Faculty Bibliography

Over the past two decades, management of open distal tibial fractures has evolved such that a staged approach, with external fixation and débridement during the index procedure, followed by definitive fixation and wound closure at a later date, is often considered the standard of care. Although definitive treatment of these complex injuries is often done by a multidisciplinary team of surgeons well versed in periarticular fracture repair and soft-tissue coverage in the distal extremity, the on-call orthopaedic surgeon doing the index procedure must understand the principles and rationale of the staged treatment algorithm to avoid compromising definitive treatment options and ensure the best possible patient outcome. The mechanism of injury, neurovascular status, size and location of soft-tissue injury, fracture pattern, and concomitant injuries in the polytraumatized patient should direct the treatment plan and anticipated outcomes. This review focuses on evaluation and management of these complex injuries with an emphasis on early aggressive débridement, principles of initial fracture fixation, and modern options for soft-tissue coverage, including local and free tissue transfer.

Background  The second and third metacarpals are firmly attached, immobile structures which for the stable pillar of the hand. The trapezoid has been described as the keystone of the wrist, allowing a wide range of functional motion as well as inherent anatomic and biomechanical stability to the carpus. Case Description  We describe a novel boxing injury with a 180-degree in situ dislocation of the right trapezoid with concomitant second and third carpometacarpal (CMC) joint dislocations. Open anatomic reduction of the trapezoid was obtained, and subsequent percutaneous pinning of the metacarpals allowed for a full functional recovery and return to sports at 6 months. Literature Review  Combined trapezoid and CMC dislocations are extremely rare and have only been previously described in high-energy mechanism injuries, involving a direct dorsal force such as from the steering wheel in a motor vehicle collision. There are no previous reports of this injury occurring in the setting of direct axial load along the metacarpals in a clenched fist such as in a punch or fighting injury. Clinical Relevance  The rare nature of this combined injury, its novel mechanism, and the difficulty in interpreting acute injury and postreduction radiographs require that the treating physician have a high degree of clinical suspicion for associated injuries when CMC dislocations are identified. Treatment strategies incorporating intraoperative fluoroscopy, open anatomic reduction of the trapezoid under direct visualization along with closed reduction, and pinning of the metacarpals reestablish carpal stability and provide excellent long-term results.

Major peripheral nerve injuries are devastating and represent a very challenging clinical problem. Despite many years of advancement in peripheral nerve research, results so far have been fair at best, with only 50% of patients regaining useful function. Advancement of techniques in imaging, better understanding of the physiology of nerve recovery, improved repair and grafting options, and secondary reconstructive techniques, including tendon and nerve transfers, have helped facilitate a degree of more effective treatment. This article presents current concepts regarding the principles of management, expected outcomes, and new advancements in major upper extremity peripheral nerve injuries.

OBJECTIVE:This pooled analysis evaluates the association between the number of nerves transferred and postoperative outcomes after intercostal nerve (ICN) nerve transfer for elbow flexion. METHODS:A systematic and pooled analysis of studies reporting individual patient demographics and outcomes after ICN-musculocutaneous nerve (MCN) transfer for traumatic brachial plexus injury was conducted. The primary outcome was the ability to attain an elbow flexion Medical Research Council (MRC) score of ≥4 at the final postoperative follow-up visit. RESULTS: = 0.126). CONCLUSIONS:These results indicate that two ICN transfers may be as effective as three ICN and four ICN transfers and highlight the potential for nonsurgical factors to influence postoperative outcomes. Taken together, this pooled analysis leads us to question the utility of transferring >2 ICNs for MCN neurotization.

Hand trauma has always been a common etiology treated by the hand surgeon. However, the amount of severe hand trauma in the United States has decreased as the safety of working environments have improved and the amount of heavy industry jobs has decreased. Largely because of this, the typical hand surgery trainee is now exposed relatively infrequently to pathologies such as brachial plexus injuries, replantation surgery, and upper-extremity reconstructive microsurgery. Our hand surgery colleagues in countries such as India and China have a different experience, though. This difference provides an opportunity for educational exchange through the form of well-structured international fellowships. The American Society for Surgery of the Hand International Traveling Fellowship is specifically designed to supplement the training of young US hand surgeons in brachial plexus surgery, replantation surgery, and reconstructive microsurgery by spending short but intensive periods at some of the premier institutions in China and India.

WE43 Mg alloy proved to be an ideal candidate for production of resorbable implants in both clinical and trial settings. In previous studies we tested biocompatibility and degradation properties of WE43 (as-cast) and artificially aged (WE43-T5) Mg alloys in a sheep model. Both alloys showed excellent biocompatibility with the as-cast, WE43, form showing increased degradability compared to the artificially aged, WE43-T5. In the present study, our group assessed the biological behavior and degradation pattern of the same alloys when implanted as endosteal implants in a sheep model. Twelve screws (3x15 mm) were evaluated, one screw per each composition was placed bi-cortically in the mandible of each animal with a titanium (2x12 mm) screw serving as an internal positive control. At 6 and 24 weeks histomorphological analysis was performed, at 6 weeks as cast, WE43, yielded a higher degradation rate, increased bone remodeling and osteolysis compared to the WE43-T5 alloy; however, at 24 weeks WE43-T5 showed higher degradation rate and increased bone remodeling than as-cast. In vitro assay of cell growth, adhesion and differentiation was also conducted to investigate possible mechanisms underlying the behavior expressed from the alloys in vivo. In conclusion WE43-T5 indicated bone/implant interaction properties that makes it more suitable for fabrication of endosteal bone screws.

We reviewed the patient demographics, injury mechanisms, fracture characteristics, treatment modalities, and outcomes of incarcerated patients who were referred for metacarpal fracture evaluation and treatment to our high-volume tertiary care center from a New York City Department of Correction infirmary facility. There is a scarcity of information in the orthopedic and plastic surgery literature on treating these common fractures in this vulnerable population. We conducted a basic statistical analysis and discuss the potential implications of these findings. We found a high incidence of stiffness that may relate to the high rates of follow-up noncompliance coupled with prolonged immobilization. Awareness of these findings may influence treating hand specialists to use less restrictive immobilization devices such as functional bracing, elastic bandage, or neighbor strapping as an effort to promote bony union without the risk of developing stiffness and the potential to compromise general hand function when treating non-thumb metacarpal fractures.

OBJECTIVES/OBJECTIVE:Double fascicular transfer is argued to result in improved elbow flexion compared to the traditional ulnar fascicular transfer because it reinnervates both the biceps and the brachialis. This study seeks to determine if double fascicular transfer should be preferred over ulnar fascicular transfer to restore elbow flexion in patients with upper trunk brachial plexus injuries (BPI) by analyzing the current database of literature on the topic. METHODS:A systematic review was conducted according to PRISMA guidelines. Inclusion criteria were studies reporting Medical Research Council (MRC) scores on individual patients undergoing ulnar fascicular transfer and double fascicular transfer (ulnar and median nerve fascicle donors). Patients were excluded if: age < 18 years old and follow-up <12 months. Demographics obtained include age, sex, extent of injury (C5-C6/C5-C7), preoperative interval, procedure type, and follow-up time. Outcomes included absolute MRC score and ability to achieve MRC score ≥3 and ≥4. Univariate and multivariate regression analyses were completed to evaluate predictors of postoperative outcomes. RESULTS:Eighteen studies (176 patients) were included for pooled analysis. Patients that underwent double fascicular transfer had a higher percentage of patients attain a MRC score ≥ 4 compared to ulnar fascicular transfer subjects (83.0% vs. 63.3%, p = .013). Double fascicular transfer was a predictor of achieving high MRC scores (OR = 2.829, p = .015). Multivariate analysis showed that procedure type was the only near significant predictor of ability to obtain MRC ≥4 (OR: 2.338, p = .054). CONCLUSIONS:This analysis demonstrates that double fascicular transfer is associated with superior postoperative outcomes and should be performed for restoring elbow flexion.