Faculty Bibliography

BACKGROUND:Treating ring avulsion injuries continues to challenge the reconstructive hand surgeon. The complex operation draws from plastic surgery and orthopedic surgery principles to provide soft-tissue coverage, skeletal fixation, tendon repair, and neurovascular reconstruction. Furthermore, the application of microsurgical techniques has enabled the revascularization and replantation of completely avulsed fingers. METHODS:A retrospective review of 22 consecutive ring avulsion injuries (seven amputations, five replantations, and 10 revascularizations) from 1987 to 2015 performed by a single senior surgeon (D.T.W.C.) was conducted. RESULTS:Of these 22 ring avulsions, 10 revascularizations, five replantations, and seven amputations (five because of clinical factors, and two because of patient request) were performed. None of the 15 replantations and revascularizations resulted in loss of the ring finger or necrosis of the revascularized tip. CONCLUSIONS:With proper patient selection, appropriate level of injury identification, and meticulous surgical execution, the restoration of form and function to the hand is feasible in ring avulsion injuries. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, IV.

BACKGROUND:The principle of relative motion has allowed patients to regain a higher degree of hand function, while protecting extensor tendon repairs. The purpose of this study was to determine whether the principle of relative motion could be a viable method to protect a flexor tendon repair. METHODS:Four fresh-frozen cadaver arms were each mounted on a testing apparatus (wrist in 30° of extension, metacarpophalangeal [MCP] joints blocked to 70°-80°). A minimum of 11 N was used to cyclically load the flexor digitorum profundus and extensor digitorum communis tendons to maximum allowable flexion and extension for 25 cycles. Measurements of elongation of the tendons were obtained through the use of differential variable reluctance transducers. Testing was performed in both intact and repaired (single 6-0 nylon suture) middle finger tendons (zone 3) with and without a relative motion flexion splint (RMFS), which placed the affected finger in 15° to 25° of relative flexion at the MCP joint. RESULTS:In all 4 hands, elongation was restricted to less than 1.3 mm in repaired tendon in the RMFS compared with elongation >2 mm in the nonsplinted condition. Average elongation was 0.86 mm (SD = 0.45). Visual examination of the tendons demonstrated no gapping with the use of the RMFS in any of the hands. All repairs had suture breakage and repair rupture without the RMFS. CONCLUSIONS:This study demonstrates that the RMFS decreases elongation and eliminates tendon-repair gapping after flexion/extension cycling in a cadaver model. It provides proof of concept that the RMFS may be a viable protective mechanism for flexor tendon repairs in zone 3.

Background/UNASSIGNED:Amniotic Band Syndrome is a clinical constellation of congenital anomalies characterized by constricting rings, tissue synechiae and amputation of body parts distal to the constriction bands. Involvement of the hand with loss of multiple digits not only leads to devastating deformities but also loss of functionality. Methods/UNASSIGNED:In this series, utilizing microvascular transfer of the second toe from both feet, along with local tissue reconfiguration, a tetra-digital hand with simile of normal cascade was reconstructed. A consecutive series of eight children with Amniotic Band Syndrome, younger than two years in age operated on by single surgeon over a twenty five year interval was reviewed. Results/UNASSIGNED:There was no flap loss. The hands were sensate with effective simple prehensile function. Conclusion/UNASSIGNED:Application of Microvascular toe-to-hand transfer for well selected, albeit severe hand deformity in Amniotic Band Syndrome is a valid surgical concept.

Fingertip amputation is the most common amputation encountered by hand surgeons. Treatment decisions are multifactorial, based on mechanism, level of injury, tissue loss, associated injuries, and patient preference, among others. In this article, we present use of the thenar flap in combination with bone graft and split-thickness nail bed graft to address the tripartite loss of distal phalanx, soft tissue, and nail bed. This method allows for a full-length and functional reconstructed fingertip that is aesthetically satisfactory and does not require microsurgical techniques.

BACKGROUND: Composite grafts consisting of adipose tissue and skin have been reported in the literature but have been restricted to areas smaller than 4 to 5 cm. The senior author (D.T.W.C.) has developed a technique of adipose tissue-preserved full-thickness skin grafts for larger areas with success similar to that achieved with conventional full-thickness skin grafts. METHODS: All cases of the senior author involving a full-thickness skin graft were identified and reviewed to identify cases in which adipose tissue-preserved full-thickness skin grafts were used. Indication for skin grafting, anatomical location of recipient and donor sites, size of graft, total number of grafts received by each patient, and percentage take were extracted from patient charts. Graft take was measured between days 5 and 14. RESULTS: A total of 72 adipose tissue-preserved skin grafts on 47 patients were identified from 1994 to 2009, with a median follow-up of 8 years. The size of defect ranged from 0.7 to 210 cm, with a median area of 6 cm (interquartile range, 2.5 to 15 cm). Only six of 72 grafts were found to have less than 100 percent take. The lowest take percentage was 85 percent in a graft with an area of 2.6 cm. There were no graft failures. CONCLUSIONS: This study confirms the proof-of-concept that both larger and distant donor- site adipose tissue-preserved skin grafts are a viable alternative to conventional defatted full-thickness skin grafting. It appears that there is a low complication rate with respect to graft failure or incomplete graft take. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

BACKGROUND: The Accreditation Council for Graduate Medical Education requires accredited fellowship programs to exhibit proficiency in six broadly defined domains; however, core competencies specifically mandated for hand surgery training have yet to be established. Several studies have demonstrated significant disparities in exposure to essential skills and knowledge between orthopedic surgery- and plastic surgery-based hand surgery fellowship programs. To determine whether significant discrepancies also exist after fellowship between hand surgeons trained in orthopedic surgery and those trained in plastic surgery, clinical practice patterns were evaluated. METHODS: A 20-question survey was created and distributed electronically to American Society for Surgery of the Hand and American Association for Hand Surgery members. Responses were compared using descriptive statistics. RESULTS: Nine hundred eighty-two hand surgeons (76 percent orthopedic and 24 percent plastic) responded, representing a 39 percent response rate. Most plastic surgery hand practices were academic-based (41 percent), whereas orthopedic practices were private (67 percent). More orthopedic hand surgeons worked in multipractitioner practices than plastic surgeons (54 percent versus 30 percent; p < 0.0001). Orthopedic hand surgeons performed a higher percentage of hand cases in their practice facilities (86 percent versus 71 percent; p < 0.0001). Plastic surgeons performed more congenital hand (56 percent versus 35 percent; p < 0.05) and digital replantation cases (53 percent versus 22 percent; p < 0.05) but treated significantly fewer open reduction and internal fixation distal radius fractures. CONCLUSIONS: Orthopedic and plastic surgery hand surgeons differ significantly in their clinical practice patterns. Differences in clinical exposure during training are reflected in practice and persist over time. Referral patterns and practice situations are also contributors to ultimate practice patterns.

PURPOSE: Local anesthetic is often used for perioperative pain control. Thrombin serves as a carrying medium for sustained release of antibiotics, chemotherapy, and growth factors. We tested the hypothesis that local anesthetic pain relief can be prolonged with the adjunct use of thrombin. METHODS: A prospective single-blinded clinical study was performed. Patients undergoing elective hand surgery inclusive of carpal tunnel release, excision of ganglion cyst, trigger finger release, and excision of mucous cyst under local block were enlisted. Before closure, patients received 1 of the following combinations: (1) control with oral analgesics, (2) 5 mL of 2% xylocaine, (3) 5 mL of 0.5% bupivacaine, (4) 2.5 mL of 2% xylocaine with 2.5 mL of 0.5% bupivacaine (XB), (5) thrombin with 5 mL of 2% xylocaine (XT), (6) thrombin with 5 mL of 0.5% bupivacaine (BT), and (7) thrombin with 2.5 mL of 2% xylocaine and 2.5 mL of 0.5% bupivacaine (XBT). There were 7 patients in each group, and patient demographics were similar between groups. Outcome measures included postanesthesia care unit (PACU) time, pain level, and number of pain pills required. RESULTS: Compared with oral analgesics alone, mean (SD) postoperative pain levels were reduced by 33.3% (8.9%) by xylocaine, 69.1% (8.7%) by bupivacaine, and 45.7% (9.4%) by XB. When thrombin was added, pain levels were further reduced by 69.9% by XT (P < 0.001), 23.1% by BT (P = 0.071), and 50.5% by XBT (P < 0.001) compared with their nonthrombin counterparts. In addition, PACU time was decreased by 34.8% by XT (P = 0.003) and 19.7% by XBT (P = 0.013) compared with xylocaine and XB, respectively. However, there was no difference in total pain pills needed between xylocaine, bupivacaine, and XB when administered with and without thrombin. CONCLUSIONS: The addition of topical thrombin to local anesthetic at the end of elective hand surgery provides for sustained postoperative pain control. Patients in this study who received thrombin and local anesthetic before wound closure had lower pain levels and were discharged from the PACU sooner than those who received local anesthetic alone. LEVEL OF EVIDENCE: Therapeutic level 2.