis and one case of late DRUJ arthrosis from implantpenetration of the joint.

Conclusion:Our report finds that the use of the intramedullary nail inthe treatment of displaced distal radius fractures ispromising but not without complications. We found goodoverall maintenance of reduction except in two caseswithout any long-term soft tissue problems in any cases.The indication for its use should be limited to extra-articular and simple intra-articular distal radius fractures.

Comparison of AO Type B and Type C Volar ShearingFractures of the Distal Radius

Institution where the work was prepared: MassachusettsGeneral Hospital, Boston, MA, TuvaluJesse Jupiter1; J. Sebastiaan Souer2; David Ring1; (1)Massachusetts General Hospital, (2)Mass General Hospital/Harvard Medical School

Purpose:Fractures of the volar articular margin of the distal radiuswith volar radiocarpal subluxation (volar shearing fractures)can be accompanied by fracture of the dorsal metaphysealcortex. We hypothesized that, among volar shearingfractures, injuries with a dorsal cortical break (AO/OTAType C fracture) are more common than isolated volarmarginal articular fractures (partial articular or Type Bfractures). We also compared wrist function and perceiveddisability after both types of fractures.

Methods:In a prospective cohort study of plate and screw fixationof the distal radius, 58 patients with a volar marginalshearing fracture of the distal radius and volar radio-carpal subluxation (volar Barton’s fracture) were fol-lowed for at least one year. Thirty-eight patients that alsohad a dorsal metaphyseal cortical fracture (Type Cfracture) were compared with 20 patients with a true(Type B) fractures in terms of demographics, injurycircumstances, and outcomes according to motion, gripstrength, pain, Gartland/Werley Score, DASH and SF-36scores at 6, 12, and 24 months follow-up.

Results:There were no differences in baseline characteristicsbetween Type B and C fractures. Patients with Type Cfractures had significantly less motion forearm rotation(163 vs. 174 degrees; p=0.05), grip strength (72% vs. 85%of opposite arm; p=0.03), and significantly more pain (2.2vs. 0.6; p=0.01) than patients with Type B fractures at theearly (6 month) follow-up, but not at later (12 and 24 monthfollow-ups). There were no significant differences in Gartlandand Werley, DASH, or SF-36 scores at any time point.

Conclusions:Type C volar shearing fractures take longer to recover, butultimately do as well as true Type B volar shearingfractures.

Significance:Volar shearing fractures are usually complete articular, TypeC fractures

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Distal Radius Fractures Treated with Multiplanar CrossPin Fixation and a Low Profile Non-Bridging ExternalFixator; the CPX System

Institution where the work was prepared: Ather Mirza, MD,Smithtown, NY, USAAther Mirza, MD; Ather Mirza, MD

Purpose:To present the findings of distal radius fractures (DRF)treated with the CPX System.

Methods:Forty-nine patients with 52 unstable DRF (40 intra-, 12extra-articular) were treated with the CPX System. Meanage 54 years (range 17–87 y). Radiological measurements,grip and pinch strength, active wrist range of motion(AROM), and outcome instruments: The Patient-RatedWrist Hand Evaluation (PRWHE) and the Disabilities ofthe Arm, Shoulder and Hand (DASH) was used todetermined patient’s outcome.

Results:Postoperatively, a removable orthosis was applied, mean6 days (range 2–10 d) and formal wrist rehabilitation began,mean of 8 days (range 2–16 d). There were no pin tractinfections, non-unions, tendon injuries or angular collapses.Radiographic parameters were not fully restored in fourpatients. Two patients had an increase in ulnar variance. K-wires and external fixation was removed, mean of 46 days(range, 39–61 d). At final follow-up (mean 14±10 months)grip and lateral pinch strength recovered 87% and 94%respectively; mean wrist AROM increased to a minimum of83% of the non-injured side; mean DASH and PRWHEscores were 12.16±14.62 and, 13.8±14.8 respectively. Onepatient developed complex regional pain syndrome whichrevolved and one patient had mild transient superficialradial nerve sensitivity without functional compromise. Allreturned to their prior employment and/or activities.

Conclusion:The CPX System combines multiplanar internal cross pinfixation with a low profile external fixator, providingmaintenance of fracture reduction while allowing rehabili-tation of the wrist, and resumption of usual activities.

Treatment of Distal Radius Fractures Using a RadialStabilization Locking Plate

Institution where the work was prepared: Texas TechUniversity Health Science Center, El Paso, TX, USAMiguel Pirela-Cruz, MD; Texas Tech Medical Center;David Esquivel, ORT; Texas Tech University HealthScience Center

Introduction:Volar plating of distal radius fractures (DRF’s) is currentlythe treatment of choice for addressing unstable fractures ofthe distal radius. However, there some fractures that requireoperative intervention but with a less invasive approach.DRF’s can now be treated with a radial locking plate thatprovides adequate stabilization of the fracture and allowsfor early range of motion (ROM).

Material and Methods:A retrospective review of 36 DRF’s was performed. Onesurgeon in one institution using a newly developed anatomicdistal radius plate carried out the surgeries on Type A (extra-articular) and some Type B (partial articular). Supplementaryfixation such as a single 0.045 k-wire was required rarely.Range of motion exercises was started one weekpost-operatively.

Results:All fractures were healed at 6 months post-operatively. A fewpatients experienced transient paraesthesias in the distributionof the superficial branch of the radial nerve. By 6 monthshowever, the paraesthesias were resolved. Range of motion,D.A.S.H. scores and SF-36 will be presented.

Conclusion:0.R.I.F. using a radial stabilization locking plate provides asimple alternative to traditional volar plating in selectivefractures. This approach reduces the surgical dissection andfacilitates post-operative recovery.

A Prospective Randomized Clinical Trial of UnstableDistal Radius Fractures treated with External Fixation,Radial Column Plating, or Volar Plating

Institution where the work was prepared: New YorkOrthopaedic Hospital, Columbia University Medical Ctr,New York City, NY, USADavid H. Wei, MSc1; Noah M. Raizman, MD2; Clement J.Bottino, MD1; Charles M. Jobin, MD1; Robert J. Strauch,MD1;Melvin P. Rosenwasser, MD1; (1)New York OrthopaedicHospital, Columbia University Medical Center, (2)GeorgeWashington University School of Medicine

Background:Optimal surgical management of unstable distal radiusfractures is controversial. External fixation and locked volarplating demonstrate excellent clinical results, but evidencefrom rigorous comparative trials is rare. Additionally,locked radial column plating as an independent method offixation has not been examined. We compare functionaloutcomes following external fixation, locked volar plating,and locked radial column plating.

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Methods:Forty-six patients with single limb injuries were randomizedas follows: twenty-two to external fixation, twelve to lockedvolar plating, and twelve to locked radial column plating.Fractures included OTA types A3 and C1-C3. At two, six,twelve, twenty-four, and fifty-two weeks after surgery,patients completed the Disabilities of the Arm, Shoulder,and Hand (DASH) questionnaire. Grip and lateral pinchstrength, range of motion (ROM), and radiographicparameters were also evaluated.

Results:At six weeks, volar plating demonstrated a significantlybetter mean DASH score compared to external fixation(p=0.037), but was not significantly different from radialcolumn plating (p=0.33). At three months, volar platingdemonstrated the best DASH score, significantly better thanexternal fixation (p=0.028) and radial column plating(p=0.027). By six months and one year, all three groupsreached DASH scores comparable to the normal popula-tion. External fixation showed significantly better gripstrength compared to radial column plating (p=0.042) atsix months, but at one year no significant differences wereobserved. Volar plating showed significantly better lateralpinch strength compared to radial column plating at threemonths (p=0.042) and one year (p=0.036), but nosignificant differences were found when compared toexternal fixation. ROM did not significantly differ betweengroups at any time beginning twelve weeks after surgery.Radial column plating maintained the best radial inclinationand radial length at one year, significantly better than bothexternal fixation and volar plating (all p<0.05).

Conclusions:Early rehabilitation of locked volar plating predictablyleads to better patient reported outcomes in the firstthree months after fixation. However, by one year allthree techniques provide excellent outcomes despiteminimal differences in strength, motion, and radiographicalignment.

Minimally Invasive Osteosynthesis (MIO) for AsianOsteoporotic Distal Radius Fractures with SmallIntramedullary Nail

Institution where the work was prepared: Komaki CityHospital, Komaki, JapanNaoya Takada; Komaki City Hospital

Purpose:Distal radius fracture is one of common injuries in Asianelderly population. Since 2006 we have used MIOtechnique with a small intramedullary nail for osteoporoticdistal radius fractures. The purpose of this study is toevaluate the clinical outcome of 20 osteoporotic distalradius fractures treated with this method retrospectively.

Methods:Twenty female patients who had sustained distal radiusfracture were treated with MIO technique using smallintramedullary nail. Their average age at the time of surgerywas 67 (range 55–85). According to the AO/OTA classifi-cation system, 9 patients were type 23-A2, 3 type 23-A3, 6type 23-C1, 2 type 23-C2. Two small skin incisions (1.5–2 cm) were used for this procedure. The small intra-medullary nail was inserted from a cortical windowbetween the 1st and 2nd dorsal extensor compartments.Three distal buttress screws were inserted into distalfragment and 2 locking screws were inserted into proximalfragment. No patient required post operative immobilization.The average follow-up period was 8.2 months (range 3–18).The range of motion of the wrist, Green and O’Brien score,Quick DASH score and radiographic outcomes were assessedat the latest follow-up and post operative complications wereevaluated.

Results:The average range of flexion and extension were 61 (range50–90) and 62 (range 45–90) degrees. The average Greenand O’Brien score was 88 (range 75–100) points. Theaverage Quick DASH score was 3.7 (range 0–13.6) points.Palmar tilt, ulnar variance, radial inclination and radialheight at the final follow-up X-ray were 10 degrees,0.5 mm, 20 degrees and 9 mm respectively. Loss ofreduction, implant failure, deep infection and tendon ornerve problems were not found postoperatively.

Conclusion and Significance:No postoperative complications were observed and theclinical outcome was good in this study. This angular stableimplant maintained reduction position even in osteoporoticbone. Small skin incisions are advantageous to cosmeticeffect. Using this MIO technique, pain and swelling can belittle and patients can quickly return to activities of daily

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living. The small intramedullary nail was found to be veryuseful for the treatment of osteoporotic distal radiusfractures, although a long-term follow-up is still necessary.

The Effect of an Unrepaired Ulnar Styloid BaseFracture on Outcome after Operative Treatmentof a Distal Radius Fracture

Institution where the work was prepared: MassachusettsGeneral Hospital, Boston, MA, USAJesse Jupiter; David Ring; J Sebastiaan Souer; MassachusettsGeneral Hospital

Purpose:The indications for ORIF of an ulnar styloid base fracturein association with fracture of the distal radius are debated.We tested the hypothesis that there is no difference inmotion or function in patients with untreated ulnar styloidbase fractures compared to patients with no ulnar fracture.

Methods:Seventy-four matched pairs of patients, one with an ulnarstyloid base fracture and the other with no ulna fracture,were culled from a prospective cohort study of plate andscrew fixation of the distal radius. Patient pairs werematched for age, gender, AO fracture type, and injurymechanism. The two cohorts were analyzed for differencesin motion, grip strength, pain, Gartland and Werley Score,DASH and SF-36 at 6, 12, and 24 months follow-up.

Results:Patients with an ulnar styloid base fracture had slightly butsignificantly less motion (styloid fracture vs. no styloidfracture) in the arc of forearm rotation at two-year follow up(164 vs. 171 degrees; p=0.03), pronation at six monthsfollow up (80 vs. 84 degrees; p=0.05), supination at sixmonths (77 vs. 82 degrees; p=0.03), and radio-ulnardeviation at six months (75.9% vs. 84.3% of oppositearm; p=0,04), but had less pain at one-year follow-up (0.5vs. 1.0; p=0.04). All other comparisons at all other timepoints showed no significant differences.

Conclusion:Patients with distal radius fractures treated with openreduction and internal fixation that have an unrepaired baseof ulnar styloid fracture are nearly identical to patients withno ulnar fracture. The small differences in motion and painwere inconsistent across time, small enough to be ofquestionable clinical relevance, did not correlate with self-rated disability or physician rated outcome scores.

Significance:Routine internal fixation of an ulnar styloid base fracture isnot recommended.

Corrective Osteotomy for Intra-Articular Malunionof the Distal Part of the Radius

Institution where the work was prepared: Ootawara RedCross Hospital, 2–7–3 Sumiyoshi-cho Ootawara-cityTochigi pref, JapanHirokazu Tochigi, MD1; Kazuki Satou, MD, PhD2;Hirofumi Yoshida, MD1; Toshiyasu Nakamura, MD,PhD2; Hiroyasu Ikegami, MD, PhD3; Yoshiaki Toyama,MD, PhD3; (1)Ohtawara Red Cross Hospital, (2)keioUniversity, (3)Keio University

Corrective osteotomy is an appealing treatment for mal-united articular fractures of the distal part of the radiussince articular incongruity may be the factor most stronglyassociated with arthrosis and diminished function after suchfractures. However, malunion cases of distal radial intra-articular fractures treated with wrist fusion or total wristarthroplasty were often observed. Enthusiasm for osteotomyhas been limited by concerns regarding the difficulty of thetechnique and the potential for additional injury,osteonecrosis,and nonunion. The purpose of this report was to present theexperience of surgeons with intra-articular osteotomies forthese injuries, with an emphasis on the techniques andoutcomes.

Material and Methods:Seven skeletally mature patients were evaluated at anaverage of eleven months after corrective osteotomy forintra-articular malunion of the distal part of the radius. Theindication for the osteotomy included articular incongruityof >2 mm as measured on a posteroanterior radiograph.According to AO classification, there were two B2, one B3,two C1,two C2. The average interval from the injury to theosteotomy was six months. Preoperative range of motionaveraged 38°of wrist extension, 35°of wrist flexion, 50°ofsupination, 69°of pronation. Preoperative grip strengthaveraged 15% of that the contralateral side. As a generalrule, osteotomy was performed at the original fracture site.The articular reduction was carefully monitored with imageintensification. The osteotomy was secured with screwsalone in one patient (with the addition of external fixator),plate and screws in six patients. Autogenous bone graft wasapplied in all patients.

Results:All of the osteotomy sites had healed without evidence ofosteonecrosis. One patient had a rupture of the extensorpollicis longus, which was treated with a tendon transfer.The final range of motion averaged 63°of wrist extention,53°of wrist flexion, 72°of pronation, 81°of supination. Thefinal grip strength averaged 77% of that on the contralateralside. The rate of good results was 43% according to amodification of the rating system of Green and O’Brien.

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Conclusions:The results of corrective osteotomy for the treatment ofintra-articular malunion are comparable with those ofosteotomy for the treatment of the extra-articular malunion.Intra-articular osteotomy can be performed with acceptablesafety and efficacy, it improves wrist function, and it mayhelp to limit the need for salvage procedures such as partialor total wrist arthrodesis.

Three-dimensional Corrective Osteotomy of MalunitedFractures of the Upper Extremity Using a NovelComputer Simulation System and a Custom-designedSurgical Device

Institution where the work was prepared: Osaka University,Suita, JapanTsuyoshi Murase, MD1; Kunihiro Oka, MD1; HisaoMoritomo1; Akira Goto, MD1; Sayuri Arimitsu1; YukariTakeyasu1; Junichi Miyake1; Kazuomi Sugamoto, MD1;Hideki Yoshikawa, MD1; Kozo Shimada, MD2; (1)OsakaUniversity, (2)Osaka Koseinenkin Hospital

Background:Three-dimensional (3D) anatomical correction is desirablefor treatment of long bone deformity of upper extremity.We developed an original system including a 3D computersimulation program and a custom-made surgical devicedesigned on the basis of simulation to achieve accurateresults. In this study, we have investigated the clinicalapplication of this system and preliminary results forcorrective osteotomy of malunited fractures of the upperextremity.

Methods:Twenty-two patients with long bone deformities of theupper extremities (four cubitus varus deformities, tenmalunited forearm fractures, and eight malunited distalradial fractures) participated in this study. 3D computermodels of the affected and contralateral normal bones wereconstructed using data from computed tomography. The 3Ddeformity axis and accurate amount of deformity around itwere quantified by comparing these models, and a 3Ddeformity correction was simulated. A custom-madeosteotomy template was designed and manufactured toreproduce the preoperative simulation during actual surgery.When we performed surgeries, we placed the template on thebone surface, cut the bone through a slit on the template, andcorrected the deformity as preoperatively simulated, whichwas followed by internal fixation. All patients underwentradiographic and clinical evaluations before surgery and at themost recent follow-up.

Results:Corrective osteotomy was achieved as simulated in all thecases. Bony union occurred in all the patients within6 months. Regarding cubitus varus deformity, the averagehumeral-elbow-wrist and tilting angles (i.e., the anterior tiltof the articular condyle of the distal humerus) were 2° and28°, respectively, after surgery. Radiographic examinationshowed that the angular deformities of malunited forearmfractures were nearly nonexistent after surgery. All radio-graphic parameters for malunited distal radius fractureswere normalized. The range of forearm rotation in cases offorearm malunion and that of wrist flexion-extension incases of malunited distal radius improved after surgery.

Conclusions:Corrective osteotomy for bone deformities of the upperextremity using a computer simulation and custom-designedosteotomy template accurately corrects the deformity andconsequently improves the clinical symptoms.

Does Delayed Fixation of Non-Displaced ScaphoidFractures Affect Union Rate

Institution where the work was prepared: Naval MedicalCenter San Diego, San Diego, CA, USANathan Hammel, MD; Leo Kroonen, MD; Eric Venn-Watson, MD; Edton Ganal, MD; Brian Fitzgerald, MD;Eric Hofmeister, MD; Michael Thompson, MD, PhD;NMCSD

Background:Scaphoid fractures are common upper extremity fractureswhich can lead to painful non-union. Surgical treatment ofnon-displaced fractures has led to equivalent union rates ascast treatment although many studies have examined thebeneficial effects of surgical fixation on the time to unionand return to sport or work. Delayed union of bothoperative and non-operative treatment can be a difficultproblem usually requiring additional surgery. This IRBapproved, retrospective study attempts to address a differencein union rates for acute, non-displaced fractures treatedoperatively within 3 weeks of injury or greater than 3 weeksafter injury.

Material and Methods:28 operatively treated non-displaced scaphoid fractureswith adequate follow up were identified from our recordsof operatively treated acute scaphoid fractures by the 3senior authors over a two year period. Of these patients, 17were treated within 21 days, at an average of 8 days afterinjury. Eleven were treated more than 21 days from injuryat an average of 47 days. These groups were similardemographically. There were more associated injuries in the

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early treatment group (5 of 17). The fractures were of thescaphoid waist in 14 of 17 in the early treatment group andin 5 of 11 in the delayed treatment group. In the delayedtreatment group there were 5 proximal pole fractures.Fixation was carried out through an appropriately placedpercutaneous or open approach. Headless, variable pitchcompression screws were used. The outcome of developmentof non-union was established by clinical and radiographic dataanalyzed by a senior author.

Results: One of seventeen patients treated early went on toa non-union for a rate of 6%. One of 11 patients in thedelayed treatment group developed a non-union for a rateof 9%.

Discussion:Our study evidences an expected union rate for non-displaced fractures despite a delay in treatment and anunfavorable fracture location mix.

Patterns of Upper Extremity Injury in Operation IraqiFreedom

Institution where the work was prepared: Naval MedicalCenter, San Diego, CA, USALeo T. Kroonen, MD; Kevin Kuhn; Anatoly Hernandez;Naval Medical Center San Diego

Introduction:While there has been some literature documenting generaldemographics of injuries from the current conflict in Iraq,to our knowledge there has been no study specificallyquantifying and describing the patterns of injury to theupper extremity. The purpose of our study was to evaluatewounding patterns to upper extremity in active duty servicemembers evacuated to a major tertiary care medical facilityafter sustaining injuries in Operation Iraqi Freedom.

Methods:After obtaining approval by the Institutional Review Board,data was retrospectively collected for all casualties returningto our tertiary care facility between April 2003 and July 2006.All patients with an injury to the upper extremity wereanalyzed. We used simple descriptive statistics to quantify theportion of the upper extremity affected, mechanism of injury,open or closed injury, bony involvement, associated neuro-logic injury to the extremity, presence of infection, totalnumber of days hospitalized at our facility, and presence ofdeep vein thrombosis.

Results:Data were recorded for total of 365 casualties received atour facility. Of these casuaties, 134 had sustained injuries to

the upper extremity. Injuries involving the shoulder (21/15.7%), brachium (26/19.4%), elbow (19/14.2%), forearm(37/27.6%), wrist (18/13.4%) and hand (53/39.6%). Themechanism of injury involved blunt trauma (34 patients/25.4%), blast injuries (68/50.1%) and burn injuries (9/6.7%). Positive wound cultures were found in 22 cases(16.4%). 90 cases (67.2%) involved a bony injury, with 52open fractures (57.8%) and 43 closed fractures (47.8%).Injuries to neurovascular structures were present in 29patients (21.6%). Deep vein thrombosis was found in threepatients (2.2%).

Discussion:Advances in body armor, trauma care and evacuationsystems have resulted in the survival of more casualties inthe current conflicts than any other previous wars. A criticalanalysis of the patterns of injury to upper extremity isuseful in order to identify potential areas for prevention,and to familiarize the upper extremity surgeon with thenature of these combat injuries. Our study indicates that, atleast at the tertiary care level, upper extremity injuriesrepresent the majority of orthopedic injuries. They oftenresult from blunt trauma and blast injuries. A high index ofsuspicion should exist for concomitant infection and/ornerve injury. Familiarity with the nature of these injurieswill assist the upper extremity surgeon in renderingappropriate treatment.

Wrist and DRUJ Arthroscopy findings in Distal RadiusFractures: Treatment and Frequency of Ulnar StyloidProcess Fractures and Triangular FibrocartilageComplex (TFCC) Injuries

Institution where the work was prepared: Yukihiko Obara,Tokyo, JapanYukihiko Obara; Saitama Social insurance hospital; EikoYamabe, MD; Hiratsuka City Hospital; Astuo Kawakita;Nerima General Hospital

TFCC injury often accompanies distal radius fracture. Aspart of the treatment of distal radius fractures, arthroscopywas performed to assess TFCC injury, and the incidence ofulnar styloid process fractures and TFCC injuries wasascertained.

Subjects and Methods:The subjects included 49 patients who underwent surgeryfor distal radius fractures. The patients’ average age was57.3 years. For treatment of the distal radius fracture, alocking plate was used. For ulnar styloid process fracturewith DRUJ instability, pinning was performed, and forTFCC fovea detachment without ulnar styloid process

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fracture, direct-vision TFCC was also performed in 9hands. The clinical results were assessed using Mayomodified wrist scores. The type and frequency of ulnarstyloid process fracture, the type and frequency of TFCCinjury, and the clinical results were investigated.

Results:An ulnar styloid process fracture was seen in 27 hands. ATFCC injury was seen in 35 hands, involving the: discproper in 19 hands, radial edge in 10 hands, and fovea in 11hands. DRUJ arthroscopy showed TFCC ulnar facetdetachment in 11 hands. The 14 patients with distal radiusfractures without TFCC injury were young (average age:45.3 years), while the 35 patients with distal radiusfractures and TFCC injury were elderly (average age:62.1 years). Ulnar styloid fracture was observed in 27hands (average age: 58.0 years) and absent in 22 hands(average age: 56.7 years). DRUJ arthroscopy was per-formed in 35 patients, and TFCC fovea detachment wasfirst seen by arthroscopy in 13 hands (average age:70.8 years), but TFCC detachment was not seen in 21hands (average age: 54.1 years). The occurrence of TFCCfovea detachment was not related to ulnar styloid processfracture. The average clinical score was 87.3 points.

Discussion:The present study confirmed that the incidence of TFCCinjury in distal radius fractures is high (71.4%). Further-more, DRUJ arthroscopy confirmed TFCC fovea detach-ment in 38%. The average age of these patients washigh, and the incidence of degenerative injury wasbelieved to be high. However, the incidence of untreatedTFCC fovea detachment was unexpectedly high, andfavorable results were obtained by performing TFCCsuturing in addition. In the future, when treating distalradius fractures, arthroscopy should be performed toaccurately assess the site of injury, following whichappropriate treatment should be administered.

Biomechanical analysis of an air-cell equipped plasticsplint (Aircast) versus conventional plaster splintin a distal radius fracture model

Institution where the work was prepared: Mayo Clinic,Rochester, MN, USAShian Chao Tay, MD, MS1; Kristin Zhao2; Kai-Nan An2;William P. Cooney2; (1)Singapore General Hospital, (2)Mayo Clinic

Background:Despite the plethora of surgical treatment options availablefor definitive treatment of distal radius fractures, acute

treatment, and in some cases, definitive treatment is stillbased on splint immobilization.

Aim:The aim of this biomechanical study is to determine theefficacy of fracture stabilization that is afforded by apolyethylene forearm-based wrist splint, StabilAir WristFracture Brace or Aircast, equipped with inflatable air-cells,as compared to a conventional plaster splint. The hypoth-esis is that distal radius fracture stabilization provided byAircast wrist brace is equivalent to conventional plastersplints.

Method:Five right sawbone forearm models and one cadaveric wristwith distal radius fractures (Universal Type IIA) weretested. A custom testing apparatus was built to hold theforearm and a pneumatic force was applied across themetacarpal heads. Fracture displacement was monitoredwith an optoelectric tracking device synchronized with theload data. The models were tested from 0 to 1.7 kg of loadin three conditions: unsplinted control; modified sugar-tongplaster splint treatment; Aircast wrist brace treatment.

Results:There was no significant difference in mean fracturedisplacements between modified sugar-tong plaster splinttreatment and Aircast wrist brace treatment in both sawboneand cadaveric models.

Conclusion:Our study validates the efficacy of the Aircast wrist brace ina biomechanical model. Clinical assessment of the brace iscurrently in progress for acute, undisplaced and reduced,stable distal radius fractures, and for the post operativesupport of open reduction internal fixation of distal radiusfractures.

Does Vacuum Assisted Wound Closure Affect TissuePressures Following Forearm Fasciotomyfor Compartment Syndrome? A Cadaver Model

Institution where the work was prepared: William BeaumontHospital, Royal Oak, MI, USARachel S. Rohde, MD; Nicholas J. Cook, MD; Gregory V.Sobol, MD; William Beaumont Hospital

Introduction:Compartment syndrome occurs when pressures withintissue compartments increase enough to compromiseperfusion of structures within the confined spaces. Surgicaldecompression via fasciotomy lowers these pressures

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allowing reperfusion, however, edematous tissues oftenpreclude primary wound closure. Temporary wound coveragefollowing fasciotomy traditionally has involved application ofsterile non-adherent dressings until definitive wound coverageis feasible. Recently, vacuum assisted wound closure devices(VAC) have gained popularity for wound coverage followingfasciotomy. However, the effect of applying a negativepressure environment to tissues recently challenged byincreased pressures is unknown. The purpose of this studywas to determine the effect of VAC dressing placement onpost-fasciotomy compartment pressures.

Materials & Methods:Fourteen fresh-frozen cadaveric upper extremities wereobtained. Ten were transhumeral amputations, while fourremained attached to the cadaver torso. Simulated forearmcompartment syndromes were induced by infusion ofHespan. Pressures at defined proximal, middle, and distallocations in each forearm were recorded prior to andfollowing fasciotomy and after placement of the vacuumassisted closure device. Statistical analysis was performedusing Randomized Complete Block Design (RCBD).

Results:There was no statistically significant difference inaverage pressure with regard to side (right versus leftarm) or location of pressure catheter within the arm(proximal, middle, distal). There was no significantdifference in the average pressure immediately followingfasciotomy compared to that after VAC placement amongspecimens within each amputation group; however, therewas a statistically significant difference in the pressurechange following VAC application between the two typesof amputations (p<0.05).

Conclusion:Placement of a vacuum assisted wound closure devicefollowing fasciotomy for forearm compartment syndromein a cadaver model does not significantly change compart-ment pressures. Whether similar pressure consistency isobserved clinically in patients treated with VAC followingfasciotomy for compartment syndrome currently is beinginvestigated.

A New Test for Evaluating Acute Ulnar CollateralLigament Injuries of the Thumb

Institution where the work was prepared: University ofNew Mexico Medical School, Albuquerque, NM, USADeana Mercer, MD; John Veitch, MD; KeikhosrowFiroozbakhsh, PhD; Amanda Medoro, MS; Alicia Lacovara,BS; University of New Mexico

Purpose:Traumatic dislocation of the thumb metacarpal phalangeal(MCP) joint can cause a spectrum of injuries to the ulnarcollateral ligament complex. Evaluation of the extent ofinjury to the ulnar collateral ligament complex of the thumbMCP joint is difficult to determine. Radiologic testing isexpensive and may delay treatment. It has been alluded toby Smith that the extent of dorsal-volar stability at thethumb MCP joint may provide insight into the structuresthat have been compromised due to injury. This biome-chanical study explores the amount of dorsal-volar insta-bility at the thumb MCP joint with sequential sectioning ofthe structures that provide ulnar stability at the thumb MCPjoint.

Methods:Fifteen fresh frozen cadaver hands (8 male and 7 female,ages 38 to 59) were used in this study. The thumb MCPjoint in all specimens were disease free. A speciallydesigned jig was used to secure the specimens in placeand to uniformly measure the thumb MCP joint anterior-posterior translation. Load was applied dorsally andvolarly and displacement measured. A fixed force of10N was applied to the proximal phalanx. The momentarm was kept constant throughout the experiment at1 cm, measured distal to the thumb MCP joint. Thedisplacement was consistently measured at 2 cm distal tothe joint. There were three groups tested (1) thumb MCPjoint ulnar structures intact prior to sectioning (intactgroup), (2) thumb MCP joint with ulnar collateralligament sectioned (MC group) (3) and thumb MCPjoint with ulnar collateral ligament and accessorycollateral ligament sectioned (MC + group). Load wasapplied to the intact group, MC group and MC+ group.Sequence of loading was randomized.

Results:The mean and standard deviation were 7.13±4.62 mm forthe intact, 12.06±4.96 mm for the MC, and 19.86±5.00 mm for the MC+ groups. The differences betweenthe groups were statistically significant (p<0.05) using a2-tailed paired student t-test. This analysis showed that themeasured displacements in the MC and MC+ groups were,respectively, 1.69 times and 2.78 times higher than those ofthe intact group (p<0.001).

Discussion:This biomechanical cadaveric study demonstrates astatistically significant difference in dorsal-volar transla-tion of the thumb MCP joint with increasing disruptionof the ulnar collateral ligament complex. The dorsal-volar translation test may help determine the extent of

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thumb MCP ulnar complex injury and help guideappropriate treatment.

American Association for Hand Surgery ConcurrentScientific Paper Session B-1

Treatment of Symptomatic Neuromas of the DorsalRadial Sensory Nerve using a Resorbable Nerve Conduit

Institution where the work was prepared: Thomas Jefferson,Philadelphia, PA, USAA. Lee Osterman, MD; Sergio Rodriguez; John Taras;Thomas Jefferson University

Established symptomatic neuromas of the dorsal radialsensory nerve are difficult problems for which no idealtreatment exists. This paper studied the role of neurolysisand wrapping of the neuroma in a resorbable collagen conduit.

21 patients, 7M,14F; average age of 33 years (20–52) met theentry criteria: intractable DRSN pain; failure of time,desensitization, and neuroleptic medication; positive electricalstudies or a surgically documented DRSN injury. All hadDRSN neurolysis and wrapping of the neuroma segment witha NeuraGen® Nerve Guide. Results were evaluated clinically,by visual analog scale, and by DASH questionnaire.

The dominant hand in 52%. 11 had previous surgery to theradial wrist including 4 direct injuries and repair to theDRSN; 7 cases of indirect injury including Dequervain’srelease, CMC arthroplasty, lipoma resection, ORIF distalradius fracture, and dog bite. The 10 closed injuries relatedto crush injury, percutaneous needles, radial fracture, andcasting. 17/21 has preop electrical studies. All had preoppain management including desensitization and neuro-leptics, 17/21 had lidocaine, 12/21 had steroid injection. 2patients on narcotic medication.The median time from

original injury to surgery was 8 months (4–37).Thecondition was work related in 5; litigation active in 4.

Mean FU 2.8 years (1.2–4.5). No patient was lost to FU.90% (19/21) were improved and 95% would repeat thesurgery. In 19/ 21 hypersensitivity was improved andpatients were postoperatively able to tolerate watchbands,bracelets and sleeves. Pre and postop 2PD and Semmesmonofilament measurements were variable and not signif-icantly different but all sensory maps identified the DRSNdistribution and tended to improve. Subjectively preopnumbness decreased in 66%.

Preop TInels decreased from 100% to 38%. Visual analogscales(0–10) improved both at rest and in activity: rest 5 to0.7; activity 7 to 1.8. Dash improved 71+/-22 to 29+/-18.Wrist ROM Improved in flexIon, radial and ulnar deviation.Grip strength improved 61% to 92%. Key and Tip pinchshowed similar data: 55% to 84%, 62% to 88%. Workreturn: 6 not working rtw usual job; 2 not working rtwmodified;; 7 working stayed working;. 4 high level athleteswere able to return to their sport.

In summary, neurolysis and wrapping with a resorbablecollagen tube is effective in significantly improving thesymptomatic neuroma of the DRSN. It is simple to perform,avoids ablation of the nerve and the harvesting of othertissues. One drawback is the expense of the conduit.

Intra- and Inter-Examiner Variability in PerformingTinel’s Test

Institution where the work was prepared: Union MemorialHospital, Baltimore, MD, USAKenneth R. Means, MD; Curtis National Hand Center; EricH. Williams, MD; Dellon Institute for Peripheral NerveSurgery: Baltimore. Clinical Instructor; Johns HopkinsUniversity School of Medicine; Scott Lifchez, MD; JohnsHopkins University School of Medicine; Reg Dunn; UnionMemorial Hospital; A. Lee Dellon, MD, PhD; DellonInstitute for Peripheral Nerve Surgery

Though initially used to detect nerve regeneration, theHoffman-Tinel sign was adopted in the early 1950’s to alsodetect sites of nerve compression. There have been fewattempts to standardize Tinel’s test. The goal of this studywas to evaluate the intra- and inter-examiner variability inthe range of forces created using different Tinel’s testtechniques.

Methods:Eight clinicians, consisting of two experienced hand andperipheral nerve surgeons (>10 years in practice), three

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junior hand and peripheral nerve attending surgeons (1–3 years in practice), and three surgeons in training (plasticor orthopedic surgery residents or hand fellows) wereincluded in the study. A Sensotec load cell with a detectionrange of 0–100 lbs was used to record the forces generatedduring the testing. Three different Tinel-type maneuverswere evaluated: 1) striking the load cell using the middlefinger only, 2) using the index and middle finger together asa “double finger” strike, and 3) preloading with theopposite thumb and then striking the thumb. Examinerswere instructed to use their customary range of force duringthe testing. Each participant performed three sets of fivestrikes per technique. Participants were blinded from theload cell recordings. Data was recorded using Labview(National Instruments, Austin, TX) software. Graphic andstatistical analysis was performed with the R-Projectsoftware.

Results:Intra-examiner: There was a significant difference withinnearly all examiners between the range of force they

generated with the middle or double finger technique andthat which they generated using the pre-load technique (seegraph). There was also a difference within nearly allexaminers when comparing the range of forces using themiddle finger and double finger techniques. Inter-examiner:There were large differences in the range of forcesproduced by the various examiners for each technique.

Conclusion:There has been no standardization for eliciting theHoffman-Tinel sign. This study demonstrates that thereare considerable intra- and inter-examiner differences in therange of forces generated during a lab simulation formultiple Tinel’s techniques that are used in clinical practice.This variability may be responsible for clinical differencesin the ability to obtain a Hoffman-Tinel sign in a patientbetween examiners and may partially explain the inconsis-tency in sensitivity and specificity reported for Tinel’s testin the literature. Further research on standardization isneeded and should be used for any studies that employTinel’s test as part of the study protocol.

Outcomes of Single Versus Double Nerve Transfersfor Elbow Flexion

Institution where the work was prepared: Mayo Clinic,Rochester, MN, USABrian T. Carlsen, MD; Michelle Kircher; Robert J.Spinner; Allen T. Bishop; Alexander Y. Shin; Mayo Clinic

Background:Restoration of elbow flexion after upper brachial plexusinjury can be restored with a single nerve transfer to thebiceps branch of the musculocutaneous nerve (MCN) froman ulnar nerve fascicle or a double nerve transfer with anadditional nerve transfer to the brachialis branch of theMCN from a median nerve fascicle.

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Purpose:Compare the outcomes of single and double nerve transfersfor elbow flexion.

Methods:A retrospective review was performed of all patients withparalytic loss of elbow flexion receiving nerve transfer torestore elbow flexion. Single and double nerve transfers werecompared in regard to injury level, elbow flexion, supination,and grip strengths, and DASH scores. Elbow flexion andsupination torque strength were measured quantitatively in sixsingle and thirteen double nerve transfer patients.

Results:Fifty-five patients (23 single, 32 double) underwent nervetransfer to restore elbow flexion. The mean time frominjury to operation was similar (178 days, single vs.181 days, double). Double nerve transfer patients trendedtoward improved elbow flexion strength (21% vs. 16%,single) when compared to the contralateral side (p = NS).MRC grade improved to 4 or better in 14/21 single and 24/30 double nerve transfer patients. Supination strengthtended to be greater in double nerve transfer patients(37% of contralateral side) compared to single nervetransfer patients (22% of contralateral side) (p = NS). Gripstrength was greater in the double nerve transfer patients(42%, single vs. 63% double, p<0.05) compared to thecontralateral side. Pre-operative DASH scores were signif-icantly greater in single (51.3) vs. double (37.3) nervetransfer patients. Single nerve transfer patients had a greaterimprovement in DASH scores (20.2 vs. 8.3, p<0.05). Finalmean DASH scores were similar in the 2 groups (29.5,single vs. 28.6, double). The injury level was differentbetween the two groups with 19/23 single nerve transferpatients having injury beyond the C5–6 level and only 16/32 of double nerve transfer patients with >C5–6 injury (Chiprobability, 0.041).

Conclusions:Outcomes are similar for single and double nerve transfers forelbow flexion. Double nerve transfer patients have greater gripstrength and tend toward improved elbow flexion andsupination strength. Patients appropriate for double nervetransfer tend to have less severe injury and lower pre-operativeDASH scores than single nerve transfer patients. Single nervetransfer patients had a greater improvement in DASH scoresto a level similar to double nerve transfer patients.

Mirza Single-Portal Endoscopic Carpal Tunnel Release.A Prospective, Randomized Study

Institution where the work was prepared: Beth IsraelDeaconess Medical Center, Boston, MA, USA

Abigail Zamora, BA; Charles S Day, MD; Albert Yeh, BA;Miguel Ramirez, MD; Beth Israel Deaconess MedicalCenter/Harvard Medical School

Hypothesis:The Mirza palmar uniportal carpal tunnel release techniqueinvolves a small longitudinal incision in the palm thatallows identification of the superficial palmar arch andassociated branches of the median nerve. This shouldreduce risk for complications that occasionally arise intraditional endoscopic release techniques.

Methods:All patients were enrolled at a single tertiary care academicmedical center. Patients were randomized to either the openor Mirza endoscopic limbs. Exclusionary criteria includedother surgical procedures on the affected limb. Follow upvisits were performed blindly at 2, 4, 8, and 12 weeks post-operatively. Outcome measurements included the standard-ized Disabilities of the Arm, Shoulder, and Hand (DASH)survey, grip and pinch strength, sensory tests (2-pt.discrimination, monofilament), and a patient satisfactionquestionnaire. Statistical analysis was performed withrepeated measures ANOVA.

Results:A total of 48 patients (mean age 54, range 26–81; 36women) have been enrolled so far. A total of 50 handsunderwent surgery (23 endoscopic, 27 open), with theaverage incision size being 1.67 cm and 2.87 cm. respec-tively. There was no significant difference between the twoprocedures with respect to improvement of sensation,DASH scores, grip strength, pinch strength, return to work,overall patient satisfaction, scar tenderness, or return todaily functions throughout follow-up (p>0.05). However,patients who underwent the open procedure reported signif-icantly better pain relief at the 2, 4, and 12 week visits thanthose who underwent the endoscopic procedure. There wereno surgical complications in either group. When asked beforesurgery, 24 patients preferred the smaller incision, 21 had nopreference, and 1 preferred the larger incision.

Conclusions:Contrary to previous studies, there was no difference in thecomplication rate between the Mirza endoscopic release andopen release. Patients preferred the smaller incision despitethere being minimal difference in functional outcome. Patientswith the open release reported greater pain relief.

Summary Sentence:Patients preferred the endoscopic incision over the openincision despite minimal difference in functional outcome.Patients who underwent the open procedure experience

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greater pain relief. There was no difference in thecomplication rate between the Mirza and open procedures.

The 6-item CTS Symptoms Scale - A Brief OutcomesMeasure for Carpal Tunnel Syndrome

Institution where the work was prepared: Department ofOrthopedics Hässleholm-Kristianstad, Hässleholm, SwedenIsam Atroshi, MD, PhD; Hässleholm and KristianstadHospitals; Per-Erik Lyrén, MSc; Umeå University; ChristinaGummesson, PT, PhD; Lund University

Purpose:We used item response theory (IRT) to derive a brief carpaltunnel syndrome (CTS) symptoms scale from a previouslyvalidated scale.

Methods:Preoperative questionnaires, including the CTS 11-itemsymptom severity and 8-item functional status scales, from693 patients (71% women) undergoing carpal tunnel releasewere analyzed. The scales were examined using reliabilityand factor analyses and IRT including differential itemfunctioning (DIF) concerning gender.

Results:Factor analysis of the two scales combined showed presenceof a dominant factor related to function including allfunctional status and two symptom severity items, and threeother factors with symptom severity items. The IRT PartialCredit Model (PCM) fit the data well. Four items wereremoved from the symptom severity scale and two items weremerged creating the new 6-item CTS symptoms scale. Factoranalysis showed one dominant factor explaining 60% of thevariance. Reliability was high (alpha=0.86). The PCMproperly fit the new scale and IRT person separation reliabilitywas 0.85. One item displayed significant but very small DIF.

Conclusions:The 6-item CTS symptoms scale has good measurementproperties and can be used for outcome evaluation in CTS.

Early Clinical Outcomes with the Use of DecellularizedNerve Allograft for Repair of Sensory Defectswithin the Upper Extremity

Institution where the work was prepared: Mayo Clinic,Rochester, MN, USAFurkan Erol Karabekmez, MD; Ahmet Duymaz, MD; SamirMardini; Steven L. Moran; Mayo Clinic

Introduction:Nerve conduits have become an established option forrepair of sensory deficits of up to 2 cm. More recently,

decellularized nerve allograft has also been advocated as anoption for nerve repair, however no clinical studies haveexamined its efficacy for sensory nerve defects. The aim ofthis study was to examine our early experience with the useof decellularized nerve allograft for repair of segmentalnerve defects within the hand and fingers.

Material and Method:From July 2007 to March 2008, 9 patients who had 10 nervegaps were treated surgically using Axogen® nerve allograft.They were 8 digital and 2 ulnar nerve defects. The etiologiesof the nerve defects were traumatic nerve transection in 6defects and neuroma resection and reconstruction in 4 defects.Eight of the affected nerves were sensory and twoweremixed,containing motor and sensory fibers. The outcomes wereevaluated with moving and static two point discriminationtests. Implantation sites were also evaluated for any signs ofinfection, rejection or graft extrusion.

Result:There were 8 men and 2 women with a mean age of 42 years(23–65). Mean nerve graft length was 2.3 cm with a range of0.5–3. Mean follow up time was 4 months (2–5). Average twopoint discriminations were 7.2 mm moving and 7.5 mm staticat last recorded follow-up. No rejection or infection sign wereseen around the graft material and sensory improvement wasobserved in all of the patients despite this short term follow up.Re-exploration of 2 fingers was required for flexor tendonrupture in one and flexor tendon tenolysis in the other. In bothcases the nerve allograft was visualized and appeared wellincorporated in the repair site.

Conclusion:Decellularized nerve allografts were capable of returningadequate sensation in nerve defects ranging from 0.5–3 cm.There were no cases of infection or rejection and materialhandling properties were excellent. Decellularized nerveallograft may provide an option for segmental nerve gapsbeyond 2 cm. Randomized comparative studies will berequired to determine efficacy in comparison to collagenconduits or nerve autograft.

Effect of Profession on Duration of Symptoms Priorto Carpal Tunnel Release Surgery

Institution where the work was prepared: Beth IsraelDeaconess Medical Center, Harvard Medical School,Boston, MA, USAEricMakhni; HarvardMedical School/Beth Israel DeaconnessMedical Center; Charles S. Day; Harvard Medical School

Introduction:The effect of patient career/profession on the duration ofsymptoms prior to carpal tunnel release has not been

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investigated. This study sought to determine if such acorrelation exists.

Methods:All records of patients seen and examined in our clinicbetween January 2005-January 2007 were reviewed. Thosepatients with the diagnosis of carpal tunnel syndrome wereincluded in this review. Records were reviewed fordemographic data (including patient profession, such as“serice,” “retired,” “medical,” “laborer,” “clerical,” or“other,”) as well as data pertaining to timing of symptomonset, disease diagnosis, and operative repair (if applicable).

Results:A total of 245 patients carried the diagnosis of carpal tunnelsyndrome among all records reviewed. 122 of these patientsultimately had corrective surgery, while the remaining 123underwent only conservative management. The average ageof those patients who received operative management wassignificantly higher than those who underwent onlyconservative management (56.3 years vs. 50.3 years;p<0.001). When considering patient profession, there wereno significant difference among any of the above-mentionedgroups when considering fraction undergoing surgery(p=0.55), duration of symptoms (p=0.61), or number ofvisits prior to diagnosis (p=0.8). However, there was a trendtowards an increasing number of visits before surgery forthose in the medical profession (p=0.1).

Conclusions:Those undergoing operative repair for carpal tunnelsyndrome are older than those undergoing conservativemanagement only. Because the two treatment groups weresimilar with respect to duration of symptoms prior tosurgery, age may play an important role when consideringoperative repair. Further, those in the medical professionhad more clinic visits pre-operatively than other counter-parts, signifying an poentially increased threshold forconservative management.

Comparison of Anterior Transposition and In SituDecompression for Ulnar Nerve Compressionat the Elbow: One Surgeon’s Experience

Institution where the work was prepared: Johns HopkinsUniversity School of Medicine, Baltimore, MD, USARon Gutmark, BA; Elizabeth N. Le, BS; E. Gene Deune,MD; Johns Hopkins University School of Medicine

Objective:The most optimal surgical technique for treatment of cubitaltunnel syndrome (CTS) has not been conclusively deter-mined. This study examined 38 operations for the treatment

of CTS using in-situ decompression (IS) (n=16) or anteriorsubmuscular transposition (ASM) (n=22).

Methods:A retrospective chart review on consecutive operationsfrom 2/2000 to 9/2007 was undertaken on 34 patients, 18males and 16 females with an average age of 44.7. Thesepatients underwent either IS (n=20) or ASM (n=22).42.1% of patients had operations on their dominant hands.Severity of ulnar nerve compression prior to and aftersurgery was determined by objective measures includingpinch and grip strength, two point discrimination, andelectromyographical (EMG) data, and by subjective measuresincluding the Dellon scoring system and patients’ question-naire (average time to survey was 54 months).

Results:The reoperation rate for the IS group was 0% (0/16) and18.2% (4/22) for the ASM group. In the IS group, averageDellon scores decreased after surgery by 1.09 pointscompared with a decrease of 0.18 points for the ASMgroup. For patients in the IS group, two point discrimina-tion decreased by 2.11 mm after surgery compared to adecrease of 1.94 mm in the ASM group. Grip and pinchstrength for the IS group increased by 39.71 and 3.35 lbs,respectively, compared to an increase of 10.18 and 3.53 lbs,respectively, for the ASM group. There were no cleardifferences between males and females using the variouscriteria, except with grip and pinch strength, which showedgreater improvement with ASM in males vs. females.Those in the younger group (<49) who underwent ASMshowed greater improvement in all criteria over the oldergroup. EMG showed greater improvement in the ASMgroup compared to the IS group with regard to latency andvelocity, but the IS group showed greater improvement inamplitude (Table 1).

Conclusion:This study illustrates a superior improvement in several keyindicators of efficacy in the IS group when compared to theASM group. However, EMG latency and velocity andsensory conduction velocity showed better performancethan the IS group, but this apparently did not correlate withsubjective symptoms. This is likely due to the moreinvasive nature of ASM and the choice of bed in whichthe nerve is placed.

Table 1 EMG Motor NerveConduction

Sensory Conduction

Surgery Latency Amplitude Velocity Latency Amplitude Velocity

IS +0.38 +0.52 +4.01 +0.38 +0.99 −5.41ASM −0.24 −0.21 +10.28 +0.15 −2.35 +0.77

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Revision Surgery after Carpal Tunnel Release UsingFascio-Cutaneous Island Flaps

Institution where the work was prepared: UniversityHospital Bern, Bern, SwitzerlandMatthias Traub, MD; Esther Voegelin; University HospitalBern

Hypothesis:The use of fascio-cutaneous island flaps in the treatment ofrecurrent or persistent carpal tunnel compression syndrome(CTS) reduces painful symptoms by providing a tension-freegliding tissue cover.

Methods:From 1997–2007, 16 patients (9 women, 7 men, aged 26 to77 years with a mean of 56.8 years) had 18 operations foreither recurrent or persistent CTS, or neuropathic painsyndrome. All patients were treated with neurolysis of thescarred median nerve followed by either a reversedposterior interosseous (n=12) or an ulnar artery perforatorflap (n=6) depending on extension and localisation ofscarring. The patients were evaluated pre- and postopera-tively using a pain visual analogue scale and the DASHscore. Sensibility, motor dysfunction, pain and success ofthe treatment were classified as good, improved or bad.Postoperative ENMG examinations were performed.

Results:Patient mean follow-up was 23.8 months (1.7 to 93.5). Thepain evaluation showed a statistically significant improvement(p<0.005) decreasing from a mean value of 6.7 to 1.5. TheDASH score was significantly improved postoperatively(p<0.005). The best results were observed in patients withoutextensive preliminary median nerve damage. The duration ofsymptoms before re-operation did not influence the outcome.Eight patients demonstrated good, six improved and twopatients maintained poor results. The two patients with poorresults suffered from extremely scarred and injured mediannerves following previous surgery.

Summary:

& Protective coverage of the median nerve by use of afascio-cutaneous island flap after failure of carpal tunnelrelease provides a tension-free gliding tissue cover andreduces the risk of adhesions

& It reduces painful symptoms effectively, however doesnot guarantee total pain relief in all patients

& Pain relief and functional recovery strongly depend onthe pre-existing condition of the median nerve

& Postoperative ENMG show release of compression butno recovery of axonal damage

Application of Fibrin Glue inMicrovascular Anastomoses:Comparative Analysis with the Conventional SutureTechnique Using a Free Flap Model

Institution where the work was prepared: Instituto deOrtopedia e Traumatologia da USP, São Paulo, BrazilAlvaro B. Cho, MD; Mattar Júnior Rames; Faculdade deMedicina da USP

Background:Several studies have already reported the utilization offibrin glue in microvascular anastomoses to minimize thenumber of sutures and to decrease the operative time.Despite the good results obtained in most of these experi-ments, its clinical application has not launched. The aim ofthis study was to clarify the controversies around the safenessof fibrin glue application in microvascular anastomoses andalso to demonstrate the potential benefits of fibrin glueapplication in a realistic free flap model.

Methods:Twenty-seven rabbits were used in this study. The exper-imental model consisted of a free groin flap transfer to theanterior cervical region. The flap’s circulation was restoredby means of an end-to-side anastomosis between thefemoral and carotid arteries, and an end-to-end anastomosisbetween the femoral and external jugular veins. The firstseven animals were used in a pilot study to test theexperimental model and train the surgical procedure. Theremaining 20 rabbits were divided into two groupsaccording to the anastomosis technique: Group I (conven-tional suture) and Group II (fibrin glue). The animals werekept alive for at least of two weeks when the anastomoseswere re-explored. We used the Student‘s “t” test to comparethe quantitative parametric data and the Mann Whitney “u”test to compare the quantitative non-parametric data.

Results:The number of sutures required to complete the arterial andvenous anastomoses was reduced in 39% and 37% in groupII, respectively. The mean arterial anastomosis time was 4,5minutes shorter in the fibrin glue anastomosis group (p=0,00004). The mean venous anastomosis time was 6,4minutes shorter in group II (p=0,0001). The ischemic timeof the flaps was 11,2 minutes shorter in the fibrin glueanastomosis group (p=0,001). The total operative time wasalso shortened by 15,6 minutes in group II (p=0,0395).

Conclusions:Both arterial and venous anastomoses were benefited fromfibrin glue application, which made them easier and fasterto perform. Despite the significant amount of suturereduction, the anastomoses maintained adequate patency

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rates and mechanical strength and the flaps’survival ratewas not negatively affected. In this study, the application offibrin glue in microvascular anastomoses was safe andreliable. The risk-benefit ratio of fibrin glue application inmicrovascular anastomoses is favorable for its use.

Pedicled Descending Branch Muscle-sparing LatissimusDorsi Flap for Trunk and Upper ExtremityReconstruction

Institution where the work was prepared: UT SouthwesternMedical Center, Dallas, TX, USACorrine Wong, MBBS, MRCS; Michel Saint-Cyr, MD; UTSouthwestern Medical Center, Dallas

Background:The major blood supply of the latissimus dorsi muscle flapis based on the descending and transverse branches of thethoracodorsal artery. This segmental blood supply allowsthe muscle to be split and harvested based solely onvascularization from the descending branch, thus sparingthe latissimus dorsi muscle function. This article reports theuse of the descending branch muscle-sparing latissimusdorsi myocutaneous flap in reconstructing defects on thetrunk and upper extremities.

Methods:Five patients with defects on the trunk or upper extremitieshad soft tissue reconstruction with a pedicled descendingbranch muscle-sparing latissimus dorsi myocutaneous flap.A transverse skin paddle design was used in all cases. Allflaps were performed by the senior author. Complicationswere recorded, and range of motion analysis was performedcomparing operated and non-operated sides during follow-upappointments.

Results:The descending branch muscle-sparing latissimus dorsi flapwas used for reconstruction of the: chest wall (2), axilla (2)and upper extremity (1). The skin paddles harvested rangedfrom 15×7 cm to 24×9 cm. All donor sites were closedprimarily. There was one case of minor wound dehiscenceon the donor site and one case of wound infection(reconstruction was for chronic, severe axillary hidradenitissuppuritiva). There were no incidences of seroma. In allcases, there was no difference in strength or range ofmotion around the shoulder joint when comparing theoperated to the non-operated side.

Conclusions:The pedicled descending branch muscle-sparing latissimusdorsi myocutaneous flap with a transversely orientated skinpaddle results in minimal functional deficit of the donor

site, absence of seroma, low rate of flap complications andan aesthetically acceptable scar.

Forearm Osseous Reconstruction with VascularizedFree Fibula Grafts

Institution where the work was prepared: Mayo Clinic,Rochester, MN, USABrian T. Carlsen, MD; Scott Thompson, BA; Steven L.Moran, MD; Allen T. Bishop, MD; Alexander Y. Shin,MD; Mayo Clinic

Background:Vascularized osseous reconstruction is indicated for largeskeletal defects. Studies reporting the outcome of vascularizedfibula for forearm reconstruction are sparse and most includeother anatomic locations.

Purpose:Report the outcomes of forearm reconstruction withvascularized fibula grafts.

Methods:A retrospective review was performed of 21 consecutivepatients receiving vascularized fibula grafts for forearmreconstruction from 1980 through 2007 at a large academicinstitution. Patients were analyzed in regard to the etiologyand location of the defect. Endpoints included time toskeletal union, post-operative complications, range ofmotion, and DASH scores.

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Results:Twenty-one patients (15 male, 6 female) with an averageage of 26.7 (6–59) were identified. The etiologies of thedefect included trauma (5), infection (4), tumor (11), andcongenital pseudoarthrosis (1). The average defect size was8.0 cm with a range from 4–13 cm. Eight patients hadreconstruction of a single bone (radius or ulna), six patientshad construction of a single-bone forearm with the graft,ten patients had fusion of the wrist with the graft, and threepatients had a combination of wrist fusion and one-boneforearm construction. At the time of the study, sixteenpatients were available for fusion analysis. Primary unionwas achieved in 10/16 (62.5%) patients at an average of5.7 months. Six of sixteen (37.5%) patients requiredadditional procedures to achieve union at one of theosteosynthesis sites with union achieved at an average of28 months after the initial operation in this group. Onepatient had an additional vascularized corticoperiostealbone graft from the medial femoral condyle. Seven of 10patients with reconstruction of tumor defects achievedprimary union, vs. two of four patients following recon-struction of infection and trauma related defects. DASHsurveys were able to be completed on nine patients at anaverage of 12 years after injury. DASH scores averaged15.2 for this group. Postoperative complications werecommon, occurring in 13/21 (62%) patients. There wasone early microvascular failure with conversion to non-vascularized bone graft. Other complications includednonunion (7), infection (3), tendon adhesion (2), radioulnarsynostosis (1), delayed microvascular thrombosis (1),fracture of the fibula graft (1), plate fracture/hardwarefailure (1), median nerve neurapraxia with delayed recovery(1), and superficial radial nerve neuroma (1).

Conclusion:Osseous reconstruction of the forearm with a vascularizedfibula graft is a complex procedure associated with majorcomplications. It can provide satisfactory outcomes inpatients with limited reconstructive options.

Intravascular Stenting Method for FingertipReplantation

Institution where the work was prepared: NarushimaMitsunaga, tokyo, JapanJun Araki; Narushima Narushima, MD; Tokyo university

Remarkable progress has been made in microsurgery.However, fingertip replantation following amputation hasnot gained much popularity because of its technicaldifficulty. We have developed the intravascular stenting(IVaS) method, in which a nylon monofilament is placedinside the vessel lumen to act as a temporary stent,

facilitating anastomosis completion. We performed 9fingertip replantations using the IVaS method. Intravas-cular stent size varied from 4–0 to 6–0 (0.199–0.07 mmdiameter). There were no cases in which the back wall ofa vessel became inadvertently caught in the anastomosis.The overall survival rate for distal digital replants was88% (8/9 replants). It is very difficult to evenlyanastomose vessels of differing diameter, especially ona supermicrosurgical scale. In this respect, the IVaSmethod plays a role in stably anchoring the two vesselends, allowing for the even spacing of suture knots, evenin vessels of different caliber. Because of its ease of useand exactitude, many surgeons may be able to use theIVaS method to reliably complete small anastomoses infingertip replantations.

Triangular Flaps: aModified Technique for the Correctionof Congenital Constriction Ring Syndrome

Institution where the work was prepared: Chang GungMemorial Hospital, Kaohsiong, TaiwanLynn PL Tan, MBBS, MRCS, MMed; Singapore GeneralHospital; Yuan-Cheng Chiang, MD; Chang Gung Universityand Chang Gung Memorial Hospital

Background:Congenital constriction ring syndrome (CCRS) is a con-genital anomaly with a wide spectrum of clinical presentation.The accepted method of correcting a circular constriction is toexcise the deep part of the constriction, and break the line ofthe circular scar with multiple Z- or W-plasties. Specificcorrection of soft tissue is recommended concurrently, tobetter correct the “sandglass” deformity.

Materials and Methods:Here we describe a technique using triangular flaps tocorrect the deformity in 7 patients with constriction ringsyndrome, involving either the upper or lower limbs. In thistechnique, triangular flaps can be introduced either proximalor distal to the ring, depending on the limb circumference, tobetter correct the contour deformity.

Results:In all 7 patients, a normal extremity contour wasobtained, with complete elimination of the deformitycaused by the constriction ring. A mean follow-up of34 months revealed an aesthetically acceptable scar, withno case of recurrence.

Conclusion:Triangular flaps designed either proximal or distal to theconstriction ring is able to correct the contour deformity ofthe limbs with better versatility and aesthetic results.

218 HAND (2009) 4:195–237

Patient Reported Outcome Following a TraumaticPeripheral Nerve Injury

Institution where the work was prepared: University ofToronto and York University, Toronto, ON, CanadaChristine B. Novak, PT, MS, PhD(c)1; Dimitri J. Anastakis,MD1; Dorcas E. Beaton, PhD1; Joel Katz, PhD2; (1)University of Toronto, (2)York University, University ofToronto

Outcome following traumatic peripheral nerve injury (PNI)is variable and the degree of disability depends on multiplefactors related to the injury and to the patient.

Purpose:The purpose of this study was to evaluate patient reportedoutcome and the presence of pain and disability followingan upper extremity PNI.

Methods:Following Research Ethics Board approval, the medicalcharts were reviewed of patients who met the followinginclusion criteria: adult patients who at the initial consultwere at least 6 months from an upper extremity traumaticPNI and had completed a DASH questionnaire and the SF-36. For the SF-36, comparisons were made between theCanadian norms and the nerve injured patients. Patientswere classified as having high pain if they exceeded 2standard deviations from the normative data. Comparisonsof the DASH scores was performed using t-tests or a one-way ANOVA between the following independent variables;pain, workers’ compensation or litigation involvement,gender, time since injury, nerve injured. Multiple linearregression was used to evaluate the variables (gender,workers’ compensation or litigation involvement, dominanthand injured, time since injury, age, nerve injured, bodilypain) that predicted outcome (DASH).

Results:There were 84 patients (19 women, 65 men) with a meanage 38 years (sd 14 yrs). The mean time following injurywas 4 years and the most frequent injury was to the brachialplexus (n=27). For all 8 domains of the SF-36 and thephysical and mental component scale, the mean values ofthe nerve injured patients indicated significantly moreimpairment than the normative values (p<0.001). Themean DASH score was 52, which indicated an elevatedlevel of disability. Patients with more bodily pain (p<0.001)and brachial plexus injuries (p=0.023) had significantly moredisability. Using manual backward elimination and 0.1 levelof significance for removal, the final model contained thepredictor variables bodily pain (beta=-.481, p<0.001), age(beta=.424, p=0.002) and nerve injured (beta=-4.683,

p=0.024) and 45% of the variance was explained with thismodel.

Conclusion:In patients with traumatic peripheral nerve injuries, disabilityas measured by the DASH is associated with more bodilypain, older age and brachial plexus involvement. Assessmentof chronic pain following PNI and further investigation intothe associated factors may provide an opportunity forefficacious treatment and better health related quality of life.

American Association for Hand Surgery ConcurrentScientific Paper Session B-2

Arthroscopic Transosseous Repair of the UlnarDisruption of the TFCC to the Ulnar Fovea

Institution where the work was prepared: Department ofOrthopaedic Surgery, Keio University, Tokyo, JapanToshiyasu Nakamura, MD, PhD; Kazuki Sato, MD, PhD;Masato Okazaki, MD; Yoshiaki Toyama, MD, PhD;Hiroyasu Ikegami, MD, PhD; Keio University

Treatment of the DRUJ instability due to ulnar disruption ofthe TFCC is a challenging issue. We described here anarthroscopic outside-in suturing (trans-ulnar suturing) of theulnar disruption of the TFCC to the ulnar fovea.

Technique:When the disrupted TFCC from the fovea was diagnosedthrough the radiocarpal or DRUJ arthroscopy, the TFCCwas tightly reattached to the fovea through two tunnelsmade from the outer cortex of the ulna to the center of thefovea using outside-in pullout technique with double 3–0polyester sutures (Ticron or Etibond). Before suturing, thefovea area was refreshed by arthroscopic shaver via DRUJportal.

Patients:We underwent the arthroscopic repair of the TFCC in 21wrists. Age ranged 14–53 (average 27), 8 male and 13female were included. There were 10 right and 11 leftwrists. TFCC tears were ulnar peripheral + horizontal in 6,fovea avulsion in 14, and proximal slit in 1. Periods frominitial injury to the surgery were 6–48 months (average 30).Pain, range of rotation and DRUJ instability were evaluated.

Results:All patients complained pain preoperatively. Pain disap-peared in 14 wrists, remained in 3 and recurred in 4. Therewere no loss of forearm rotation pre- and postoperatively.Preoperative DRUJ instability was noted as ,,b in 2, + in6,++ in 13 and postoperatively, 16 wrists indicated no

HAND (2009) 4:195–237 219

instability. We obtained excellent results in 13, good in 2,fair in 3 and poor in 3.

Conclusion:Arthroscopic trans-ulnar suturing technique is promisingprocedure in ulnar disruption of the TFCC with DRUJinstability.

Efficacy and Safety of Clostridial Collagenasefor Injection in Patients with Dupuytren’s Contracture:Results of a Phase III Trial

Institution where the work was prepared: Indiana HandCenter, Indianapolis, IN, USAF. Thomas D. Kaplan, MD1; Bronier L. Costas, MD1;Vincent R. Hentz, MD2; Lawrence C. Hurst3; JohnLubahn4; (1)Indiana Hand Center, (2)Stanford UniversityMedical Center, (3)SUNY-Stony Brook, (4)Hamot MedicalCenter

Purpose:Injectable Clostridial collagenase (AA4500) is an investi-gational, minimally invasive, nonsurgical treatment forDupuytren’s contracture (DC). Single-center trials demon-strated that injection of AA4500 into Dupuytren’s cordscorrected metacarpophalangeal (MP) and proximal inter-phalangeal (PIP) joint contracture to 0°Æ-5°Æ of normal inmost cases; no placebo-injected cords achieved thisresponse. Two phase III studies (Collagenase Option forReduction of Dupuytren’s [CORD] I and CORD II) areevaluating the efficacy and safety of AA4500 in a largerpatient population. Results of the double-blind phase ofCORD I are presented here.

Methods:CORD I is being conducted at 16 US sites: an open-labelextension is ongoing for patients who require additional

therapy for failure of placebo or involvement of otherjoints. Enrollment required MP and/or PIP flexion defor-mities °Ã20°Æ. Patients received °Â3 0.58-mg collagenaseinjections in the cord affecting a primary joint at 4 weekintervals. Follow-up occurred 1 day, 1 week, and 1 monthafter each injection. Primary efficacy variable was primaryjoint correction to 0°Æ-5°Æ of normal after the lastinjection. Cords affecting subsequent joints could be injected.Flexion contracture, range of motion, grip strength, andadverse events were evaluated.

Results:In the randomized, double-blind, placebo-controlled phaseof CORD I, 306 adults (80% male; mean age 63±9.5 years)who had a mean duration of symptoms of 61±77 monthsand a mean baseline contracture of 50¨¬ ±20¨¬ wereevaluable for efficacy. 62% had one hand affected; 38%had bilateral disease. 58% of patients had no priortreatment; 38% had surgery; and 14% had physical therapy.Patients receiving AA4500 achieved a 79.3% reduction(from 50.2¨¬ to 12.2¨¬) in joint contracture vs 8.6% (from49.1¨¬ to 45.7¨¬) on placebo (P<0.001). Post-treatmentjoint contracture was °Â25¨¬ in 82.2% of patients andwithin 0°Æ-5¨¬ of normal (the primary end-point) in 64%of patients. In contrast, only 6.8% of patients on placeboachieved joint contracture to within 0°Æ-5¨¬ of normal(P<0.001). The most common adverse events included pain,swelling, bruising, and pruritis at the injection site, andtransient lymph node swelling and pain. No systemic allergicreactions were noted. Three SAEs possibly related to drugoccurred (2 tendon ruptures and 1 complex regional painsyndrome).

Conclusions:The results of this phase III study confirm previous clinicaltrials (J Hand Surg 2007;32A:767), which showed thatinjectable Clostridial collagenase effectively and safelycorrected or significantly improved MP and PIP contracturesin most patients with 1 or more DC-affected joints.

Treatment of Scaphoid Nonunions Using VascularizedBone Grafts Transplanted Through a Dorsal Approach

Institution where the work was prepared: Kyoto UniversityHospital, Kyoto, JapanRyosuke Kakinoki, MD, PhD1; Ryosuke Ikeguch1; TakashiNakamura1; Taiichi Matsumoto, MD2; (1)Kyoto University,(2)Kurashiki Central Hospital

PurposeTo report surgical outcomes of 17 patients with scaphoidnonunions using vascularized bone grafts transplanteddorsally.

220 HAND (2009) 4:195–237

Patients and methods:17 scaphoid nonunions in 17 patients (16 males and afemale) underwent surgery using vascularized bone graftssupplied by the 1–2 intercompartmental supraretinaculararteries. All vascularized bone grafts were transplantedthrough the dorsal capsule, leaving the palmar radiocarpalligament intact. The mean age of the patients at the time ofthe surgery was 27 years (range, 13–59). The mean intervalbetween the injury and surgery was 4.3 years (range,8 weeks to 42 years). Four patients had had surgery for thescaphoid before the present operations. Arcs of thedorsiflexion, palmar flexion, radial deviation and ulnardeviation and the grip strength of the bilateral wrists weremeasured before surgery and at the time of the final follow-upin each patient. The arc angles and grip strength of the affectedhands were expressed as percentages of those of thecontralateral hand. The radiolunate angles of the affectedwrists were measured on the postoperative and preoperativeplain X-ray films. The postoperative status of the affectedwrists was assessed using a modified Mayo Wrist Scores.

ResultsBone union was obtained in all patients except a patient. Theaverage interval between the surgery and bone union was11.9 weeks (range, 8–30 weeks) in the remaining 13 patients.The DISI deformity was corrected after the operations in allpatients having shown DISI deformity before the surgery. Therespective preoperative and postoperative average arcs of theaffected wrists were 80±12% and 74±14% in the dorsiflex-ion, 76±17% and 62±18% in the palmar flexion, 55±21%and 53±26 in the radial deviation, 94±23% and 75±12% inthe ulnar deviation. The preoperative and postoperative gripstrength were 71±17% and 84±17%, respectively. Thepalmar flexion and ulnar deviation significantly decreasedpostoperatively. The radiolunate angles significantly de-creased from –10.2±9.7% preoperatively to 1.2±9.4% post-operatively in the patients having had the DISI deformitybefore surgery. The mean modified Mayo Wrist Score was 74(range, 60–90). There were no patients who developedavascular necrosis of the proximal scaphoid.

Conclusion:Vascualrized bone grafts transplanted to scaphoid nonunionsdorsally corrected the DISI deformity and prevented the de-velopment of the avascular necrosis of the proximal scaphoid.

Underutilization of Upper Extremity Reconstructionfor Persons with Tetraplegia: The Patient Perspective

Institution where the work was prepared: RehabilitationInstitute of Chicago, Chicago, IL, USAMichael S. Bednar, MD1; Rebecca Ozzelie, OTR/L2;Elizabeth Jordan, OTR/L, CHT1; (1)Loyola University -Chicago, (2)Rehab Institute of Chicago

While it is estimated that 65% of persons with tetraplegiawould benefit from upper extremity reconstruction, fewer than10% actually have the procedure performed. Recent studiessuggest barriers to these procedures include an inadequatereferral network between physiatrists and surgeons and thehestitancy of physiatrists to recommend these procedures totheir patients. At our institution, tetraplegic patients are seen ina multidisciplinary clinic, including both physiatry and handsurgery. The physiatrists encourage all patients to be evaluat-ed. Despite this, only 18% of patients who are candidates forupper extremity reconstruction choose to have the procedures.The goal of this study is to survey the patients who chose notto have surgery to determine reasons for their choice.

Over 5 years, 113 patients were evaluated. Twenty eightpatients were ineligible for surgery. Fifteen had surgery. Ofthe remaining 85, 70 were contacted to participate in thisstudy and 30 agreed. Of the participants, the mean age was36 years old, 90% were male. An IRB approved telephonesurvey, based on the instrument designed by Curtin, wasadministered by one of two occupational therapists. Questionsincluded those derived from the disability dimension of theStandford Health Assessment Questionnaire to determinefunctional status. All questions were answered on a 4 pointscale. Data was analyzed using a cluster analysis.

Four clusters of patient attitudes were identified. The first,named “conflicted” had the lowest time since injury(6.4 years). Their concerns centered on having to rely onothers, waiting for recovery, and not wanting more surgery.The second cluster, named “waiting for the cure”, statedthis was their only concern. They had the highest level offunction. They had the smallest increase in interest inhaving surgery after attending clinic of any of the clusters.The third cluster, named “too costly”, cited cost, relying onothers, and business of life as barriers. This group had thelowest ADL scores and the longest time since injury. Thelast cluster, named “questioning”, stated they still didn’tunderstand the benefit of the surgery. This group had thelargest increase in interest in surgery after attending clinic.

Each of the four groups presented with unique issues andconcerns regarding their decision to not have upperextremity reconstruction. Each of the groups requiresdiffering degrees of education about the procedures andrehabilitation, insurance issues, and social support.

The Point Prevalence Of The DRUJ InjuriesComplicating Perilunate Injuries

Institution where the work was prepared: Kleinert Institutefor Hand and Microsurgery, Louisville, KY, USATuna Ozyurekoglu, MD; Paolo Sassu; Sandy Hanlin;Christine M. Kleinert Institute for Hand and Microsurgery

HAND (2009) 4:195–237 221

Purpose:To find out the prevalence of the distal radioulnar jointrelated injuries associated with Perilunate dislocations attheir initial presentation to the hand surgeon.

Methods:Twenty-two perilunate dislocations in 21 consecutivepatients were evaluated and treated at our Level 1 TraumaCenter between November 2003 and July 2006. Twofemale and 19 male patients with a mean age of 37 (range19–59) formed the group. Nine patients were involved inmotor vehicle accidents, 12 patients fell from height. Therewere 8 perilunate dislocations and 14 transscaphoid fracturedislocations in the group. Five had contralateral wrist injuries.Pathologic findings were analyzed for each wrist by reviewingthe patient charts, operative notes and digital images. Thedistal radioulnar joint (DRUJ) related injuries were defined bythe presence of a fracture at the base of the ulna styloid,widening or subluxation of the DRUJ, distal radioulnarinstability noted or treated at the time of initial surgery.

Results:Eleven wrists (50%) showed DRUJ related injuries. Eightof these had a displaced fracture at the base of the ulnastyloid, one had a flake of bone at the prestyloid area, onehad a fracture of the ulnar shaft with DRUJ instability, andone had widening of the DRUJ. Three non-displaced ulnastyloid fractures were not included. Of the eleven DRUJrelated injuries only eight received initial treatment. Fourwrists showed ulnar translocation of the lunate, four hadassociated fracture of the radius; eight had a fracture linethrough the triquetrum.

Conclusion:The point prevalence of the DRUJ injuries complicatingPerilunate injuries at their initial presentation was estimatedas 0.50, with a confidence interval of 28.8–71.2. Becausethe initial appraisal of both the osseous and ligamentouspathology is important in the management of perilunatedislocations DRUJ related injuries should also be addressedat their initial presentation.

Endoscopic Cubital Tunnel Recurrence Rates

Institution where the work was prepared: OrthopaedicSpecialists, Davenport, IA, USATyson Cobb, MD; Orthopaedic Specialists, PC; Patrick T.Sterbank, PA-C; ORTHOPAEDIC SPECIALISTS, P.C; JonLemke, PhD; Genesis Medical Center

Hypothesis:Endoscopic Cubital Tunnel release has a recurrence rate nogreater than open cubital tunnel release.

Methods:After approval of our institutional review board wereviewed 134 consecutive cases of endoscopic cubitaltunnel release in 117 patients. Post operative outcome wasmeasured by the Modified Bishop classification. A recurrencewas identified if the patient was symptom free immediatelyfollowing surgery but had symptoms reappear after aminimum 3 month post operative period as described bySeradge et al in 1998. Two literature control groups were usedfrom published reports of recurrence rate following opencubital tunnel release. Seradge, et al reported recurrence in 21of 160 patients under going cubital tunnel release with medialepicondylectomy at 3 or more months. Lankester and Giddinsreported 1 of 20 patients with recurrence after 10 months withsimple decompression.

ResultsOf the 134 cases of Endoscopic Cubital tunnel releasesthere were 104 cases for 94 patients with 3 month postoperative follow-up. There were no exclusions and includedconcomitant surgeries and co morbidities. The mean followup time for the 104 cases was 736 days ranging from 92 to1,766 days. The 94 patients consisted of 58 males(61.70%), 36 females (38.3%), age range from 21–89 andthe mean was 49 for males and 47 for females. One case(0.96%) met the criteria for recurrence at 4 months postprocedure. Of the 104 cases, 92.31% had more than4 months follow-up.Data was then compared to the literature control groupsused from published reports of recurrence rates followingopen cubital tunnel release. Pooled the combinedcontrols had 22 of 180 cases (12.22%) with recurrences.The procedure recurrence percents varied significantlywith p-value=0.0004. The data was analyzed usingSTATXACT for an exact test comparing the tworecurrence percents.

Summary:We are 95% confident our true recurrence rate is between0.02% and 5.24%. Recurrence after Endoscopic CubitalTunnel release is not greater than recurrence following opencubital tunnel release.

Outcome Following Acute Primary Darrach Resectionfor Comminuted Fractures of the Distal Ulna at the timeof Operative Fixation of Unstable Fractures of the DistalRadius

Institution where the work was prepared: New YorkUniversity Hospital for Joint Diseases, New York, NY,USADavid E. Ruchelsman, MD; Keith B. Raskin, MD; MichaelE. Rettig, MD; NYU Hospital for Joint Diseases

222 HAND (2009) 4:195–237

Background:Optimal acute management of the highly-comminuteddistal ulna head/neck fracture sustained in conjunction withan unstable distal radius fracture requiring operativefixation is not well-established.

Purpose:To determine the clinical, radiographic and functionaloutcomes following acute primary Darrach resection forcomminuted distal ulna fractures performed in conjunctionwith the operative fixation of unstable distal radiusfractures.

Methods:Between 2000–2007, eleven consecutive patients, mean age63 years (range, 45–75) were treated for concomitantclosed, comminuted, unstable fractures of the distal radiusand ulna metaphysis. All eleven patients underwent acuteprimary Darrach distal ulna resection through a separatedorsal ulnar incision with ECU tenodesis for irreparabledistal ulna head/neck fractures at the time of operativefixation of the distal radius fracture. According to the Qmodifier of the Comprehensive Classification of Fractures,there were six comminuted fractures of the ulnar neck (Q3),and five fractures of the head/neck (Q5). Operative fixationof the distal radius fracture included volar plate fixationfollowed by 6 weeks of cast immobilization in four patients,and standard spanning external fixation with supplementalpercutaneous Kirschner wires in seven patients. At a mean of3.5 years postoperatively, clinical, radiographic, and wrist-specific functional outcome with the modified Gartland andWerley wrist score were evaluated.

Results:At latest follow-up, mean wrist range of motion measured55° flexion, 50° extension, 85° pronation, and 75°supination. Mean grip strength measured 90% of thecontralateral, uninjured extremity (range, 55–120).No patienthad clinical evidence of ulnar stump instability or symptomsrelated to the dorsal ulnar sensory nerve. Final radiographicassessment demonstrated restoration of distal radius articularparameters without ulnar stump instability or ulnar carpaltranslocation. According to the system of Gartland andWerleyas modified by Sarmiento, there were seven excellent and fourgood results. No patient required a secondary surgicalprocedure at latest follow-up.

Conclusion:Acute primary Darrach resection yields satisfactory clinical,radiographic, and functional results in appropriately selectedpatients and represents a reliable alternative when anatomicrestoration of the distal ulna/sigmoid notch cannot beachieved. Distal ulna resection concomitant with distal radius

fixation may help avoid early or late secondary proceduresrelated to distal ulna fixation or symptomatic post-traumaticdistal radioulnar joint arthrosis.

Low Calcaneal Bone Mineral Density is Associatedwith a High Risk to Sustain a Distal RadiusFracture – a Population-Based Study

Institution where the work was prepared: Department ofOrthopedics Hässleholm-Kristianstad, Hässleholm, SwedenIsam Atroshi, MD, PhD1; Fredrik Åhlander, MD1; MatsBillsten1; Henrik G. Ahlborg, MD, PhD2; Dan Mellström,MD, PhD3; Claes Ohlsson, MD, PhD3; Östen Ljunggren,MD, PhD4; Magnus K. Karlsson, MD, PhD2; (1)Hässleholmand Kristianstad Hospitals, (2)Lund University, (3)Gothen-burg University, (4)Uppsala University

Introduction:Osteoporosis is defined by the World Health Organizationas a bone mineral density (BMD) T-score below -2.5measured with a dual-energy X-ray absorptiometry (DXA)total body scanner. Portable heel scanners have gainedincreasing interest but their fracture predictive ability is lessevaluated. We used a DXA heel scanner to estimate theprevalence of osteoporosis in a population with distal radiusfracture and evaluate calcaneal BMD’s predictive ability.

Material and Methods:Patients aged 20 to 80 years with distal radius fracturetreated at one emergency hospital during two consecutiveyears were invited to calcaneal BMD measurement. Of 421eligible patients, 333 (79%) participated; 270 women, meanage 63 (SD 12) years, and 64 men, mean age 54 (15) years.A Calscan DXL heel scanner estimated BMD (g/cm2) andT-score values. A population-based cohort including 153women, mean age 58 (13) years, and 305 men, mean age 74(5) years, served as controls. The comparison between thefracture and control populations involved women 40 to 80and men 60 to 80 years. The age-specific prevalence ofosteoporosis (T-score below -2.5 SD) was determined andthe ability of calcaneal BMD to discriminate between thefracture and normative cohorts was assessed by receiveroperating characteristic (ROC) analysis.

Results:The prevalence of osteoporosis in women aged 40 to80 years with a distal radius fracture was 32% comparedwith 16% in the control group (age-adjusted prevalenceratio (PR) 1.46, 95% CI 1.01–2.11, p=0.046), and in menaged 60 to 80 years were 44% and 6%, respectively (PR10.5, 95% CI 5.9–18.7, p<0.001). Age-adjusted BMD waslower in the fracture cohort than the normative cohort;mean difference (95% CI) in women 0.11 (0.10–0.13) and

HAND (2009) 4:195–237 223

in men 0.13 (0.09–0.18) g/cm2 (p<0.001). One SD lowerBMD was associated with an increased odds ratio (95% CI)for having a distal radius fracture of 1.8 (1.4–2.3) in womenand 2.3 (1.6–3.3) in men. The area under ROC curve (95%CI) was in women 0.63 (0.57–0.69, p<0.001) and in men0.77 (0.67–0.87, p<0.001).

Conclusions:The prevalence of osteoporosis based on DXA-measuredcalcaneal BMD is significantly higher in individuals with adistal radius fracture than in a normative cohort. Impairmentin calcaneal BMDby one SD is associatedwith approximatelydoubled risk of a distal radius fracture.

Clinical and Radiographic Outcomes FollowingUtilization of Purpose-Designed Threaded Pinsfor the Treatment of Extraarticular DistalRadius Fractures

Institution where the work was prepared: The PhiladelphiaHand Center, PC, Philadelphia, PA, USAJohn S. Taras, MD; The Philadelphia Hand Center, PC;Joshua Abzug, MD; Hahnemann University Hospital

Hypothesis:Purpose-designed threaded pins are effective for thetreatment of extraarticular distal radius fractures (T-Pin®,Union Surgical, Philadelphia, Pennsylvania).

Methods:A prospective study was undertaken to evaluate patients withextraarticular distal radius fractures who underwent fixationwith threaded pins. Flexion, extension, pronation, supina-tion, and JAMAR grip strength values were recorded. Datafrom the uninjured extremity provided a baseline by which tocompare the patient’s range of motion and strength. Pre- andpostoperative radiographs were performed to assess volarangulation and ulnar variance. Statistical analysis wasperformed utilizing Signed Ranks test on SPSS.

Results:67 patients underwent fixation of their extraarticular distalradius fracture with purpose-designed threaded pins. Theflexion-extension arc returned to 66% (87 degrees: 42degrees flexion; 45 degrees extension) of the patients’normal arc by the 3 month period, and was 83% (119degrees: flexion 54 degrees; extension 65 degrees) ofnormal by 1 year postoperatively. The pronation-supination arc was 83% (142 degrees: 77 pronation; 65degrees supination) of the contralateral side by 3 monthspostoperatively and 94% of normal (159 degrees: 83degrees pronation; 76 degrees supination) by 1 year.JAMAR grip strength at position 3 returned to 72% of

normal at an average of 7 months. Preoperative radiographsdemonstrated an average of 11.85 degrees of dorsalangulation and ulnar variance of minus 1 millimeter. Thepostoperative radiographs showed improvement to anaverage of 5.22 degrees of volar tilt and ulnar variance of0.7 millimeters (p<0.05). There were 3 complicationsreported with 1 loss of reduction in a patient who wasweight bearing in that upper extremity.

Summary:Purpose-designed threaded pins are safe and effective implantsfor the treatment of extraarticular distal radius fractures.Patients regain 90% of their range of motion by 1 yearpostoperatively and 72% of their strength by approximately6 months postoperatively. Radiographic reduction is im-proved significantly with regard to radial length and volar tilt.

Outcome of Nonoperative Treatment of Ulnar-SidedWrist Pain

Institution where the work was prepared: University ofPittsburgh Medical Center, Pittsburgh, PA, USARobert Joseph Goitz, MD; Ali Razfar; John M. Duffy, PAC;Robert Alexander Kaufmann, MD; Deborah Kowalchuk;James Irrgang; Camilo D. Borrero; Jeffrey D. Towers;University of Pittsburgh Medical Center

Hypothesis:Patients with acute ulnar-sided wrist pain can be effectivelytreated with a splint and steroid injection. Physicalexamination and MRI findings will predict failure ofnonoperative treatment.

Methods:Forty-five patients with less than a three month history ofulnar-sided wrist pain were followed prospectively. Allpatients underwent a physical examination, radiographs andMRI. Patients were provided a custom fabricated Muenstersplint. If pain continued after 1 month, patients received asteroid injection and continued splint wear for an additionalmonth. If they continued to have pain, then surgery wasoffered. Univariate logistic regression was performed toestimate the effect of potential predictors on the odds offailing non-operative treatment.

Results:The mean age was 37.5 (range, 12–76 years) and themedian duration of symptoms was 1.5 months. Thirty-threepatients (75%) associated their pain with a traumatic event.40.0% of patients were successfully treated with a splintalone. Nineteen patients received an injection at an average of34 days following initial presentation. 58% of injectedpatients had successful relief of symptoms. 16 patients

224 HAND (2009) 4:195–237

ultimately underwent surgery and 2 patients that failedsplinting and injection deferred surgery for an overall successrate of 60% of this non-operative regiment. The TFCC stresstest was the only finding that had a significant effect on theodds (OR 13.6, 95% CI 2.57, 71.86) of failing non-operativetreatment. The likelihood ratio for a positive TFCC stress testwas 2.40, which increased the post-test probability of failingnon-operative treatment from 40% to 62%. The negativelikelihood ratio was 0.18, which decreased the probability offailing non-operative treatment from 40% to 11%.

Summary:Patients with acute ulnar-sided wrist pain have a 60%chance of successful treatment with a splint and injection.Patients with a positive TFCC stress test have a higherchance of failing nonoperative treatment and may be bettertreated with immediate surgery.

Baseline Characteristics of Patients Enrolled in TwoPhase III Studies of Injectable Clostridial Collagenasefor Dupuytren’s Contracture

Institution where the work was prepared: The Indiana HandCenter, Indianapolis, IN, USAF. Thomas D. Kaplan, MD; Indiana Hand Center; MarieBadalamente, PhD; SUNY-Stony Brook; Robert N. Hotchkiss,MD; Hospital for Special Surgery; John D. Lubahn, MD;Hand, Microsurgery and Reconstructive Orthopaedics;Stephen Coleman, MD; Rivercity Hospital; Stephen Hall,MD; Emeritus Research

Purpose:Prior studies have shown that intralesional injections ofClostridial collagenase (AA4500)—an investigational, min-imally invasive, nonsurgical treatment for Dupuytren’sContracture (DC)—reduce the degree of contracture inmetacarpophalangeal (MP) and proximal interphalangeal(PIP) joints to within 5° of normal in most patients; placeboinjections did not produce this response. The demographicsof subjects participating in 2 multicenter, phase III studiescomprising randomized, double-blind, placebo-controlledand open-label extension phases investigating the efficacyand safety of Clostridial collagenase are representative of alarger number of patients than previously studied.

Methods:Studies designated Collagenase Option for Reduction ofDupuytren’s (CORD) I with 16 US sites and CORD II with5 Australian sites are ongoing. Enrollment required flexiondeformities of ≥20° of the MP and/or PIP joints. Patients inthe double-blind phase receive up to 3 injections of 0.58 mgof collagenase in the primary joint, at 4–6 week intervals.

In the open-label phase, patients receive up to 5 additionalinjections (up to 3 injections/joint). Patients are to befollowed for up to 12 months post first injection.

Results:Baseline characteristics for the 374 patients enrolled in bothstudies (Table) are available. Mean age was 63±9.4 years.At time of diagnosis, 21% of patients were <45 years old(mean age, 53±13 years), 45% of patients had a familyhistory of DC. Comorbidities included collagen diseases(knuckle pads [4%,] Ledderhose’s disease [5%,] Peyronie’sdisease [5%]), diabetes (7%), and epilepsy (2%.) Diseasewas unilateral and bilateral in 60% and 40% of patients,respectively and mean number of affected joints perpatient was 3±2. Mean duration of symptoms was 62±78 months. Mean contracture was 50°±20°, and meanrange of motion was 44±20. Overall, 56% of patientshad no treatment prior to study entry. The toplineefficacy and safety data for the double-blind phase ofCORD I became publicly available in June 2008. Resultsfrom this analysis will be presented.

Conclusions:Baseline characteristics of this large population of patientswith DC are similar to those from previously reported trialsinvestigating Clostridial collagenase. Exceptions includebilateral disease, which was twice as common in the CORDstudies, and frequency of comorbid fibrotic disorders such asPeyronie’s Disease, which were lower among patients in theCORD studies.

Baseline Characteristic CORD 1 CORD 2 Total

Male 246/308 (80) 56/66 (85) 302/374 (81)

Age, y 63±9 64±9 63±9

Aget at diagnosis, y 53±12 52±13 53±13

Hand affected

Left 82/307 (27) 17/66 (26) 99/373 (27)

Right 109/307 (36) 15/66 (23) 124/373 (33)

Both 116/307 (38) 34/66 (52) 150/373 (40)

Number of affected joints/pt 3.0±2.2 3.3±2.1 3.0±2.2

MP 1.7±1.4 1.5±1.5 1.6±1.5

PIP 1.3±1.3 1.8±1.5 1.4±1.3

Duration of symptoms, mo 61±77 69±83 62±78

Contracture, ° 49±20 52±15 50±20

Range of motiom, ° 45±20 42±16 44±20

Prior treatment*

None 173/308 (58) 31/66 (47) 209/374 (56)

Surgery 116/308 (38) 35/66 (53) 151/374 (40)

Physical therapy 44/308 (14) 5/66 (8) 49/374 (13)

Values are presented as n/N (%)or mean ± standard deviation.

*Patients may had >1 type of prior treatment.

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Line Scan Diffusion Spectrum of Rat DenervatedSkeletal Muscle

Institution where the work was prepared: HIratsuka CityHospital, HIratsuka City, kanagawa, JapanEiko Yamabe, MD1; Toshiyasu Nakamura, MD, PhD2;Yukihiko Obara, MD2; Koji Abe, MD2; (1)Hiratsuka CityHospital, (2)Keio University

Introduction:In case of peripheral nerve palsy such as radial, ulnar, andmedian nerve injury, denervated skeletal muscle showsincreased T2 in the MR images. However, it takes certainamount of time, typically up to a week, before this changebecomes visible. Since the mechanism behind this changeis considered to be increased extracellular fluid (ECF), wehypothesized that the same change can be detected earlierby measuring diffusion. We measured both T2 and apparentdiffusion coefficient (ADC) using peripheral nerve injurymodel of rats.

Materials and Methods:Total of 12 male rats were used, weighing approximately200 g each. We made the nerve injury model by cuttingthe left posterior tibial nerve. At 1, 3, 5, 7, 14, 28 daysafter the surgery, T2 and ADC of gastrocnemius muscle,which was the target muscle of posterior tibial nerve,were measured using line scan diffusion method on a1.5T clinical imager

Results:In the T2 weighted images, it was difficult to recognize thechange until 7 days after injury. After two weeks, it becameobvious in the T2 weighted images. T2 value increasesgradually over two weeks, while ADC value increases rightafter injury, and decreases 5 days after injury. Four weeksafter injury, ADC returned to normal, but T2 value stayed athigh value (Fig. 1).

Discussion:Although both T2 and ADC are considered to reflect thestate of extracellular fluid, our results show the cleardifference between the time courses of T2 and ADCvalues after injury. Although clear mechanism behindthese phenomena is not clear, diffusion MRI seems to bea better clinical tool for early diagnosis of peripheralnerve injury.

Conclusions:ADC increased quickly after injury, and was detectable oneday after injury. Diffusion MRI can be a useful tool forearly detection of peripheral nerve injury.

Fig. 1: Time Courses of ADC and T2 ratios

Anatomical Features of the Pronator Quadratus musclefor the treatment of Distal Radius Fractureswith a Palmar Locking Plate - Cadaveric Study

Institution where the work was prepared: Komaki CityHospital, Komaki, JapanNaoya Takada; Komaki City Hospital

Purpose:Minimally invasive osteosynthesis (MIO) with a palmarlocking plate is one of the beneficial treatments for distalradius fractures. Since 2004 we have been using thistechnique through 2 small skin incisions (1.5–2 cm)without dividing the pronator quadratus (PQ) muscle.However, there has been no report of the cadaveric studyfor this procedure. The purpose of this study is tounderstand the anatomical features of the PQ muscle forreduction of the fracture, plating and inserting screws.

Methods:Ten forearms of 5 fresh cadaveric specimens were usedfor this study. A skin incision was made on each of thevolar sides of the forearms and the PQ muscle wasexposed. The width (PQW) from the proximal edge ofthe PQ to the distal edge of it, and the distance (PRD)from the distal edge of the PQ to the joint surface of thedistal radius were measured. After inserting the plate(length 86 mm) under the PQ, the distal part of the platewas held on the distal part of the radius and theproximal part of the plate was pulled off with a fixedlocking sleeve from the radius. When the muscle fiberof the QP starts to tear, the distance from the volarcortex of the radius to the proximal edge of the platewas measured.

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Result and Conclusion:The average PQW, PRD and PD were 34.5 mm (range 25–40 mm), 16.5 mm (range 15–20 mm) and 11.9 mm (range25–40 mm). The length of the plate should be more than51 mm (PQW + PRD) for this procedure to prevent damageto the PQ. For controlling the plate under the PQ it shouldbe performed in the 12 mm area between the PQ and thevolar cortex of the radius. It is important to understand theanatomical features of the Pronator Quadratus muscle andthe data given above for the successful MIO and preventionof soft tissue damage.

Profit Margins for Inpatient and Outpatient OrthopedicProcedures: a Comparative Study

Institution where the work was prepared: Beth IsraelDeaconess Medical Center, Harvard Medical School,Boston, MA, USAEricMakhni; HarvardMedical School/Beth Israel DeaconnessMedical Center; Charles S. Day; Harvard Medical School

Introduction:In an era of decreasing reimbursement in the health caresystem, cost-control becomes elevated in importance. Thisstudy sought to determine profit margins for differentorthopedic procedures.

Methods:We reviewed the costs and revenues of all surgeries in theDepartment of Orthopedic Surgery over a one year periodfrom July 2004–2005. All procedures were classified as onefo the following: back, foot/ankle, hand, joints, spine,sports, trauma, or “other.” Further, each surgery wasdesignated as “inpatient” or “outpatient.” Within eachsubgroup, the revenue, cost (direct and indirect), andaverage-length-of-stay (for inpatient procedures) werenoted.

Results:A total of 4117 orthopedic surgeries were performed fromJuly 2004–2005. There were 1933 inpatient procedures and2184 outpatient procedures. For inpatient cases, the overallaverage-length-of-stay was 4.6 days. This length of staywas 5.3 for spine and 4.8 each for trauma and joints cases.Hand and back cases were 2.3 and 2.7, respectively. Profitmargins were highest for hand ($2,420) and lowst for jointsand trauma (-$464 and -$1,244, respectively).For outpatient procedures, the most profitable cases werethose of hand/wrist ($266). Sports and foot/ankle caseswere substantially less profitable ($128 and $158, respec-tively), and trauma cases were profitable by only $19.Spine procedures, however, had a profit margin of -$217.

Conclusions:Even though surgeon reimbursements for different ortho-pedic sub-specialties are pre-determined, many orthopedicprocedures, when taking expenses into consideration, arenot profitable for the governing hospital. Of all sub-groups,hand/wrist procedures were the most profitable in both theinpatient and outpatient setting. In the inpatient setting,increasing length-of-stay may be associated with decreasedprofits, but serial annual analysis is required to furtherelucidate this correlation.

Modeling of Upper Extremity Problems

Institution where the work was prepared: University ofLouisville, Louisville, KY, USASteven J. McCabe, MD, MSc; Stephanie Tapp; University ofLouisville

Due to the complexity and expense of randomized trialsthey have not been commonly applied to answer researchquestions in upper extremity disorders. Decision analysiscan be used to model the management of medical disordersand provides an alternative when randomized trials are notpossible or practical. The similarity in the general manage-ment principles of many upper extremity inflammatorydisorders opens the possibility of creating a generic decisionmodel that can be easily adapted to a large number of upperextremity conditions providing efficient analysis of manage-ment decisions. For example, trigger digit, DeQuervain’stenosynovitis, carpal tunnel syndrome, and tennis elbow canall be treated with splinting, oral medication, injection, andsurgery.

Markov modeling is a commonly used technique fordecision analysis that has features that make it attractive forupper extremity problems. Markov models are especiallysuited to evaluate recurring events that are commonly seen inupper extremity care, and the time in a state of health that isalso an important feature of upper extremity care.

Our purpose was to develop a Markov Model that iscomprehensive yet flexible enough to evaluate the man-agement of upper extremity inflammatory conditions. Onemajor objective was that the model must be easily adaptedto answer multiple questions for a variety of conditions.

We created a Markov model that has the capability toconsider treatments such as splinting, injection, and surgeryapplied in a sequential fashion, each for a variable amountof time or number of applications. The evaluation ofdiagnostic tests and cost-effectiveness evaluation are alsopossible. The model accurately portrays clinical care andcan be easily adapted to represent a variety of upper

HAND (2009) 4:195–237 227

extremity problems by changing the treatments available,the number of applications or time each treatment isapplied, the cost, potential complications, disutility of anytreatment, and the efficacy of each treatment.

Using adaptation of this basic decision analysis model,researchers can answer many questions about managementof upper extremity disorders.

The Determination of Finger Laterality Dominanceduring Routine Activities

Institution where the work was prepared: University ofMissouri, Columbia, MO, USADustin Christiansen, MD; Rukmini Rednam, MD; Steven L.Henry, MD; Stephen H. Colbert, MD; Bradley A. Hubbard;University of Missouri

Background:Finger injuries and some reconstructive procedures requireincisions on, or sacrifice of, a fingertip pulp. We find noobjective basis for the dogma regarding the relativeimportance of radial and ulnar sensory surfaces of thedigits. This study attempts to quantify the use (value) ofeach half of each digit tip during various activities.

Materials & Methods:Seventeen volunteers participated in twenty-two routineactivities using paint-covered items. Standardized photo-graphs were taken, and the degree of involvement of theradial and ulnar halves of each fingertip was calculatedusing a template that allowed measurement of the percentageof the half of the fingertip (hemi-pulp) that was covered inpaint. Intra- and inter-digital comparisons were made todetermine hemi-pulp and finger dominance.

Results:One hundred forty-five fingertip uses, or instances, wereanalyzed, 110 from the dominant hand (22 activities×5fingers), and 35 from the non-dominant (7 activities×5fingers). A statistically significant preference of the radialor ulnar hemi-pulp was noted in 75 instances, 51.7% of allinstances examined. Rates of laterality dominance weresimilar between the dominant and non-dominant hands.The thumb accounted for 14 of the 75 significant instancesof laterality dominance (18.67%), with 10 (71.4%) instancesof ulnar predominance and 4 (28.6%) favoring the radial.Among the fingertips, the radial hemi-pulp was favored 53(86.9%) times, and the ulnar 8 (13.1%) times. Comparison ofthe entire fingertip of the index, long, and ring fingers revealeda predilection for use of the more radial finger, except in the

case of gripping activities, in which the more ulnar digit wasconsistently favored. Finally, the ten sensory surfaces of thedominant hand were ranked based on the means of the percentof the hemi-pulp used across all activities. In decreasing order,they were ulnar thumb, radial index, radial thumb, radial long,ulnar index, radial ring, radial small, ulnar long, ulnar ring,and ulnar small.

Conclusion:A significant difference in the side of the fingertip used in theactivities examined occurs more than half the time. Forthe thumb, this is usually the ulnar surface, for the fingers,the radial. Activities requiring finer hand movements favoruse of more radial digits, while strength activities favorthe ulnar. The ten sensory surfaces of the digit tips can beplaced in a rank order based on use, which may representtheir relative importance for sensory input during theactivities examined

A Case Study of the RSD Or Psudo-Gout Handand Extremity

Institution where the work was prepared: Mayo Foundation,,Rochester, MN, USACeloa Sue Robinsom, BS, in, ED, Cert; Life and LeisureHand and Physical Therapy

This is a case study of an actual experience of minewhen I developed a very painful right wrist after abump on the dorsum of the right wrist,leaving a bruise,I am on coumadin due to atrial fibulation and my INRwas 3.7. The blood from the bruise intered the rightwrist joint producing a great deal of pain and re-striction of motion.Being I am a Hand PhysicalTherapist I thought I was having Reflex SympatheticDystrophy. This presentation is how I rehabed my rightwrist, hand and upper extremity emphasizing that atherapist has to be very gentle with the resultant hand,wrist and upper exctremity in order to obtain a fullyfunctional hand, wrist and upper extremity. I saughthelp from my Ambulatory Phramist,Marcel D Bizien.Pharm D, PhD at the Kasson Mayo Family Clinic,Kasson, MN,my General Practioner, Dr.Michael W.Justice MD and a physician that was a Hand PhysicalMedicine Specialist, Dr Keith Bengtson. MD. Withtheir guidence and input I have been able to, so far obtain afunctional right hand and upper extremity. Throught thispresentation my objectives are to empower Hand Occupationand Physical Therapist with the skills to produce a funtionalHand when the hand, wrist and upper extremity are involvedwith RSD and /or pseudo-gout.

228 HAND (2009) 4:195–237

American Association for Hand Surgery Posters

Omental Free Tissue Transfer for Coverage of ComplexUpper Extremity and Hand Defects - The Forgotten Flap

Institution where the work was prepared: Lutheran GenaralHospital, Chicago, IL, USAIris A. Seitz, MD; University of Chicago; Craig S. Williams,MD; Clinical Orthopedic Surgery Northwestern UniversityFeinberg School of Medicine; Thomas A. Wiedrich, MD;Northwestern University Medical School; Loren Schechter,MD; Lutheran General Hospital

Background:Free omental tissue transfer is one of the oldest and mostversatile reconstructive options for trunk, head and neck,and extremity defect coverage. Its usefulness is due to theflap’s long vascular pedicle, large vessel size, relativelythin contour, tissue flexibility and large surface area. Mostseries have focused on use of this tissue for trunk andhead and neck reconstruction. We report our experiencewith omental free flap coverage of complex upperextremity defects.

Material and Methods:A retrospective analysis of 3 cases of omental free flaps forupper extremity reconstruction between 1999 and 2008 wasperformed. Indication, operative technique and outcome wereevaluated.

Results:All patients were male; age range was 20–38 years.Indications included tissue defects due to severe trauma orinfection. One patient sustained a crush injury resulting innear complete amputation of both hands requiring revascu-larisation. The second patient had a crush, degloving injuryof the dorsal hand. The third patient had massive tissue lossof the forearm and arm due to necrotizing fasciitis andcompartment syndrome. All patients had several operationsincluding revascularisation, wound debridement and fixa-tion of associated fractures. The mean defect size was280 cm2 with all patients achieving complete woundcoverage with omental free flap and split thickness skingraft. No flap loss or major complications were noted.One patient required additional surgery secondary toosteomyelitis 4 months after the initial injury, and asubsequent debulking procedure 9 months later. Thesecond patient had a superficial wound infection at theabdominal donor site that healed with local care.Laparoscopic assisted omental free flap harvest wasperformed in all cases in conjunction with the generalsurgery team. Mean follow-up was 3 years.

Conclusion:The omental free flap is a valuable, often overlookedreconstructive option. The long vascular pedicle and largeamount of pliable, well vascularized tissue allow the flap tobe aggressively contoured to meet the needs of complexthree dimensional defects. In addition,laparoscopic assistedharvest may aid with flap dissection and result in reduceddonor site morbidity.

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Surgical Outcome of Middle Phalanx Fractures

Institution where the work was prepared: Department ofHand Surgery, Singapore General Hospital, Singapore,SingaporeHui Ling Chia, MRCS, MBBS; Shian Chao Tay; Beng HoiTan; Singapore General Hospital

Aim:There are many excellent reports on the outcome of middlephalangeal base fractures. However, there is a paucity of reportson surgical outcomes specific to fractures of the shaft and/orcondyles of the middle phalanx (MP). A retrospective reviewwas thus performed to evaluate the outcome of surgicallytreated middle phalangeal shaft and condylar fractures.

Method:All patients with surgery performed in 2005 and 2006 forMP fractures involving the shaft or condyles were included.Main outcome measures included clinical, functional andradiographic assessments. Using the modified Al-Qattan’sclassification, fracture displacement was graded before andafter surgical fixation. Outcomes were classified intoexcellent, good and fair (modified from Barton, 1979).Patients with open or multiple fractures (on the samefinger) were excluded.

Result:A total of 76 MP fractures were operated on 65 consecutivepatients. Of these, 20 (26.3%) were MP fractures involvingthe shaft and/or condyles (3 condylar, 8 subcondylar, and 9shaft). Moderately displaced (Type IIB) fractures were thecommonest. Methods of fixation ranged from mini-plateand screws (25%), interfragmentary screw (45%), inteross-eous wire with kirschner wire (20%) or a combination (10%).Except for one lateral approach, all fractures were approacheddorsally. Based on the modified Al-Qattan’s classification, 15of 20 fractures had excellent reduction after fixation. Meanfollow-up time was 196.8 days. Seventeen of 20 fractureswere followed to union with three fractures lost to follow-upbefore union. The average time to union was 113.5 days. Themean distal interphalangeal joint (DIPJ) motion was40 degrees. One-third of patients were found to havean extensor lag of the DIPJ (range 15–40 degrees). Allpatients with extensor lag had undergone either plate orinterosseous wire fixation and most of them (83.3%) ofthem occurred in patients with condylar and subcondylarfractures. 30% of patients had good outcomes, and 70%fair outcomes according to the modified Barton’s criteria.The single patient with lateral approach with lateralplating had a fair outcome. Mean return to work was45.9 days in our series.

ConclusionSurgical outcome of MP fractures of the shaft or condyleswas complicated by a high rate of DIPJ stiffness andextensor lag. This is despite early rehabilitation. Poorprognostic factors include condylar and subcondylar fractures,and the severity of initial fracture displacement. Fractureswhich were amenable to interfragmentary screw fixationsalone, tended to have better outcomes.

Nerve Grafting in Upper Extremity

Institution where the work was prepared: Boston UniversitySchool of Medicine, Boston, MA, USAHarilaos T. Sakellarides, MD; Boston University School ofMedicine

Purpose:To demonstrate that severe injuries of the hand can betreated by nerve grafting with very satisfactory end results.

Methods:Previously applied methods of nerve grafting had disap-pointing results. Over a span of 15 years, new techniqueshave been used, namely microscope, microsurgical tech-niques, and fine suture material. Evaluation of nerve repairswas according to the British method. Experimental workproved: 1) The detrimental role of tension at the suture line. 2)The deleterios effect of postoperative stretching on successfulfunctonal recovery. 3) Regeneration axons advanced moreeasily through nerve grafts of 2 cm with two tension freeanastomoses compared with a single suture under tension. Theepineurium was the primary source of connective tissueproliferation.

Results:Motor recovery for Meidan nerve: Excellent 40%; Good40%; Fair 20%. Ulnar nerve: Excellent 38%; Good 40%;Fair 22%. Radial nerve: Excellent 42%; Good 38%; Fair 20%.

Conclusions:Encouraging results were obtained providing certain detailsof the method are strectly followed.

Latissimus Dorsi Transfer for Massive Rotator CuffTears via an axillary approach

Institution where the work was prepared: AlleghenyGeneral Hospital, Pittsburgh, PA, USABradley Palmer, MD; Mark Baratz; Allegheny GeneralHospital

Massive tears of the rotator cuff are a challenge for both thepatient and surgeon. Treatment options include debridement

230 HAND (2009) 4:195–237

(1) and repair with or without tendon graft (2, 4). Whenrepair is not feasible the latissimus dorsi can be transferredin those patients who have good passive motion andminimal wear of the glenohumeral joint (6, 7,8,12). Thisarticle describes a technique borrowed from the plasticsurgery literature to harvest the tendon using lightedretractors through a small transverse incision beneath theaxilla. This technique gave adequate visualilzation torelease the tendon, mobilize the muscle and pass the tendonto anterolateral incision. The comestic result is superior topreviously described approaches.

Complication of Hand Extensor Tendon Lacerationsin Emergency Caesarean Section

Institution where the work was prepared: Advocate LutheranGeneral Hospital, Park Ridge, IL, USATaizoon Baxamusa, MD, FACS1; Preetha Prazad, MD2;Henry Mangurten, MD2; (1)University of Illinois atChicago, (2)Advocate Lutheran General Children’s Hospital

Accidental fetal injury is a serious but underreportedcomplication during caesarean delivery, particularly afterone that is emergent. The most commonly documentedinjury is skin laceration. Though the majority of reportedlacerations are superficial, a few are deep and requiresurgical intervention. We report a case of severe multipleextensor tendon lacerations with open metacarpophalangealjoint injuries sustained at the time of an emergencycaesarean delivery that resulted in excellent functionaloutcome following surgical repair.

Community-acquired Methacillin-resistantStaphylococcus Aureus in the Suburban PlasticSurgery Hand Patient Population

Institution where the work was prepared: Lehigh ValleyHospital, Allentown, PA, USAMarshall Miles, DO; Terry-Lynn Burger, RN, BSN; RobertX. Murphy Jr, MD, MS; Lehigh Valley Hospital

Introduction:Methacillin-resistant staphylococcus aureus (MRSA) is afrequent cause of infection in the postoperative patient. Weobserved increasing numbers of community-acquiredMRSA infections in patients presenting to the hand surgeryservice at our suburban academic center. It is an importantissue, as unsuspected community-acquired MRSA handinfections can too easily be admitted to the hospital,inadequately treated, and allow for nosocomial spread.The objective of this study was to examine the trend in theincidence of community-acquired MRSA hand infections inthe plastic surgery patient, in order to sensitize practitioners

to have a high index of suspicion for this entity andpromote early recognition and treatment of this organism.

Methods:A multi-hospital retrospective chart review was undertakento compare the incidence of community-acquired infectionsin plastic surgery hand patients from 2000 through 2007.

Results:Only two community hand MRSA infections were treatedin 2000, as compared to three in 2001 and 2002, four in2003, five in 2004, six cases in 2005, 14 in 2006, and 13 in2007.

Conclusion:This retrospective review of infections at our institutionclearly delineates an increasing number of community-acquired MRSA hand infections. The plastic/hand surgeonmust be aware of the increased prevalence of this entity toadequately combat this organism and prevent prolongedhospital stays, expanded morbidity, and inflated treatmentcosts.

Radiographical Diagnosis of the Carpal Bone Fractures

Institution where the work was prepared: Showa UniversitySchool of Medicine, Tokyo, JapanHirotsune Hirahara, MD; Souichirou Takigawa, MD;Katsunori Inagaki, MD; Kazutoshi Kubo, MD; HideyoMiyaoka, MD; Showa University School of Medicine

Carpal bone fractures are common, in the majority of casesthis involves scaphoid, triquetrum or hamate. Sometimesfractures can be difficult to identify due to complicatedanatomical shape of the bones. Statistical analysis wasperformed on 252 retrospectively identified carpal bonefractures, that occurred in the past 16 years. 159 cases(63.1%) involved the scaphoid, 39 cases (15.5%) weretriquetral fractures and 28 cases (11.1%) were hamatefractures. No trapezoid fractures were seen and the othercarpal bones were only involved in less than 11% of cases.The authors feel that this is possibly due to the difficulty indiagnosing these fractures. However, it is possible thatthese fractured were misdiagnosed more often. Tomographyand CT scanning are often needed. Unfortunately theseconstitute a greater radiation dose the patient of up to 10times for tomography and even 250 times for CT. The costof these techniques are also 2–3 times more and are usuallyadded to the cost of initial plain radiographs. The authorsnewly developed special radiographic techniques to betteridentify capitate and trapezoid fractures, using conventionalradiographic equipment. When compared to the techniquethat is currently used we saw a great improvement in

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idetifying the normal anatomy of these bones. Thistechnique can easily be incorporated in standard clinicalpractice and should be used when there is a clinicalsuspicion for a capitate or trapezoid fracture. This willresult in an easier diagnosis of fractures that otherwise mayhave remained occult and will decrease the need for other,more expensive, imaging techniques. This will have to beproven in further clinical research.

Sagittal Band Rupture in a Patient With an AnomalousExtensor Medii Proprius Tendon

Institution where the work was prepared: Geisinger MedicalCenter, Danville, PA, USAJohn Thomas Riehl, MD; Joel Christian Klena, MD;Geisinger Medical Center

A cadaveric study of extensor medii proprius tendonincidence is presented along with a case report of sagittalband rupture involving an extensor medii proprius tendon.A review of the available literature is also presented.

A 22 year old male suffered an acute injury to the longfinger of his dominant hand while playing volley-ball. Thepatient had persistent pain for approximately one-and-one-half years with undiagnosed ulnar extensor tendon sublux-ation. During operative reconstruction the patient wasfound to have an anomalous slip of extensor tendon to thelong finger. The tear of the sagittal band was between theanomalous tendon and the extensor digitorum communisslip. The anomalous tendon was utilized as a radially-basedsling to reconstruct the injured sagittal band with anexcellent functional outcome.

Multidimensional Assessment of Chronic NeuropathicPain

Institution where the work was prepared: Hand and Micro-surgery Center of El Paso and UTEP, El Paso, TX, USAJose J. Monsivais, MD; Hand and Microsurgery Center ofEl Paso; Kris Robinson, PhD, FNP; University of Texas atEl Paso; Diane B. Monsivais, PhD, RN; The University ofTexas at El Paso

Introduction:Chronic pain affects 76.5 million people with an annualcost of $100 billion in health care, lost work productivity,and reduced income. Three out of four people with chronicpain are undertreated based on clinical practice guidelines.A frequent reason for this is the inadequate assessment ofpain. Unidimensional pain (typically a scale of 0–10)assessment is the most common in most practices. Thisunidimensional measure does not reflect the psychosocial

impact of pain or the impact on associated co-morbiditiesand function. Thus, the one time snapshot of assessment isnotoriously inadequate and does not reflect the true impactof chronic pain.Multidimensional assessment of pain: We suggest a three-part assessment. The first is a screening measure such as theBrief Pain Inventory (BPI) that is widely available toclinicians at no cost. Not only does the BPI assess theseverity of pain, it assesses the impact on psychosocialfunction and activities of daily life. The BPI is a highlyreliable and valid instrument. Second, is the assessment ofanxiety and depression of which there are many non-proprietary tools that can be used without cost, such as theZung depression scale. Last, is the identification of comorbidities, such as diabetes and other endocrinopathies,insomnia, deconditioning, etc., that influence and areinfluenced by chronic neuropathic pain.

Purpose:The purpose of this presentation is to demonstrate the use of amultidimensional assessment of pain that identifies areasamenable to treatment and enhance outcomes in terms ofphysical and psychosocial function, pain, and surgical results.

Methods:An exploratory, correlational research design guided thestudy. Through convenience sampling, we recruited 92patients seeking pain management treatment for a neuro-pathic at a hand and microsurgery specialty clinic. Surveytools include the BPI, the SF-36vr2, a depression scale, andthe unidimensional 1–10 pain scale. A statistician calculateddescriptive statistics and conducted Pearson correlationcoefficients. Post hoc analysis consisted of linear regression,ANOVA and MANOVA.

Results:The multidimensional assessment guided treatment that led topatient satisfaction and improved outcomes. We will presentcase studies emphasizing how the multidimensional assess-ment influenced treatment decisions and ultimately led to paincontrol and improved physical and psychosocial function.

Ganglion cysts in children: Experience at the Hospitalfor Sick Children

Institution where the work was prepared: Hospital for SickChildren, Toronto, ON, CanadaM. Amir Mrad, MBBS; Tatiana Cypel, MD; Ronald Zuker;University of Toronto

Purpose:Bumps and lumps are common among children. Howev-er, one bump that shouldn’t be overlooked is called a

232 HAND (2009) 4:195–237

ganglion cyst. A ganglion or a synovial cysts is amuscinous filled cyst which is usually found adjacent tojoint capsule or tendon sheath. A common problem inadults, ganglion cysts are much less common in children.In this study, we aimed to detect the epidemiology,etiological factors, symptomatology, treatment and out-come of patients diagnosed with a ganglion cyst at TheHospital for Sick Children.

Methods:Records from the Pathology Department at The Hospitalfor Sick Children were searched for all cases of ganglioncyst operated between January 2000 and December2007.

Results:Thirty-four patients were diagnosed with ganglion cysts.The mean age was 15.7 years, ranging from 5 months to17 year old. Male:female ratio was 1:1. Solid lump was theinitial presentation of the ganglion in 36% of the cases. Painwas the most common symptom to indicate surgicalremoval. Only 11.4% of the patients reported previoustrauma history. In 70% of the cases the diagnosis was doneclinically and 61% of the patients were affected on the rightside of the body. The most common sites of occurrencewere volar wrist (25.7%), dorsal wrist (22.8%) and thevolar aspect of the base of ring (17.1%). Surgical excisionwas the treatment of choice for 94.2% of patients withsymptomatic lesions. Only one patient (2.8%) presentedwith recurrence in this series.

Conclusions:Ganglion cysts are not uncommon in children. Amongall symptoms that ganglions can present with, pain wasthe most common symptom that indicated surgery.Surgical removal was the most effective treatmentfor symptomatic patients, with a very low rate ofrecurrence.

Operative Treatment Rates for Hand Pathologies basedon Diagnostic Indications and Referral Patterns

Institution where the work was prepared: Harvard MedicalSchool/Beth Israel Deaconess Medical Center, Boston, MA,USAMelvin Chugh Makhni, BS1; Henry Horton1; EricMakhni1; Christine Y. Ahn2; Charles Day1; (1)HarvardMedical School/Beth Israel Deaconness Medical Center,(2)Na

Background:This study looks at the distribution of hand and wristpathologies as well as the referral patterns to orthopaedic

surgeons to see how these factors correlate with likelihoodof operative management.

Methods:We performed a retrospective chart review study of 1916consecutive adult hand and wrist cases in the orthopaedichand clinic at our academic tertiary care medical center,from January 2005 to January 2007. Over 300,000 datapoints were analyzed for the 1916 cases; each individualdiagnosis pertaining to the hand or wrist was assigned asa unique case. Cases were designated as traumatic(trauma <21 days prior), acute non-traumatic (symptomatic<90 days), or chronic (>90 days).

Results:Traumatic pathologies represented 10% of cases, acutecases comprised 32%, and 58% were chronic. 41% oftraumatic cases underwent surgical management ascompared to 35% of chronic cases (p=.04); acutepathologies were treated with surgery 29% of the time,significantly less than chronic cases (p=.03). Traumaticcases underwent surgery immediately after first recom-mended significantly more commonly than acute orchronic cases (p=.006, p=.009). Overall, acute andchronic surgeries were performed when recommendedat similar rates. However, 95% of acute strains andfractures were operated upon when recommended ascompared to only 75% of chronic cases (p=.05), while atrend regarding neurological symptoms showed 89% ofpatients with chronic symptoms underwent surgery whenrecommended versus 76% of patients with acute symp-toms (p=.08). -64% of the 1916 diagnoses were fromfemales. Cases involving females resulted in surgery32% of the time, as compared to 39% of male cases(p=.004). -Cases were referred by primary care physi-cians 68% of the time and from specialists 8% of thetime. 13% came from the ER, while the rest were fromother referral sources. Cases referred by specialistsresulted in surgery 41% of the time, as compared toonly 32% of cases from primary care physicians (p=.04).96% of cases from the emergency room resulted insurgery immediately upon recommendation, as comparedto 89% of cases referred from primary care physicians(p=.02).

Discussion:A better understanding of operative management rateswill allow orthopaedic surgeons to convey to patients thelikelihoods that cases will result in surgery. -Increasededucation of primary care physicians about musculo-skeletal differentials and conservative treatment options

HAND (2009) 4:195–237 233

may enhance the utility of orthopaedic surgeons topatients.

The Lateral Approach to PIPJ Ascension Arthroplasty

Institution where the work was prepared: University ofManitoba, Winnipeg MB, CanadaGhazi Ayedh Althubaiti, MD; Kenneth Murray; MehrdadGolian; University of Manitoba

Introduction:The dorsal approach is currently the most widely usedapproach for surface replacement arthroplasty of PIPjoint. One of the major disadvantages of the dorsalapproach is the need to divide or detach the central slipof the extensor tendon, which weakens extension and delaysphysiotherapy.

Purpose:Report our initial results of using the lateral approach as analternative approach in 5 patients with 6 PIP arthroplasties.

Method:A retrospective chart review of all of our patients who hadPIP joint Ascension arthroplasty who were operated onusing lateral approach between 2004 and 2008.

Results:Among seven patients who underwent Ascension PIPaprthroplasties, five patients were operated on using thelateral approach. One patient had 2 adjacent jointssimultaneously replaced. All of our patients were startedon immediate ROM from first post-operative day. Theaverage arc of motion was 49 degrees before surgery and78 degrees after surgery with the average gain of 29degrees to the arc of motion 6 weeks after surgery. Pain

decreased in all patients after surgery. Two patients hadjoint subluxation, one of them had 2 adjacent fingers PIPJarthroplasty that made physiotherapy and buddy tapingdifficult which affected the joint stability.

Conclusion:Although this is a small study, but it seems to show thatlateral approach for PIPJ Ascension arthroplasty may offerthe advantage of preserving the extensor tendon andstarting early ROM that improves the final outcome.One of the learned lessons from this study is not to“arthroplasty” two adjacent digit hence it will affect thelateral stability of both joints and make physiotherapy andbuddy taping difficult.

Learning Objectives:The audience will be introduced to the lateral approachPIPJ Ascension arthroplasty.Never use this approach to simultaneously treat twoadjacent digits.

Carpal Tunnel Syndrome: Factors Influencing PermanentNerve Damage

Institution where the work was prepared: The Hand Center,Houston, TX, USAMichael Fitzmaurice, MD1; Michael Brown2; RandolphLopez, MD2; Mark Khorsand2; Andrew Lee2; DouglasHarpe2; Nur Nurbhai2; P Stephen Mahoney1; (1)BrownHand Center, (2)The Hand Center

12,171 patients with carpal tunnel syndrome (CTS) werestudied over twelve-years to determine the treatmentfactors that contribute to permanent nerve damage(PND). The diagnosis was established electrodiagnosti-cally and categorized into mild, moderate, severe orprofound. Various treatment modalities were studiedincluding the Brown procedure endoscopic carpal tunnelrelease only, as well as various non-operative interven-tions: Non-steroidal anti-inflammatory drugs (NSAIDS),NSAIDS and oral steroids, and injected steroids. Theincidence of resultant permanent nerve damage wasfurther categorized as to duration of CTS subsequent todefinitive electrodiagnostic confirmation of CTS. Patientswith more severe CTS as well as patients with a longerduration of CTS regardless of severity had a higherincidence of PND. Those patients who underwent non-operative treatment had longer durations of symptomsand higher rates of PND. Treatment with injectablesteroids prior to definitive surgical treatment resulted ina significantly higher incidence of PND.

234 HAND (2009) 4:195–237

Quantifiying Upper Extremity Replant Patients Qualityof Life Using Utility Theory

Institution where the work was prepared: University ofMontreal & McGill University, Montreal, QC, CanadaOren Tessler, MD, MBA1; Genevieve Landes, MD2; Jean-Paul Brutus, MD3; Patrick Harris, MD2; H. BruceWilliams, MD1; Andreas Nikolis2; (1)McGill University,(2)Université de Montréal, Hôpital Notre-Dame, (3)CentreHospitalier de l Université de Montréal

Purpose:Improvements in microsurgical technique have dramaticallyincreased replant survival rates to over 90% since the initialreport of upper extremity replantation in 1964. Tissuesurvival however, does not always correlate with usefulextremity function. Measuring functional outcomes hasbeen historically difficult because of the heterogeneity ofmechanisms involved in the injury, patient factors, andassociated injuries. Research in this field has thus attemptedto develop increasingly specific evidence-based surgicalindications. Utility theory represents a group of economicgame theory-derived Health Related Quality of life assess-ment tools designed to help quantify uncertainty in medicine.It has been used extensively in medical decision-making overthe past 40 years and has proven to be valid, reliable, andresponsive for a large number of clinical conditions. Thisstudy is a novel attempt to examine the validity of utilitytheory measures as it applies to upper extremity replantpatients.

Methods:Patients treated by the Quebec Replant Center wereevaluated at a point of one year or greater from their finalreconstructive procedure. Using the EuroQol, Visual Ana-log Scale (VAS), Time Trade-Off (TTO), and StandardGamble (SG) questionnaires, we compare scores to thepreviously validated hypothetical clinical marker states ofmonocular and binocular blindness and to traditionalreplant outcome measures, including objective (ROM,sensibility, etc.), subjective (satisfaction, pain, etc..), andDASH assessments.

Results:We report that utility theory can represent a highly reliable,valid, and responsive standardized tool that can be useduniversally in assessing replantation results.

Discussion:It is our belief that utility theory can be developed as asimple and unified score for the multitude of surrogatemeasures in use to evaluate replantation outcomes.

Learning Objectives:

1. Participants will be able to identify patients who willlikely benefit from surgical replantation.

2. Participants will be able to communicate realisticoutcome expectations with patients.

3. Participants will be able to develop more specifictreatment algorithms for upper extremity replantprograms.

Lunotriquetral Instability: Treatment via DorsalCapsulodesis

Institution where the work was prepared: University ofCalifornia, Davis, Sacramento, CA, USARobert R. Slater, MD; University of California, Davis

Introduction:Instability of the lunotriquetral (LT) joint is one source ofulnar wrist pain, and symptoms can be disabling. Tradi-tional treatment options have focused either on indirectmanagement via ulnar shortening osteotomies in an effortto tighten all ulnar-sided soft tissue structures or onarthrodesis of the LT joint. Ideally, it would be better totreat the pathology directly while still preserving intercarpalmotion. A new technique to achieve that goal is describedherein.

Methods:The wrist is approached dorsally and the dorsal intercarpalligament (DICL) is dissected. A strip of the ligament isharvested from its distal, radial insertion, rotated on itsorigin off the dorsal triquetrum and then anchored to thelunate. Pin fixation maintains the intercarpal alignmentpost-operatively while the wrist is casted. Supervised handtherapy follows pin and cast removal.

Illustrative Case:A male custodian presented with post-traumatic ulnar-sidedwrist pain. Clunking occurred as the injured wrist movedfrom radial to ulnar deviation. Grip strength was 75% andROM was 90% vs. the opposite wrist. Fluoroscopy showedLT instability. At surgery, the LT disruption was confirmedarthroscopically. Open reconstruction was performed asdescribed. The cast and K-wires were removed at 8 weeks.Outcome was excellent: return to full activities and laborwithout pain.

Results:Excellent results were obtained as evidenced by eliminationof pain and return of grip strength to nearly match theuninjured side. ROM remained slightly decreased, particu-larly in flexion, but did not cause functional limitations.

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Discussion:The treatment of flexible deformities of the wrist due tointercarpal ligament injuries remains controversial. Tenod-eses and arthrodeses have been utilized in the past for LTinstability but with problems due to stiffness and nonunion.Ulnar shortening has different complications and does notattack the pathology directly. The technique described herewas developed in an effort to solve these challengingdilemmas. Favorable results suggest the technique is a validoption that warrants consideration and further investigation.

Plate Arthrodesis of the Proximal Interphalangeal Joint

Institution where the work was prepared: Medical Collegeof Georgia, Augusta, GA, USASamuel Schroerlucke, MD; Simeon Marcus Fulcher, MD;Clay Spitler, MD; Medical College of Georgia

Hypothesis:Several fixation techniques have been described forproximal interphalangeal joint (PIP) arthrodesis. Theliterature is sparse with respect to plating and suggests thatit has inferior fusion rates, is technically difficult, frequentlyrequires hardware removal and should be reserved only forextensive PIP joint trauma. A review of all plate arthrodesesof the PIP joint at our institution reveal an excellent fusionrate, no need for future hardware removal, and a technicallysimple and reproducible surgical technique for all con-ditions requiring a PIP fusion.

Methods:Between November 2001 and June 2007, 21 patients,totaling 27 fingers, had PIP arthrodeses using platingtechniques by a single surgeon. The indications weretrauma with open fractures in 8 fingers, contractures ofthe PIP joint in 7 fingers, posttraumatic arthritis in 8 fingers,degenerative or inflammatory arthritis in 3 fingers, andsalvage of a failed tension band wire arthrodesis in onepatient. The technique was performed by the same surgeon(SMF) through a dorsal approach using mini-plates andscrews (1.3, 1.5 or 2.0 mm). Patients were analyzed forpreoperative diagnosis, age, time to fusion, need forsubsequent procedures, and type and size of plate used.

Results:Twenty-six of twenty-seven (96%) PIP joints achievedfusion with an average time to union of fifty-six days.Average age of the patients was 47. The most commonplate used was a 5 hole 2.0 mm plate, however, three1.3 mm T-plates and four 6 hole 1.5 mm plates were used.The single nonunion was an acute open fracture whichdeveloped an infection requiring early hardware removal.No other finger required hardware removal.

Summary:The literature suggests that plating for PIP arthrodesis ascompared to other methods has an inferior fusion rate, thenecessity for frequent plate removal, and states that theprocedure itself is technically demanding.

& We present a 96% fusion rate (26/27) of proximalinterphalangeal joints treated by plate arthrodesis.

& No patient required hardware removal for prominenthardware.

& Surgical technique is technically simple and reproducible.

Forearm Compartment Syndrome. A 5-Year Review

Institution where the work was prepared: University ofTexas- Houston/Health Science Center, Houston, TX, USAErik Marques, MD; University of Texas- Houston

Background:Appropriate and timely treatment of upper extremitycompartment syndrome is dependent on accurate diagnosisof the underlying process, including both common andinfrequent etiologies. If treatment is delayed, compartmentsyndrome may result in tissue loss and permanent functionalimpairment.

Methods:A retrospective chart review was conducted on all cases offorearm compartment syndrome (CS) managed by a singleplastic surgeon over a 5-year period (12/2002 to 12/2007)at an academic medical center.

Results:Fourteen extremities in eleven patients (9 male, 2 female)were diagnosed with forearm CS preoperatively. Averageage was 37.5 years (range 11 months to 57 years). The mostcommon cause was direct trauma to the affected extremity(7/14; 5 penetrating, 2 crush injuries). In the remainingextremities, the etiologies included: advanced infection;avulsion amputation of index finger at PIP joint; infiltratedantecubital intravenous line during blood transfusion(Figure 1); radial artery punctures for arterial blood gas inan anti-coagulated patient (bilateral upper extremity); andafter prolonged CPR in an obtunded, ventilated patient onpressor support (bilateral upper extremity). All affectedextremities underwent emergent fasciotomy. Treatment wasdelayed (>6 hours) in 3 patients (4 extremities), of which 2patients (3 extremities) were unconscious; both patientsdeveloped Volkman’s contractures.

Discussion:This case series highlights several important points regardingforearm CS: (1) Although forearm compartment syndrome is

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frequently caused by direct trauma, less common etiologiesmust be considered. (2) Prompt diagnosis and timelytreatment are required for salvage of limb function (3) A highindex of suspicion is necessary when patients are anti-coagulated and/or unconscious (ie. sedated, obtunded, venti-lated). (4) We must strive to educate our referring physiciansabout the diagnosis, treatment, and multiple potential etiolo-gies of upper extremity compartment syndrome.

The Rise of Methicillin Resistant Staphylococcus Aureusin Surgically Treated Hand Infections

Friedrich JB, Division of Plastic Surgery, University ofWashington, Seattle, WA and Imahara SD, Division ofPlastic Surgery, University of Washington, Seattle, WA

Background:Hand surgeons are commonly asked to treat bacterialinfections of the hand. Recently, an alarming increase inthe incidence of community-acquired methicillin-resistantStaphylococcus aureus (ca-MRSA) infections has beenobserved among all soft-tissues, including the hand. Inaddition to the inherent morbidity of hand infections, thispathogen poses further treatment and prevention challenges.Prior studies of ca-MRSA infections of the hand, specifi-cally regarding risk factors, are small in number. Thepurpose of this study is to determine the change in

incidence of surgically-treated ca-MRSA hand infections,and to identify risk factors associated with this pathogen.

Methods:A retrospective review of a county hospital dischargedatabase was performed to examine all surgically-treatedhand infections over a 10-year time period (1997–2007).Examined data included demographic information, socialfactors, nature and location of infection, surgical management,and postoperative antibiotics. The yearly incidence of ca-MRSAwas calculated. Independent variables associated withca-MRSA were determined, and were then analyzed vialogistic regression to determine risk factors for ca-MRSAhand infections.

Results:There were 159 surgically-treated hand infections duringthe study period. Forty-eight (30%) were culture-positivefor ca-MRSA. Mean age was 40 years, mean inpatientlength of stay was 4.9 days, and 72% of patients were male.The yearly incidence of ca-MRSA increased over the studyperiod (p<0.001). Variables independently associated withca-MRSA were IV drug use (p=0.002), and secondadmission for a separate hand infection (p=0.005). Thefollowing were not associated with ca-MRSA: age, gender,homelessness, incarceration, other co-morbidities includingHIV and diabetes mellitus, and infection type/location.Binary logistic regression identified increasing year ofinfection (OR 1.39, 95% CI 1.18–1.63) and IV drug use(OR 3.91, 95% CI 1.67–9.13) as significant risk factors forca-MRSA hand infections.

Conclusions:Like ca-MRSA infections of other soft tissues, theincidence of surgically treated ca-MRSA hand infectionsincreased with time in the last decade. Additionally,more recent infection and injection drug use wereassociated with an increased likelihood of ca-MRSA.Factors previously thought to be associated with thispathogen, such as homelessness, incarceration, and otherco-morbidities were not found to be risks in this study.Future prospective studies are needed to further definerisk factors for, and optimal treatment of ca-MRSA handinfections.

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