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62ND ANNUAL MEETING OF THE

AMERICAN SOCIETY FOR SURGERY OF THE HANDSEPTEMBER 27-29, 2007 • SEATTLE, WASHINGTON

THE FUTURE IN HANDAdvancing evidence-based care through scientific discovery

M E E T I N G A B S T R A C T S

62ND ASSH ANNUAL MEETING ABSTRACTS

This booklet contains the abstracts for the

Scientific Session papers as submitted by the authors.

Abstracts are in presentation order by day and time.

These abstracts are also available in

the Annual Meeting CD-ROM and

on the ASSH website www.assh.org

Symbol Key

l Something of Value—The authors of those presentationspreceded by a l have indicated that they have receivedsomething of value in the form of: research or institutionalsupport, stock or stock options, equipment or services, paid travel, royalties or as a consultant or employee of acommercial company or institution related directly or indirectlyto the subject of the presentation.

u Nothing of Value—The authors of those presentationspreceded by a u have indicated that they have not receivedanything of value in the form of: research or institutionalsupport, stock or stock options, equipment or services, paid travel, royalties or as a consultant or employee of acommercial company or institution related directly or indirectlyto the subject of the presentation.

s Documentation of FDA Status—The authors of thosepresentations preceded by a s have indicated that the FDAhas not cleared the listed pharmaceuticals and/or medicaldevices for the use described in this presentation or that the listed pharmaceuticals and/or medical devices are beingdiscussed for an off-label use.

*AFSH Grant Research Acknowledgement—The authors of those presentations preceded by a * have indicated thatresearch related to their presentation was supported by anAFSH Research Grant.

The ASSH does not view the existence of these interests orcommitments as necessarily implying bias or decreasing thevalue of the presentations.

Disclaimer

The material presented in this continuing medical educationprogram is being made available by the American Society forSurgery of the Hand for educational purposes only. Thismaterial is not intended to represent the only, or necessarilythe best, methods or procedures appropriate for the medicalsituation discussed, but rather is intended to present anapproach, view, statement, or opinion of the authors orpresenters, which may be helpful or of interest to otherpractitioners. The attendees agree to participate in thismedical education program sponsored by ASSH with fullknowledge and awareness that they waive any claim they mayhave against ASSH for reliance on any information presentedin this educational program. In addition, the attendees alsowaive any claim they have against ASSH for any injury orother damage, which may result in any way from theirparticipation in the program. The ASSH are not responsible forexpenses incurred by an individual who is not confirmed andfor whom space is not available at the meeting. Costs incurredby the registrant, such as airline or hotel fees or penalties, arethe responsibility of the registrant. All of the proceedings ofthis ASSH meeting, including the presentation of scientificpapers, are intended for limited publication only, and allproperty rights in the material presented, including commonlaw copyright, are expressly reserved to the speaker and ASSH.No statement of presentation made is to be regarded asdedicated to the public domain. Any sound reproduction,transcript, or other use of the material presented at thiscourse without the permission of the speaker or ASSH isprohibited to the full extent of common law copyright in suchmaterial. The approval of U.S. Food and Drug Administrationis required for procedures and drugs that are consideredexperimental. Instrumentation systems discussed and/ordemonstrated in ASSH educational programs may not yethave received FDA approval.

The ASSH assumes no responsibility or liability for the use ormisuse of any information, materials or techniques describedin the following abstracts and it makes no warranty,guarantee or representation as to the absolute validity orsufficiency of any information provided.

1

Financial Disclosure and FDA Status

Clinical Trial Paper 01Thursday, September 27, 2007, 2:20 - 2:27 PM

Corticosteroid Injection For Lateral Elbow Pain: A Randomized Placebo Controlled Clinical Trial

l Marjolijn Henket, MD, Boston, MADavid Ring, MD, PhD, Boston, MAJames Cowan, BA, Boston, MASantiago Lozano-Calderon, MD, Boston, MAChaitanya Mudgal, MD, Boston, MAJesse Jupiter, MD, Boston, MA

HYPOTHESIS: Corticosteroid injection is often used for treatment of lateralepicondylitis in spite of poor scientific support. We performeda randomized clinical trial comparing dexamethasone injectionwith injection of lidocaine alone (placebo) for treatment oflateral epicondylitis.

METHODS:64 patients enrolled in the protocol (27 men, 37 women): 31dexamethasone and 33 placebo. This abstract is based onpreliminary data from 43 patients (20 dexamethasone, 23placebo) that have completed the protocol. At the initial visitwe evaluated depression (CESD), pain catastrophizing (PCS),neuroticism (EPQ-R) and baseline Disabilities of the Arm,Shoulder and Hand (DASH). At one and six months werecorded pain and satisfaction using visual analogue scales (p-VAS, s-VAS), DASH score, and grip strength.

RESULTS/STATISTICS: From enrollment, to one month, to six months after injection,the mean DASH score improved from 28.3 to 26.6 to 12.9 inthe placebo-group and from 31.2 to 25.6 to 18.9 in thedexamethasone-group. The mean p-VAS score improved from5.9 to 3.7 to 2.5 in the dexamethasone-group and from 4.8 to4.3 to 1.6 in the placebo-group. The mean s-VAS improvedfrom 6.5 to 8.5 in the placebo-group and from 4.7 to 6.9 inthe dexamethasone-group. The improvements within eachcohort were statistically significant, but the differencesbetween cohorts were not. A positive correlation betweenDASH-scores and depression (r = 0.64, p<0.01) and poorcoping/catastrophizing (r = 0.65, p<0.01) was found at allvisits.

SUMMARY POINT:Lateral epicondylitis is a benign, self-limiting tendinosis of middle age. Perceived disability from this condition is strongly related to depression and poor coping mechanisms.Dexamethasone injection did not provide significantly betterpain relief or perceived disability than placebo at any timepoint. Corticosteroid injection is not an evidenced basedtreatment of lateral epicondylitis.

• Received support from unrestricted research grants fromJoint Active Systems, AO Foundation, Small Bone Innovations,Smith and Nephew, Wright Medical, and Biomet.

2


Corticosteroid Injection in Diabetic Patients with Trigger Finger: A Prospective, Randomized, Placebo-Controlled Double-blinded Study

l Martin I. Boyer, MD, St. Louis, MOKeith Baumgarten, MD, Sioux Falls, SDDavid Gerlach, MD, St. Louis, MO

HYPOTHESIS: A diagnosis of diabetes mellitus leads to no change in theeffectiveness of corticosteroid injection for trigger finger.

METHODS:Thirty-one diabetics and 29 non-diabetic patients wereenrolled. The non-diabetic patients were given corticosteroidinjections in an unblinded manner. The diabetic cohort wasrandomized into a corticosteroid group (19 fingers) or aplacebo group (15 fingers). Both diabetic groups were double-blinded. All patients had HgA1c levels drawn upon initialevaluation. Additional injections, surgical intervention, andrecurrent trigger finger symptoms were recorded. Treatmentsuccess was defined as the complete symptom resolution ornear-complete resolution of trigger finger symptoms that didnot require surgical intervention.

RESULTS/STATISTICS: After one to two injections, 86.2 percent of non-diabeticpatients had a successful outcome compared to 63.2 percentof the Diabetic Corticosteroid Group (p=0.03) and 53.3percent of the Diabetic Placebo Group (p=0.006). Nosignificant difference was found within the diabetic groups.Surgery was performed on 10.3 percent of the Non-Diabetic

Group compared to 36.8 percent of the DiabeticCorticosteroid Group and 40 percent of the Diabetic PlaceboGroup. There was a significant difference in prevalence ofsurgery between the Non-Diabetic Group and DiabeticCorticosteroid Group and the Diabetic Placebo Group (p=0.04and p=0.02). No difference was found between the diabeticgroups for time to surgery, persistence of symptoms, norsymptom recurrence. Long term glycemic control, as measuredby HgbA1c levels, was not correlated with success or failure ofsteroid injection. The presence of nephropathy andneuropathy significantly influenced the need for surgery(p=0.008 and p=0.03).

SUMMARY POINT:Corticosteroid injections were significantly more effective in non-diabetic patients than in diabetics. In diabetics,corticosteroid injections did not decrease the surgery rate,time to surgery, number of recurrences, or improve symptomrelief compared to injection of placebo. Corticosteroidinjection may be less efficacious in patients with systemicmanifestations of diabetes.

• Received support from OREF (#3-001)

3


Outcomes of Carpal Tunnel Surgery with and without Supervised Postoperative Therapy

u Jay F. Pomerance, MD, Arlington Heights, ILIlene Fine, BA, Arlington Heights, IL

HYPOTHESIS: There is no difference in clinical outcomes after carpal tunnel release using either a supervised therapist directedpost-operative therapy program or no formal therapy.

METHODS:A prospective randomized study was completed using acontemporary short incision and a two week program oftherapy. Patients were randomized into two treatment groups:one group received instruction on a home therapy exercises tobe followed after carpal tunnel release while a second groupreceived the home program in addition to a therapist directedprogram for 2 weeks. Variables measured were: patient age,gender, pre and postoperative pain scores, grip and pinchstrengths, return to modified and regular work, insurancecoverage and job category. Both groups were followed for 6months postoperative.

RESULTS/STATISTICS: 150 patients (110 women and 40 men) entered andcompleted the study. Average age was 46 years (range 29-70years). The average age, gender distribution, insurancecoverage, and breakdown of job categories between groupswas not statistically significant (student t-test, p>.05). No difference occurred in return to work times between thosewith and without postoperative therapy (student t-test,p>.05); however, patients covered by worker’s compensationinsurance were slower to return to both modified and regularwork compared to the other groups (2 tailed t test, p>.05). The postoperative grip and pinch strengths, pain and DASHscores did not show statistical differences at any of themeasured time periods between groups (student t-test,p>.05). Therapy added significantly to the cost of care.

SUMMARY POINT:The present randomized study failed to show benefit inparameters measured to a 2 week course of supervised handtherapy after carpal tunnel release using a short incision.The cost expenditure for supervised therapy for anuncomplicated carpal tunnel release should be reconsidered.

4


Excision of the Trapezium with Kirschner Wire Stabilisation of the Pseudarthrosis: Is there a Benefit to Ligament Reconstruction or Tendon Interposition at 5-Year Follow-Up?

u Soham Gangopadhyay, FRCS Nottingham, United KingdomTim Davis, FRCS, Nottingham, United KingdomHelen McKenna, OT, Derby, United Kingdom

HYPOTHESIS: There is no benefit to the addition of ligament reconstructionor tendon interposition following excision of the trapezium forpainful osteoarthritis of the thumb base after a minimumfollow up of 5 years.

METHODS:141 patients were prospectively randomised for treatment bytrapeziectomy alone (T; n=50), trapeziectomy with palmarislongus interposition (T+PL; n=43) or ligament reconstructionand tendon interposition (T+LRTI; n=48) using 50% of theFCR tendon. A K-wire stabilised the pseudarthrosis for 4weeks in all cases. The three treatment groups were wellmatched for age, hand dominance and length of final follow-up (mean=7, range=5-14 years).

The patients underwent assessments of thumb pain, stiffnessand strength preoperatively, and at 3 months, 1 year and after a minimum of 5 years postoperatively. The subjectiveoutcomes of the three treatment groups were compared usingthe Kruskal-Wallis test. Thumb strengths were comparedbetween the three groups using analysis of variance. Temporal changes in the subjective outcomes and theobjective measurements were assessed for significance using the paired t-test.

RESULTS/STATISTICS: At the 5 year follow-up, 77% (T=78%; T+PL=72%;T+LRTI=79%) of the 141 patients had no pain or only mildpain after use. Thumb key pinch strengths at 5 years did notdiffer significantly between the three procedures [T= 4.0 kg(95%CI, 3.6–4.4); T+PL= 3.4 kg (95% CI, 2.8–4.1); T+LRTI=3.7 kg (95%CI, 3.4–4.0)]. The tip pinch strengths at 5 yearswere also similar after each of the operations [T= 2.7 kg(95%CI, 2.4–3.0); T+PL= 2.4 kg (95%CI, 2.0–2.9); T+LTRI=2.7 kg (95%CI, 2.3–3.0)]. No cases of late deterioration wereevident at final follow-up.

SUMMARY POINT:After an average of 7 years, the outcome of trapeziectomywith temporary K-wire stabilisation of the pseuadarthrosis was not improved by either tendon interposition or ligamentreconstruction.

REFERENCES:1. Davis TRC, Brady O, Dias JJ. Excision of the trapezium for

osteoarthritis of the trapeziometacarpal joint: a study of the benefit of ligament reconstruction or tendon interposition. J Hand Surg 2004;29A:1069-1077

2. Burton RI, Pellegrini VD. Surgical management of basal joint arthritis of the thumb. Part II. Ligament reconstructionwith tendon interposition arthroplasty. J Hand Surg 1986;11A:324–332

5


Early Patient Response and the Incidence of Flare Reaction after Extra Articular Steroid Injection:A Prospective, Randomized, Double- Blind Assessment

u Charles A. Goldfarb, MD, St. Louis, MORichard Gelberman, MD, St. Louis, MOKathleen McKeon, BA, St. Louis, MOBen Chia, BA, St. Louis, MOMartin Boyer, MD, St. Louis, MO

HYPOTHESIS: To evaluate the timing of improvement after extra articularsteroid injection, the incidence of a postinjection pain flare,and the hypothesis that a pH balanced injection solution willdecrease the incidence of a postinjection flare.

METHODS:One hundred and twenty- five patients with trigger finger (88 patients) or de Quervains tenosynovitis (37 patients) wereprospectively randomized in this double blind study to receiveeither an injection of steroid, lidocaine, and bupivacaine alone(standard injection, acidic pH) or an injection of steroid,lidocaine, bupivacaine, and bicarbonate (balanced injection,neutral pH). All patients completed a visual analog scale (VAS)for pain before and immediately after the injection, daily forseven days, and at 6 weeks. A flare reaction was defined as anincrease in the VAS score by two or more points any time afterthe injection.

RESULTS/STATISTICS: All patients immediately responded to the steroid injection but pain rebounded to preinjection levels by Day 1. In bothgroups the pain then gradually declined over the course of 7 days. In the balanced group, 23 of the 68 patients (34%)had a flare reaction and in the standard group, 18 of the 57patients (32%) had a flare reaction. The difference betweengroups was not significant (p>.05).

SUMMARY POINT:Patients respond to extra articular steroid injections withgradual improvement over the course of the first week. An increase in pain, or flare reaction, occurred in 33% ofpatients and was most common on postinjection day one with a duration of two days. A pH balanced injection solutiondid not significantly decrease the risk of a flare reaction.

6

Lightning Round Paper 01Thursday, September 27, 2007, 3:45 - 3:48 PM

Natural History of Congenital Trigger Thumb

u Goo Hyun Baek, MD, Seoul, KoreaMoon Sang Chung, MD, Seoul,,KoreaJi Hyeung Kim, MD, Seoul, KoreaHyun Sik Gong, MD, Seoul, KoreaYoung Ho Lee, MD, Seoul, KoreaSang Ki Lee, MD, Seoul, Korea

HYPOTHESIS: The aims of the present study were to analyze the rate ofspontaneous resolution, and to understand the natural historyof congenital trigger thumb.

METHODS:Seventy one thumbs in 53 children were reviewed frompatients seen between April 1994 to March 2004. Thirtychildren showed bilateral involvement. Only the right thumbwas involved in 15 children and the only the left in eight.Patients were diagnosed as having congenital trigger thumbduring initial out-patient department visits. Activemanagement in the form of passive stretching or splinting wasnot done. None had surgical treatment. Degrees of flexiondeformity were measured at routine 6-months follow-up visits.

RESULTS/STATISTICS: Of the 71 thumbs, 45 (63.4%) resolved spontaneously. Mean time from initial visit to spontaneous resolution was47.9 months. Although spontaneous resolutions were notobserved in remained 26 thumbs, flexion deformitiessignificantly improved in 22 thumbs (84.6%, P-value<0.01).The degrees of flexion deformity significantly decreasedbetween consecutive 6-months follow up visits over the 4 year period following initial presentation. After this time, thedegree of flexion deformity showed a decreasing trendbetween visits.

SUMMARY POINT:Spontaneous resolution of flexion deformity was observed in almost two thirds of patients. Moreover, flexion deformityshowed an improving pattern in those that did not experiencespontaneous resolution. We conclude that in cases ofcongenital trigger thumb, A1 pulley release is rarely required.

REFERENCES:1. Baek GH, Chung MS, Park YB, Yoo KH. The relative

incidence of congenital anomalies of the hand. J Korean Orthop Assoc. 1997;32:796-801

2. Mulpruek P, Prichasuk S. Spontaneous recovery of trigger thumbs in children. J Hand Surg Br. 1998;23:255-7

3. Watanabe H, Hamada Y, Toshima T, Nagasawa K. Conservative treatment for trigger thumb in children. Arch Orthop Trauma Surg. 2001;121(7):388-90

7

HYPOTHESIS: No study has compared the results of the K-wires to those ofthe locking plates in the treatment of the osteoporotic distalradius fractures. The purpose of this randomised prospectivestudy was to compare two techniques, one percutaneous withK-wires and the other one using open surgery with lockingplates.

METHODS:Our series contained sixty eight 72-year-old patients onaverage, all affected by osteoporosis. They involved in everycase displaced and comminutive distal radius fractures. Thegroup 1 included 31 fractures treated by K-wire cementing(calcium phosphate cement) and group 2, 37 fractures treatedby locking plate and injection of cement into the fracture. Thetwo groups were homogeneous if we considered the age, thesex, and the type of fracture.

RESULTS/STATISTICS:The patients were revised with an average follow-up of 7months. The average quantity of cement injected in the group1 was 2.5 ml, against 2 ml in the group 2. We observed onthe whole 6 cases of volar and dorsal leaks of cement, and 4cases of tenosynovitis. The clinical results on the prematurerecovery of the force and the mobility were better with thegroup 2 (no significant difference) as well as the results on thepain and the DASH. The radiological results were in favour(significant difference) of the locking plate with notably a netdecline of secondary displacements.

SUMMARY POINT:Both techniques are also effective on pain. But the score offunctional evaluation is of more premature recovery withlocking plate, as well as maintaining the reduction of thefracture at long term follow-up.

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Percutaneous K-Wire Cementing vs. Locking Plates in Osteoporotic Distal Radius Fractures:A Randomized Comparative Trial

u Sybille Facca, MD, Illkirch, FranceStéphanie Gouzou, MD, Illkirch, FranceOliver Körting, MD, Illkirch, FrancePhilippe Liverneaux, MD, PhD, Illkirch, France


Locked Volar Plating of Distal Radius Fractures in Immunosuppressed Patients

Erik Peteson, MD, Rochester, MNu David Dennison, MD, Rochester, MN

HYPOTHESIS: Volar locked plating of displaced, unstable distal radiusfractures, in adult patients on chronic immunosuppressivemedication, is associated with union, functional motion andgrip, and, maintenance of reduction.

METHODS:A retrospective study identified identified 11 patients with 11 distal radius fractures that had been on chronicimmunosupressive medication. There were seven women andfour men with a mean age of 59.9 years (40-82 years). Therewere two open fractures. According to the Orthopedic TraumaAssociation classification there were two 23A3, one 23B3,and there were nine 23C fractures (one 23C1, one 23C2, and

seven 23C3). All patients received preoperative antibiotics andunderwent reduction and fixation with a volar, fixed-angleplate. Postoperative measurements included wrist flexion andextension, grip strength and forearm rotation. Postoperativeand final radiographic indices were compared for subisdence.Follow-up averaged 14.9 months (range 3-34 months).Statistical analysis was performed with an alpha less than orequal to 0.05.

RESULTS/STATISTICS:All radius fractures healed and there were no infections. Meanwrist flexion was 47 degrees and wrist extension 47 degrees.The mean pronation was 77 degrees and supination was 76degrees. Grip strength averaged 16.3 Kg versus 25.1 kg forthe opposite extremity. The final mean radial height, volar tilt,and radial inclination were +0.1mm (ulnar negative)(range -2.0to +2.5mm), 13 degrees (range 5-23 degrees), and 21 degrees(range 15-27 degrees), respectively. The mean articular gap orstep was 0.3 mm. There was a significant decrease betweenthe final and postoperative mean radial height (p=0.03).Complications were limited to one patient with apostoperative carpal tunnel syndrome.

SUMMARY POINT:Locked volar plate fixation of distal radius fractures, in patientswith chronic immunosuppression, was associated with union,functional wrist and forearm motion and grip strength. Whileno patients had ulnar impaction, a statistically significant lossof radial height was observed at final follow-up.

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Long-term Outcome Assessment for Closed Reductionand Percutaneous Pinning of Distal Radius Fractures

u Louis W. Catalano, III, MD, New York, NYFrank Raia, MD, New York, NYSteven Glickel, MD, New York, NYAlton Barron, MD, New York, NYJason DeFrancis, MD, New York, NYRyan Grabow, MD, New York, NY

HYPOTHESIS: Closed reduction and percutaneous pinning is an effectivemethod for treating 2 and 3 part distal radius fractures with alow complication rate and long-term outcomes of the injuredwrist similar to the uninjured wrist.

METHODS:We retrospectively reviewed 45 patients with 46 AO type A2,A3, C1 or C2 distal radius fractures treated with closedreduction and percutaneous pinning. The average age of thepatients was 57.3 years. All patients were treated with, at aminimum, 2 pins obliquely from the radial styloid and 1 pinperpendicular to the styloid starting at the dorsal rim of thedistal radius just distal to Lister’s tubercle. The pins wereremoved between 5 and 6 weeks. We saw all patients backfor follow-up examination at an average of 52.7 months, witha minimum of 21 months. Measurements included activerange of motion, grip strength, pain assessment, DASH scores,and final radiographic assessment. The paired t-test was usedto determine significant differences (p value <0.05).

RESULTS/STATISTICS:Active range of motion and grip strength of the injured wristwere statistically equal to the uninjured wrist for each of theparameters (Table 1). Eighty-five percent of patients were painfree. DASH scores averaged 9. Six patients lost 5 degrees ofvolar tilt when comparing the immediate postoperativeradiograph to the final radiograph; 1 lost 10 degrees.Complications included 1 early loss of reduction requiringrepeat pinning, 1 superficial pin tract infection, and 1 transientsuperficial radial nerve neuropraxia.

Table 1: Functional Outcomes

Wrist Range of Motion (degrees)Injured Noninjured P value67.2 +/- 11.5 Flexion 73.2 +/- 11.3 .0864.3 +/- 11.3 Extension 65.7 +/- 10.9 .6182.0 +/- 8.4 Pronation 82.3 +/- 8.5 .8181.7 +/- 8.1 Supination 84.6 +/- 6.7 .1522.3 +/- 8.0 Radial deviation 23.7 +/- 8.6 .7634.2 +/- 7.9 Ulnar deviation 35.3 +/- 9.0 .30

Grip strength (pounds): Injured 58.7 +/- 22.6 Noninjured 55.8 +/- 26.1 (p=0.59)

Pain at rest: 38 none, 7 mild, 1 moderatePain with activity: 36 none, 8 mild, 2 moderate

DASH score: average 9.5 +/- 14.2

SUMMARY POINT:Patients treated with closed reduction and percutaneouspinning for distal radius fractures had no statistically significantdifferences in outcome measurements when comparing theinjured wrist with the uninjured wrist at long-term follow up.Complications were uncommon. Pinning is an efficacioustreatment option for 2 and 3 part distal radius fractures withexcellent long-term results.

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Postoperative Dysesthesias After Trans-arterial Axillary Block andUltrasound-Guided Infraclavicular Block for Upper Extremity Surgery

u Tiffany Tedore, MD, New York, NYAndrew Weiland, MD, New York, NYJacques YaDeau, MD, PhD, New York, NYDaniel Maalouf, MD, New York, NYSarani Tong-Ngork, MD, New York, NYMichael Gordon, MD, New York, NY

HYPOTHESIS: There is a significant reduction in the incidence of dysesthesiasfollowing the ultrasound-guided infraclavicular blockcompared with the trans-arterial axillary block.

METHODS:216 patients presenting for surgery of the elbow, forearm,wrist, or hand will be randomly assigned to receive either a trans-arterial axillary block or an ultrasound-guidedinfraclavicular block. The primary endpoint of the study is the incidence of postoperative dysesthesias in the two studygroups. Participants are contacted by a blinded member of theresearch team at 48 hours and 10 days after the procedure to assess for the presence of neurological dysfunction. Anypostoperative dysesthesias are further evaluated and followeduntil resolution. Significance will be calculated using Fisher’sexact test for nominal variables and the unpaired t test forcontinuous variables.

RESULTS/STATISTICS:This study is still ongoing. 169 patients have currently beenenrolled. Interim analysis reveals that the rate of dysesthesias is 20.6% in patients receiving an axillary block and 8.9% inpatients receiving an infraclavicular block (P=0.0817), with a trend towards statistical significance. This P value wascalculated using Fisher’s exact test.

SUMMARY POINTS:• The ultrasound-guided infraclavicular block is a relatively

new technique in the field of regional anesthesia. • The more established trans-arterial axillary block is

associated with a postoperative dysesthesia rate of up to 19%. There is no published data regarding the dysesthesia rate associated with the ultrasound-guided infraclavicular block.

• Interim analysis reveals less dysesthesias in patients receiving the ultrasound-guided block than in those receiving the axillary block.

REFERENCES:1. Horlocker TT, et al. The risk of persistent paresthesia is

not increased with repeated axillary block. Anesthesia and Analgesia. 1999;88(2):382-7

2. Urban, M.K. et al. Evaluation of brachial plexus anesthesia for upper extremity surgery. Regional Anesthesia and Pain Medicine. 1994;19(3):175-82

3. Ootaki, C. et al. Ultrasound-guided infraclavicular brachial plexus block: an alternative technique to anatomical landmark-guided approaches. Regional Anesthesia and Pain Medicine. 2000;25:600-04

4. Sandhu, N.S, Capan, L.M. Ultrasound-guided infraclavicularbrachial plexus block. British Journal of Anaesthesia. 2002;89:256-9

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Long Term Results Using STT-Arthrodesis for Treatment of Kienböck`s Disease

u Karlheinz Kalb, MD, Bad Neustadt, Saale, GermanyKarl-Josef Prommersberger, MD, Chefarzt, Bad Neustadt, Germany Jörg van Schoonhoven, MD, Chefarzt, Bad Neustadt, Germany Olivia Schmitt, MD, Bad Neustadt, Saale, Germany

HYPOTHESIS: Long-term results after STT-fusion for advanced Kienböck´sdisease will a) show osteoarthritis of the radiocarpal joint andb) therefore require total wrist fusion due to increasing pain inmany patients.

METHODS:Between 1992 and 1995 41 patients underwent STT-fusion for advanced Kienböck´s disease. All of them were rated asstage 3a or higher according to Lichtman and Ross. 23 (56%)patients were available for follow-up at a mean time of 132(108-162) months. Follow-up examination consisted of aradiological and clinical examination using the modified MAYOwrist score, and DASH-Score. Pain was graded with use of the visual analogue scale ranging from 0 (= no pain) to 100 (= maximum pain). Degenerative changes at the radiocarpal joint were graded according to Jupiter and Knirk. Statisticalanalyzes were performed to correlate radiological and clinical results.

RESULTS/STATISTICS:There were 3 nonunion. All of them healed after revisionsurgery. One patient required total wrist fusion and wasexcluded from follow-up. Arc of wrist extension – flexionaveraged 36°-0-30°, ulnar/radial deviation measured onaverage 22°-0-15° , and pro-/supination 77°-0-71°. Gripstrength averaged 78% of the contralateral hand. The meanpain level was 32. The modified Mayo-Wrist score showedgood results with an average of 71 points. Average DASH-score was 26. Radiologically degenerative changes of varyingdegrees were found in all patients. There was no correlationbetween the amount of degenerative changes and the painlevel. No patient needed further surgery at time of last follow-up.

SUMMARY POINT :Osteoarthritis of the radio-carpal joint is common in STT-fusionfor advanced Kienböck´s disease. There is no correlationbetween radiological results and the pain level. Conversion of STT-fusion to total wrist fusion is rarely required. ThereforeSTT-fusion remains our treatment of choice for advancedKienböck´s disease.

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A Biomechanical Study of Distal Interphalangeal Joint Subluxation Following Mallet Fracture Injury

u Sohail N. Husain, MD, Chicago, ILJeffrey Dietz, MD, Chicago, ILDavid Kalainov, MD, Chicago, ILEugene Lautenschlager, PhD, Chicago, IL

HYPOTHESIS: Volar subluxation of the distal interphalangeal (DIP) joint willoccur when a defined percentage of the distal phalanxarticular surface is injured.

METHODS: Thirty-six fresh frozen fingers were dissected to the metacarpalbase. The fingers were divided into 2 groups: non-arthritic DIP joints (31 fingers) and arthritic DIP joints (5 fingers).Obliquely oriented fractures through the dorsal lip of the distalphalanx were created with an osteotome. After securing to a jig, each finger was flexed and extended 1,200 times byapplying alternating tension to the flexor and extensortendons. Fluoroscopic images were obtained to measurefracture fragment size and DIP joint subluxation. The Pearsoncorrelation coefficient was calculated to assess the relationshipbetween fracture fragment size and magnitude of DIP jointsubluxation.

RESULTS:In the non-arthritic group, 15 DIP joints subluxated and 16 DIPjoints remained reduced. No DIP joint subluxated when thefracture fragment measured 43% or less of the joint surface,whereas all DIP joints with a defect greater than 52% of thejoint surface subluxated. For fingers with DIP subluxation,there was no significant correlation between the percentageof articular surface damage and the amount of jointsubluxation (R = 0.14). In the arthritic specimens, the fracturefragments averaged 56% of the articular surface and only 1 of 5 joints subluxated.

SUMMARY POINTS: • Volar subluxation of the DIP joint is unlikely with dorsal

lip fractures involving less than 43% of the distal phalanx joint surface.

• Volar subluxation of the DIP joint is expected with dorsal lipfractures involving more than 52% of the distal phalanx joint surface.

• Subluxation of the DIP joint with a similar-sized defect may be less likely to occur when the joint is arthritic.

REFERENCES:1. Wehbe MA, Schneider LH. Mallet fractures. J Bone Joint

Surg 1984;66A:658-669 2. Kalainov DM, Hoepfner PE, Hartigan BJ, Carroll C IV,

Genuario J. Nonsurgical treatment of closed mallet finger fractures. J Hand Surg 2005;30A:580-586

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Comparison of Intramedullary Nailing versus Plate-Screw Fixation of Metacarpal Fractures

u Kagan Ozer, MD, Denver, COAllison Williams, PhD, Denver,COSyed Gillani, MD, Denver, COSteven Peterson, DVM, MD, Denver, COSteven Morgan, MD, Denver, CO

HYPOTHESIS: Intramedullary nail (IMN) fixation of the metacarpal fracturesprovides better clinical outcomes than plate-screw (PS)fixation.

METHODS:Between 2004 and 2006, we have treated 52 consecutiveclosed displaced metacarpal fractures operatively using one of the two fixation methods percutaneous intramedullary nailfixation (n=38)(Hand Innovations, Inc; Miami, FL) and plate-screw fixation (n=14)(Synthes, Paoli, PA). Patientcharacteristics, mechanism of injury, pattern of fracture andpreoperative radiographic parameters were similar in bothgroups. The study was designed a priori using the followingoutcome measures: total active motion (TAM) of the digit,DASH score, and radiographic parameters. The data wereanalyzed using Mann-Whitney and chi-square tests.

RESULTS/STATISTICS:Mean follow-up time were 18 weeks in IMN group and 19weeks in PS group. The mean and median DASH scores forIMN group were 238.2 and 250 respectively. For the PS groupthe mean TAM was 228.2 and the median was 247.5. Thedifference between the groups was not statistically significant(z=-0.786, p=0.44). The mean and median TAM for IMNgroup were 238.2 and 250.0, respectively. For the PS groupthe mean TAM was 228.27 and the median TAM was 247.5.The difference between the groups was not statisticallysignificant (z = -0.766, p = 0.43). The association betweenhardware type and fracture location (proximal, middle, distalthird of metacarpal) was not statistically significant (p=0.772).Radiographic healing also did not reach a statisticalsignificance (p=0.9) between groups. However, 5 patients inIMN group (13%) displayed hardware failure (loss ofreduction, protrusion to the metacarpal head) with no failureobserved in PS group during the study period.

SUMMARY POINT:• There were no significant differences in the clinical

outcomes using either technique• Hardware failure rate was significantly higher in IMN group

14


The Wide Awake Approach to Dupuytren's Disease:Fasciectomy under Local Anaesthetic with Epinephrine and No Tourniquet

u Rebecca A. Nelson, MD, Halifax, Nova Scotia, CanadaDon Lalonde, MD, FRCSC, Saint John, New Brunswick, CanadaPhil Barnsley, MD, Halifax, Nova Scotia, CanadaMike Bell, Ottawa, Ontario, Canada

HYPOTHESIS: The Wide Awake Approach to Dupuytren's contractureinvolves fasciectomy under local anaesthetic with epinephrine,without the use of a tourniquet, performed in the clinic oroffice. It produces equivalent outcomes to fasciectomy undergeneral anaesthetic with a tourniquet, with fewer risks to thepatient.

METHODS:A multicentre retrospective review was conducted on 64 patients with Dupuytren’s fasciectomies under localanaesthesia or general anaesthetic with tourniquet between1998-2007. Data on patient demographics, comorbidites,cost, as well as pre- and post-operative total active motion(TAM) on was collected and evaluated using Microsoft Exceland SAS.

RESULTS/STATISTICS:A total of 86 fingers were treated, 67 under local and 19under general anaesthetic. The group included 12 females and 52 males. The average postoperative TAM for individualsundergoing general anaesthetic was 210o +/- 20 (D3), 224o+/- 31 (D4) and 195o +/- 20 (D5). The average postoperativeTAM for individuals with local anaesthetic and epinephrinewas 229o +/- 46 (D5), 218 +/- 31(D4), and 185o +/- 47(D3).There were no significant differences between any of thesegroups (p = 0.19, p=0.60 and p=0.90 respectively). Theaverage increase in TAM per digit 85o (D5), 54o (D4) and 55o (D3) for the local anaesthetic group. Complication ratesand types were similar with both techniques. There was asignificant cost savings associated with performing fasciectomyin the clinic or office compared with day surgery.

SUMMARY POINT:• The Wide Awake Approach to Dupuytren’s contracture

under local anaesthetic with epinephrine produces equivalent results to fasciectomies performed under a general anaesthetic.

• Fasciectomy under local anaesthetic has health benefits to patients and cost benefits to health care providers.

• These data support the use of local anaesthetic with epinephrine when performing Dupuytren's fascietomies.

REFERENCES:1. J Hand Surg 2005;30A:1061-72. PRS 115:802, 2005

15


A Biomechanical Comparison of Antibulking Techniques for Flexor Tendon Repairs

Mordechai Vigler, MD, New York, NYu Steve Lee, MD, New York, NYJoel Williams, BS, New York, NYMathew Cordova, MBS, New York, NYMartin Posner, MD, New York, NYMichael Hausman, MD, New York, NY

HYPOTHESIS: Zone II flexor tendon repairs may create a bulging effect withincreased bulk and resistance to tendon gliding. Abiomechanical study was performed to assess 2 methods oftendon antibulking for work of flexion and strengthcharacteristics

METHODS:24 fresh frozen rays of the porcine forelimb were placed in acustom jig. The deep flexor tendon was sectioned at the levelof the metatarsophalangeal joint, just distal to the intact A1and A2 pulleys. All repairs utilized a 4 strand modified Kesslercore suture and a running circumferential epitendinous suture.Tendons were divided into 3 groups, prior to repair: Group 1 - Non-modified tendon.Group 2 - A 45 degree bilateral notch was excised from bothtendon ends (Figure 1a).Group 3 - A triangular longitudinal central wedge was excisedfrom both tendon ends (Figure 1b).Work of flexion, 2mm gap formation and ultimate load tofailure were tested. Statistical analysis was performed usingthe Anova and student t-test.

RESULTS/STATISTICS:Both antibulking techniques (Groups 2 & 3) had significantlyless work of flexion than Group 1 (36J and 34J versus 142J, p< 0.001). There was no significant change in work of flexionbetween groups 2 & 3 (p > 0.05). (Figure 2). There was nosignificant difference in terms of 2mm gap formation betweenthe 3 groups (p > 0.05). Group 3 exhibited a significantlyhigher load to failure when compared to Group 2 (p < 0.05),but no significant change when compared to Group 1 (p>0.05).

SUMMARY POINTS:• Antibulking repair techniques may be employed to

decrease the work of flexion without adversely affecting the strength of the repair.

• Such repairs may be beneficial in certain zone II injury patterns where tight tolerances of the annular pulley system restrict tendon gliding.

REFERENCES:1. Elliot D, Khandwala AR, Ragoowansi R. The flexor

digitorum profundus :demi-tendon" - a new technique for passage of the flexor profundus tendon through the A4 pulley. Journal of Hand Surgery (Br) 2001;26B:422-426

2. Smith AM, Forder JA, Annapureddy SR, Reddy KSK, Amis AA. The porcine forelimb as a model for human flexor tendon surgery. Journal of Hand Surgery (British) 2005; 30B:307-309

3. Lane JM, Black J, Bora FW Jr. Gliding function following flexor-tendon injury. A biomechanical study of rat tendon function. Journal Bone and Joint Surgery (Am) 1976; 58:985-990

16


Biomechanical Characteristics of Suture Repair Methodsof the Flexor Digitorum Superficialis Tendon in Zone II

David M. Edelstein, MD, New York, NYByung Heum Kim, MD, New York, NYJoshua Landa, MD, New York, NYJoel C. Williams, BS, New York, NYMatthew A. Cordova, MBS, New York, NYu Steve K. Lee, MD, New York, NY

HYPOTHESIS: Distal to the bifurcation of the FDS in zone II, the newly-designed FDS corset stitch will show less of an increase inwork of flexion, will sustain higher loads at 1 and 2 mm gapversus the Figure eight and the Modified Becker suturetechniques. The new stitch will be faster to perform than theModified Becker.

METHODS:In eight fresh frozen hands (twenty-four fingers), the FDStendons distal to the bifurcation in zone II were transectedand repaired with 5-0 Prolene using either a Figure eight,Modified Becker or the new corset stitch. Pre and post repairwork of flexion was tested. The tendons were loaded tofailure and to forces of 1 and 2 mm gap. Time to completionfor the above listed suture techniques was measured. ANOVAtesting was performed to compare differences between thegroups.

RESULTS/STATISTICS:For 1 and 2 mm gap measurements, the new corset stitch

was significantly stronger (16.6 N, 14.6 N) than the Figure 8(6.4 N, 4.6 N) and the Modified Becker (5.0 N, 7.8 N)(p<0.05).The FDS corset stitch was significantly faster (7m 40s) toperform than the Modified Becker (11m 7s) (p <0.05). Nodifference in work of flexion was noted between the 3 suturerepair groups.

SUMMARY POINTS:• The new corset stitch is significantly stronger than the

other suture techniques with regard to force to 1 and 2 mm gap.

• The new corset stitch is significantly faster to perform thanthe Modified Becker.

• No difference in work of flexion was noted between the three groups.

Figure 1: Force to 1 and 2 mm gap

REFERENCES:1. Miller L, Mass DP. A Comparison of Four Repair Techniques

for Champer's Chiasma Flexor Digitorium Superficialis Lacerations: Tested in an In Vitro Model. J Hand Surg 2000;25A: 1122-1126

2. Boulas HJ, Strickland JW. Strength and Functional RecoveryFollowing Repair of Flexor Digitorum Superficialis in Zone II.J Hand Surg 1992; 18B :22-25

3. Tang JB. Flexor Tendon Repair in Zone 2C. J Hand Surg 1993; 19B: 72-75

17


Botox Therapy for Ischemia Digits

u Michael W. Neumeister, MD, Springfield, ILChristopher Chambers, PhD, Springfield, IL

HYPOTHESIS: Raynaud’s phenomenon (RP) is an episodic digital asphyxiacaused by arterial insufficiency whose etiology remains poorlyunderstood. Clinically, treatment for RP is difficult and oftenrequires invasive surgical procedures that are not fullysuccessful in resolving the morbidity associated with thecondition. Recently, Botox® has been used as a therapy forpatients with RP. We reviewed our experience with Botoxinpatients with ischemic fingers.

METHODS:A retrospective review of patients treated with Botox forintractable pain and ischemia of the digits was performed.Monitoring re-establishment of peripheral blood flow usinglaser Doppler (LD) imaging was performed. Before and 5minute after perfusion LD images were obtained andquantitated the results. In vitro tissue bath experiments wereperformed to establish a dose-response curve.

RESULTS/STATISTICS:14 patients had been injected between Jan 2004 and Jan2007 for complaints of pain and ulceration due to ischemia.All patients responded well to the therapy, showing 70-+300% increases in perfusion (post- Botox® injection/pre-Botox® injection). Additionally, patients reported improvementsin range of motion and marked decrease of pain following theinjections.

SUMMARY POINT:We are continuing to follow these patients for relief from painand ulceration. We are currently exploring the mechanisms bywhich Botox® affects the peripheral vasculature through invitro tissue bath experiments. While our and other’s experiencewith Botox® for the treatment of RP has shown some earlysuccess, clearly continued investigation of its clinical usefulnessis warranted, as are studies designed to elucidate the properdosing for patients with RP.

18


MRI of Acute Pediatric Wrist Injury: A Prospective StudyCorrelating Imaging Findings with Clinical Outcome

u Mohamed Khalid, FRCS (Trauma & Orth), Birmingham, United KingdomDominic Power, MA, FRCS (Trauma & Orth), Birmingham, United KingdomZia Jummani, MBBS, Abergavenny, United KingdomDavid Robinson, FRCR, Abergavenny, United Kingdom

HYPOTHESIS: MRI predicts outcome in clinically suspicious butroentgenographically occult wrist injury in the paediatric population.

METHODS:This prospective observational study was designed to establishthe role of wrist MRI in predicting outcome after paediatricwrist injury with negative radiographic assessment. All childrenpresenting to the Emergency room between July 2002 andJune 2005 were examined by an experienced clinician andplain radiographs including full 4 view scaphoid series wereobtained. All patients with negative radiographic assessmentbut suspicious clinical evaluation were referred for wrist MRI.Scanning was carried out using a 1.5 Tesla Siemens scannerwith a dedicated wrist coil. T1 weighted and STIR images wereobtained. All patients were followed up for a minimum of 6 months.

RESULTS/STATISTICS:3,421 cases were assessed using the protocol. 171 childrenmet the criteria for inclusion and 178 MRI scans wereperformed (4 bilateral injuries; 1 protocol violation notstudied). Average age was 13 years (range 7-16). There were86 females and 84 males. Left and right wrists were injured in 95 and 75 cases respectively. MRI findings are shown in thetable 1.

Table 1. Distribution of results following MRI Scaphoid fractures 12(6.7%)Scaphoid bruising 42(23.6%)Distal radius fractures 06(3.37%)Distal radius / ulnar bruising 28(15.7%)Other carpal fractures 02(1.1%)Other carpal bruising ( Capitate 7, trapezium 3, triquetrum 1) 11(6.1%)Normal 77(43.2%)Movement artefact 13(7.3%)Claustrophobia 01(0.56%)The distribution of scaphoid bruising is shown in the table 2.

Table 2. Location of bruisingDistal pole 29/42Waist 06/42Proximal pole 03/42Entire bone 04/42

Three of the scaphoid waist bruises (50%) and 1 with entirebone involvement progressed to fractures. Bruises in otherlocations did not fracture.

At a minimum 6 month follow up all subjects who had anormal MRI were asymptomatic. During the same study period40% of adults who had a normal MRI for occult wrist injurieswere still sympromatic.

SUMMARY POINT:Carpal bruising is common in the paediatric population.Scaphoid waist bruising may lead onto subsequentradiographic fracture. MRI is a valuable tool in assessing the injured wrist. Movement artefact, although present in7.3% was severe only in 2 cases. MRI does not require special positioning of the painful wrist and hence accepatbility was high.

19

Paper 01Friday, September 28, 2007, 8:45-8:52 AM

Clinical Outcomes of Capitolunate Versus Four-Corner Arthrodesis

u R. Glenn Gaston, MD, Indianapolis, INJeff Greenberg, MD, Indianapolis, INRobert Baltera, MD, Indianapolis,INAlex Mih, MD, Indianapolis, INHill Hastings, MD, Indianapolis, IN

HYPOTHESIS: There is no difference in the clinical outcomes of isolatedcapito-lunate versus four-corner (capitate, hamate, lunate,triquetrum) intercarpal arthrodeses.

METHODS:We retrospectively identified 50 patients having been treatedwith either isolated capitolunate fusion (27 patients, Group 1)or four-corner fusion (23 patients, Group 2) in our practice.Patient demographics were similar between the two groups.Follow up evaluation included wrist range of motion (flexion-extension, radial-ulnar deviation, and pronation-supination),grip strength, visual analogue scale, DASH, and radiographs.Parametric data was analyzed using a Student t-test andpower analysis with Biostat software.

RESULTS/STATISTICS:Thirty patients have completed follow up to date (16 Group 1,14 Group 2). Mean time to follow up was 29 months forGroup 1 and 45 months for Group 2. There were no statisticaldifferences in wrist range of motion in any plane, gripstrength, visual analogue scale, or DASH between the twogroups. The study is sufficiently powered to demonstrate adifference in DASH of 10 (considered minimal importantchange), VAS of 1, loss of 10 degrees of motion in any plane,and a difference in grip strength of 5 pounds when setting áat 0.05, B at 0.8, M at 1. Table 1 illustrates the meanoutcomes for each group. Four patients were revised to totalwrist arthrodesis (2 in Group 1, 2 in Group 2). There was onenonunion that required revision in Group 1.

Table 1Group Grip Flex-Ext Rad-Uln Pro-Sup VAS DASH1 69.1 51.0 61.2 98.7 1.76 18.52 68.8 56.6 67.9 94.3 1.09 18.5

*Grip, flexion-extension, radial-ulnar deviation, and pronation-supination are listed as percentages as compared with thecontralateral wrist.

SUMMARY POINT:We found no statistically significant difference in the clinicaloutcomes following isolated capito-lunate and four cornerwrist arthrodesis.

20


Four Corner Arthrodesis Using a Circular Plate and Distal Radius Bone Grafting: A Consecutive Case Series

u Gregory Merrell, MD, Providence, RIErin McDermott, BA, Providence, RIArnold-Peter Weiss, MD, Providence, RI

HYPOTHESIS: Four corner fusion via plate fixation with autogenous bonegrafting can be a predictable method for addressing SLAC /SNAC wrists and prevents further arthrosis.

METHODS:A retrospective clinical and radiographic assessment wasperformed in a consecutive cohort of 28 patients whounderwent a standardized four corner arthrodesis with a 2ndgeneration circular plate and distal radius bone grafting for adiagnosis of SLAC or SNAC wrist. Follow-up examination of allpatients included VAS pain scores, VAS activity ratings, workstatus, PA/lat radiographs, grip strength, range of motion, andcomplications/re-operations was obtained on each patient bydirect re-evaluation (no chart or phone reviews).

RESULTS/STATISTICS:Average follow-up was 2.7 years. Radiographs demonstratedunion in all (100%) of cases, no screw breakage, carpalcollapse, or unexplained severe pain. In addition, no evidenceof secondary arthritic changes at the radiolunate joint were noted, with maintenance of joint height. One casedemonstrated evidence of screw back-out (one screw). Onepatient underwent re-operation for radial styloid impingementpain (Rx=radial styloidectomy). Range of motion averaged56% of the uninjured side (avg. extension=450; aveflexion=320). Grip strength averaged 77% of the uninjuredside. The mean VAS pain and activity scores were 1.8/10 and2.6/10. Only one patient had to change jobs secondary towrist impairment.

SUMMARY POINTS:Despite recent reports indicating a high non-union rate withplate fixation, standardized 4 corner arthrodesis using arecessed, dorsal circular plate and distal radius bone graftingproduced excellent and reproducible results in this consecutiveseries with direct follow-up examination. Importantly, thedevelopment of secondary arthritic changes at the radiolunatejoint were not noted indicating a reasonable durability to theprocedure. This study indicates that exacting technique withquality bone graft is required to obtain optimal results.

REFERENCES:1. Vance et al JHS 20052. Kendall et al JHS 20053. Shindle et al JHS European 2007

21


Osteotomy of the 1st Metacarpal with Trapezioplasty

u Jorge L. Orbay, MD, Miami, FLAlexis Jimenez, MD, Miami, FLJose Nunez, MD, Miami, FLIgor Indriago, MD, Miami, FL

HYPOTHESIS: Motion preserving reconstructive procedures for osteoarthritisof the trapezio-metacarpal joint commonly involve excision ofthe trapezium and can result in a weak pinch. Simpleosteotomy of the 1st MC avoids trapezial excision, but doesnot correct joint subluxation and has been shown to provideunpredictable results.

METHODS:We performed a retrospective review of all the cases treatedbetween March 1st 1998 and December 31st 2002 withosteotomy of the 1st MC and trapezioplasty. Indication for theprocedure was severe pain due to trapezio-metacarpal arthritisthat did not respond to conservative treatment. Through aWagner approach, an always present palmar trapezialosteophyte was removed and the trapezium was shaped topermit joint reduction (trapezioplasty). A 1st MC dorsal closingwedge osteotomy corrected the underlying instability and wasfixed with a small condilar plate. The trapezio-metacarpal jointwas reduced and pinned for four weeks. Thumb function wasallowed after pin removal and no further support wasprovided. br>

RESULTS/STATISTICS:Of out of 45 patients who underwent the procedure in thisinterval, 34 or (76%) were followed for a minimum of 48months, average 53 (range: 48-73 months). At their finalfollow-up all patients were satisfied with their degree of painrelief; 24 patients reported no pain and 10 mild pain. Rangeof motion was adequate as all patients could reach the flexioncrease at the base of the small finger, adduct their thumb tothe 2nd metacarpal, flatten their hand and oppose theirthumb to the pulp of their extended index finger. Pinchstrength averaged 12.6 lbs or 88% of the non-operated site.

SUMMARY POINT:Osteotomy of the 1st MC with Trapezioplasty providessatisfactory pain relief, useful motion at the 1st CMC joint anda strong pinch while preserving the trapezium.It is a technicallyinvolved procedure that requires attention to surgical detail.

22


Distal Interphalangeal Joint Fusion: A Morphometric and Biomechanical Analysis

u Nathan L. Van Zeeland, MD, Nashville, TN

HYPOTHESIS: 1. Differences exist in height and width of the male and

female distal phalanx 2. Incidence of trailing screw thread penetrance and distal

phalanx fracture varies for three headless compression screws

3. There are significant differences in biomechanical performance of headless compression screw disal interphalangeal joint (DIP) fusion constructs

METHODS:1. Bilateral index, long and ring fingers of six male and six

female formalin-fixed cadavers were dissected. Height and width of the distal phalanx (72 fingers) were measured 5mm proximal to the distal tuft using digital calipers.

2. Three randomly assigned groups of 24 fingers had a Miniacutrak, Herbert or Mini-Kompressor screw placed. Trailing screw thread penetrance and distal phalanx fracture were recorded.

3. Half of specimens underwent AP bending while the remaining half were tested in axial torsion, using ramped, cyclic loads. Cycles to 0.5, 1.0 and 1.5mm of displacementin AP bending were recorded. Cycles to achieve 5, 10 and 15 degrees of angular displacement were recorded in torsional testing. Student t-test and Kruskal-Wallis test was applied.

RESULTS/STATISTICS:1. Average male distal phalanx height was 4.22mm,

compared to 3.54mm (p<0.05) in females .2. Incidence of penetrance/distal phalanx fracture was

19/24(79%), 15/24(62%) and 13/24(54%) for Mini-Kompressor, Herbert and Miniacutrak screws, respectively.

3. Herbert had significantly (p<0.05) more cycles to displacement in AP bending and axial torsion compared to Miniacutrak and KMI Mini-Kompressor. Miniacutrak screw had significantly (p<0.05) more cycles to displacement in AP bending and axial torsion compared to KMI Mini-Kompressor screw

SUMMARY POINTS:• Female distal phalanx significantly smaller than male.• Female distal phalanx height averages less than most

commercially available headless compression screws• KMI Mini-Kompressor screw has highest incidence of screw

thread penetrance than Miniacutrak or Herbert screw.• Herbert screw performed better biomechanically than

Miniacutrak and Mini-Kompressor screw• Miniacutrak screw performed better biomechanically than

Mini-Kompressor screw

REFERENCES:1. Distal interphalangeal joint arthrodesis comparing tension-

band wire and herbert screw: a biomechanical and dimensional analysis. Wyrsch et al. J Hand Surg 1996;21A:438-443)

2. A comparison of fixation screws for the scaphoid during application of cyclical bending loads. Toby EB et al. JBJS. 1997; 79A:1190-1197

3. A biomechanical analysis of intrascaphoid compression using the herbert scaphoid screw system. Lo et al. J Hand Surg Br. 1998; 23B 209-213

23


Relationship between Postoperative Clinical and Radiographic Resultsof Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

u Norimasa Iwasaki, MD, Sapporo, JapanJyunichi Ishikawa, MD, Sapporo, JapanNaoki Suenaga, MD, Sapporo, JapanTatsuya Masuko, MD, Sapporo, JapanMichio Minami, MD, Sapporo, JapanAkio Minami, MD, Sapporo, Japan

HYPOTHESIS: After performing ulnar shortening osteotomy (USO) to treatulnar impaction syndrome, there is no significant relationshipbetween the occurrence of degenerative changes at the distalradioulnar joint (DRUJ) and the clinical outcomes.

METHODS:Fifty-three wrists in 51 patients with ulnar impaction syndromewere treated with USO. There were 28 males and 23 females,ranging in age from 14 to 67 years (mean, 37.5). All patientspresented with ulnar wrist pain, positive ulnar variance, and allhad experienced failed conservative treatment. The length ofthe shortening equaled the amount of positive ulnar variancemeasured on the preoperative radiograph. Clinical assessmentwas based on the Mayo wrist score system. The existence ofdegenerative changes of the DRUJ was determined byradiographic findings, including osteophytes on the inferioredge of the DRUJ, joint space narrowing, and subchondralsclerosis. Statistical comparisons were performed using pairedor unpaired t-tests.

RESULTS/STATISTICS: At a mean follow-up of 26 months, the wrist scoressignificantly improved from 52.1 to 84.5 points, with 18(34%) wrists rated excellent; 17 (32%), good; 11 (22%), fair;and seven (12%), poor. In 13 (34%) wrists, there were somepostoperative degenerative changes at the DRUJ. Anosteophyte on the inferior edge of this joint was found in 12(23%) wrists. Joint space narrowing and subchondral sclerosiswas observed in eight (15%) wrists and one (2%) wrist,respectively No significant differences in the clinical scoreswere found between the patients without and those withpostoperative degenerative changes of the DRUJ (85.2 vs.81.1).

SUMMARY POINTS:• Ulnar shortening osteotomy is an effective procedure for

the treatment of ulnar impaction syndrome. • Although postoperative osteoarthritic changes of the DRUJ

were found in 34% of treated wrists, there was no significant relationship between such radiological changes and clinical results.

24


Aging Transplants of Osteogenic Stem Cells Show aSignificant Expansion of the Hematopoietic Compartment

l Mahesh H. Mankani, MD, San Francisco, CAKent Yamaguchi, MD, San Francisco, CA

HYPOTHESIS: Osteogenic populations of human bone marrow stromal cells(BMSCs), when combined with a hydroxy-apatite tricalciumphosphate (HA/TCP) matrix, form substantial cortical bone anda nascent marrow cavity in immunocompromised recipientmice within 8 weeks. We hypothesized that these boneconstructs undergo increases in bone, resorption of theHA/TCP particles, and increases in bone marrow beyond 8weeks.

METHODS:Human BMSCs, in conjunction with HA/TCP particles, wereplaced into the dorsal subcutaneous space of immunodeficientmice. Transplants were harvested from 7 to 104 weeks.Histologic sections from transplants harvested before 9 weeks(early) or after 60 weeks (late), underwent histomorphometry.The fraction of bone, of HA/TCP particle, of fibro-vasculartissue, and of hematopoietic tissue (marrow) were identified ineach transplant. Results were compared using an unpaired ttest.

RESULTS/STATISTICS:Twelve transplants were evaluated, including 4 early and 8late. Transplants were equivalent in human donor identity,BMSC passage number, and number of BMSCs. Earlytransplants were harvested from 7 to 9 weeks (mean 8) whilelate transplants were harvested from 60 to 104 weeks (mean76). With aging, transplant bone fraction remainedunchanged, particle fraction decreased slightly, fibrous tissuefraction decreased very significantly, and hematopoieticfraction increased very significantly (Figure 1). Bonemorphology evolved substantially; bone progressed from thickand multi-lamellar to thin and attenuated, becoming lessprominent in the transplant interior while forming a corticalshell at the periphery (Figure 2).

Figure 1: Histomorphometry

Figure 2: Early (2A+2B, 7 weeks) and late (2C+2D, 83 weeks)timepoints (b bone, h hematopoiesis, f fibrousvascular tissue,p particle, s skin, m muscle)

SUMMARY POINT:The construct formed in vivo by transplanted humanosteoprogenitor cells undergoes significant remodeling evenafter bone formation has occurred. From a tissue engineeringperspective, long-term in vivo studies are necessary toestablish final bone morphology and bone mechanicalproperties before clinical trials are initiated.

l Received support from the University of California REACand the Veteran's Administration REAP

25


Prolongation of Rodent Hind Limb Allografts with Topical TacrolimusAlone After Total Withdrawal of Systemic Immunosuppression

l Mario G. Solari, MD, Pittsburgh, PAKia M. McLean, MD, Pittsburgh, PAJustin M. Sacks, MD, Pittsburgh, PATheresa Hautz, MD, Pittsburgh, PAJignesh Unadkat, MD, Pittsburgh, PAW.P. Andrew Lee, MD, Pittsburgh, PA

HYPOTHESIS: Skin is the most immunogenic component of a compositetissue allograft (CTA). Clinically this has manifested as multipleacute skin rejection episodes in most of the human CTArecipients. Intravenous steroid pulses and increased systemicimmunosuppression have been used to mitigate theserejection episodes. Topical immunotherapy is a practicaltherapeutic option to provide local immunosuppression withminimal systemic toxicity. The present study was performed toinvestigate the potential of topical tacrolimus to maintain aCTA after total withdrawal of systemic therapy.

METHODS: Wistar Furth to Lewis (full MHC mismatch) orthotopic hindlimb transplants were performed. Groups included: I- topicaltacrolimus alone, II- anti-lymphocyte serum (ALS, 0.5mL) (2doses) + 21 days cyclosporine (CsA 10/mg/kg/day), III- ALS (2doses) + 21 days CsA + topical tacrolimus once daily. Biopsiesof skin, muscle, and bone were taken forimmunohistochemistry and H&E.

RESULTS/STATISTICS: All animals in Group I (n=7) developed grade 3 clinicalrejection by POD 9, similar to historical controls withouttreatment. In Group II, the mean onset of grade 3 rejectionwas POD 40(n=7). In Group III (n=5), two animals developedgrade 3 rejection on POD 35 and 56. One animal is on-goingand rejection free at POD 38. The remaining 3 experimentalanimals reached the 100 day endpoint without grade 3rejection. The survival in Group III is statistically significant(p=.01) when compared to Group II by the log-rank test of theKaplan-Meier survival curves.

SUMMARY POINT: This study demonstrates the feasibility of maintaining a CTAon topical tacrolimus therapy alone after withdrawal ofsystemic immunosuppression. Preoperative depletion of T cells with ALS, along with a short course of systemicimmunosuppression, prevents acute rejection, while topicaltacrolimus inhibits immune cell function in the skin. This novelregimen could reduce or eliminate the morbidity associatedwith systemic immunosuppression in clinical CTA.

REFERENCES:1. Fujita T, Takahashi S, Yagihashi A, Jimbow K, Sato N.

Prolonged survival of rat skin allograft by treatment with FK506 ointment. Transplantation. 1997 Sep 27;64(6):922-5

2. Berger TG, Duvic M, Van Voorhees AS, VanBeek MJ, Frieden IJ; American Academy of Dermatology Association Task Force. The use of topical calcineurin inhibitors in dermatology: safety concerns. Report of the American Academy of Dermatology Association Task Force. J Am Acad Dermatol. 2006 May;54(5):818-23

l Received support from the Plastic Surgery EducationalFoundation

26


Involvement of Notch Signaling in Osteoinduction of Adipose-Derived Stem Cells

u Michael W. Neumeister, MD, Springfield, ILDamon Cooney, MD, Springfield, ILChristopher Chambers, PhD, Springfield, IL

HYPOTHESIS: Tissue engineering holds great promise forreconstructive/regenerative medicine. Adipose derived stemcells (ADSC) have been touted as an easily obtainablepopulation to use in such projects; however, little is knownregarding the molecular mechanisms that regulate ADSCphysiology. The hypothesis of this study investigated howinhibition of endogenous Notch signals impacted ADSCproliferation and osteogenic differentiation.

METHODS:ADSC isolated from the inguinal fat pads of male Lewis ratswere plated at 2 different densities (1,300 cells/cm2 or 5,200cells/cm2) and treated with either vehicle or a Notch inhibitor(DAPT), which prevents a critical proteolytic step during Notchactivation. For the proliferation studies, cells were grown for 5days in growth media containing either 0.1% DMSO (vehicle)or 1microM DAPT (Sigma). Proliferation was assessed by theMTT assay; cell numbers were extrapolated from a MTTstandard curve. For the differentiation experiments, ADSCswere grown for 3 days in osteoinduction media only then onthe 4th day, either DMSO (0.1%) or DAPT (1microM) wasadded. Cells were incubated for an additional 4 days; matrixdeposition was assessed by Alizarin Red (AR) staining andquantitation.

RESULTS/STATISTICS:DAPT treatment of rat ADSC resulted in a significant reductionin cell proliferation at both low and high cell plating densities.This effect was confirmed by manual cell counts as well. DAPTtreatment of osteoinduced ADSC resulted in a significantreduction in extracellular matrix deposition in ADSC plated atlow density. This effect was not seen at the higher cell densityplating. However, similar amounts of AR staining were foundin low density DAPT treated ADSC, high density DMSO- andDAPT-treated ADSCs.

SUMMARY POINT:Endogenous Notch signals on ADSC physiology are important,both at the level of proliferation and differentiation. Notchinhibition effectively reduced ADSC proliferation andnegatively regulated extracellular matrix production byosteoinduced ADSC

27


Outcome after Bilateral Hand and Forearm Transplantationwith Particular Regard to Acute and Chronic Rejection

u Stefan Schneeberger, MD, Pittsburgh, PAJignesh Unadkat, MD, Pittsburgh, PAMichael Rieger, MD, Innsbruck, AustriaBettina Zelger, MD, Innsbruck, AustriaW.P. Andrew Lee, MD, Pittsburgh, PARaimund Margreiter, MD, Innsbruck, Austria

HYPOTHESIS: Although hand transplantation has become a clinical reality,repetitive acute rejection as well as chronic rejection, whichrepresents the major cause of graft lost after organtransplantation, remain unsolved threats. We here report on clinical courses and experimental features of acute andchronic rejection in limb transplantation.

METHODS: Between March 2000 and May 2006, three patientsunderwent bilateral hand or forearm transplantation inInnsbruck. After induction therapy with ATG (n = 2) orAlemtuzumab (n = 1), tacrolimus, prednisolon ± MMF weregiven for maintenance immunosuppression. Later, tacrolimus(n=1) or MMF (n=1) was replaced by sirolimus/everolimus.

RESULTS/STATISTICS: Three, six and two rejection episodes where successfullytreated with steroids, anti-CD25 or Alemtuzumab.Subsequently, skin histology remained normal without signs of rejection. Maculopapulous erythematous lesions on the skinas the visual appearance of rejection correlated well withhistomorphological findings. Immunohistochemistry identified

the majority of infiltrating cells as CD3+, CD4+ and CD8+ T-lymphocytes. Less than 5% are CD20 and CD79a positive B-lymphocytes. Upon progression, CD68+ macrophagescomprise a large proportion of the infiltrate. The infiltrate first appears in the perivascular space of the dermis. Uponprogression, it spreads to the interphase between dermis andepidermis and then towards the outermost layers of the skin.Finally, necrosis of keratinocytes and then necrosis and loss of the epidermis can be observed. Although myointimalproliferation in graft arteries was identified as the key featureof CR in an experimental setting of rat limb transplantation,investigation of hand vessels by histology, angiography andCT-angiography in humans revealed no signs of luminalocclusion.

SUMMARY POINT: Despite complicated postoperative courses, patients are nowfree of rejection. The histologic features of CR have beenidentified in an experimental limb transplant model andalthough CR was not observed in the three patients describedhere it remains a potential threat to long-term graft survival.

28


Novel Strategy for Tolerance Induction in a Preclinical Modelof Composite Tissue Allotransplantation in Mini Swine

u Jignesh Unadkat, MBBS, MRCS, Pittsburgh, PAMario Solari, MD, Pittsburgh, PAJustin Sacks, MD, Pittsburgh, PAStefan Schneeberger, MD, Pittsburgh, PAKodi Azari, MD, Pittsburgh, PAW.P.Andrew Lee, MD, Pittsburgh, PA

HYPOTHESIS: A novel protocol using induction therapy, bone marrowtransplant (BMT) and short-term immunosuppression willprolong composite tissue allograft (CTA) survival thuseliminating the need for chronic immunosuppression.

METHODS:MHC mismatched Yucatan mini swine were used as apreclinical models. Heterotopic hind limb allotransplants wereperformed from male donor to female recipients. Group1:Control (no immunosuppression). Group 2: CTA with dailyFK506 (0.1mg/kg IM) for 1 month. Group 3: CTA withradiation, BMT (10-15 x 106 cells/kg IV) and daily FK506 for 1month followed by gradual weaning over 3 months. Group 4:CTA with radiation, BMT and daily FK506 for a month. Endpoint taken as skin and muscle rejection or survival to >150days. Tissue biopsies taken on day 15, 30, 50, 100 & 150.Donor chimerism assessed by real time PCR for the Ychromosome. Donor alloreactivity assessed using MLR usingperipheral blood mononuclear cells.

RESULTS/STATISTICS:Radiation achieved significant cellular depletion as shown inthe figure. Early results demonstrate allograft survival to 5 daysin group 1, 34 days in group 3 and 87 (+/-37) days in thegroup 4. Group 2 animal died on day 24 due to sepsis. H&Estain of skin, muscle and bone revealed decreasedmononuclear cells 1 month post transplant in group 4compared to other groups. There was 24% chimerism ingroup 4 as against 9% in group 3 in the first one month. MLRrevealed donor specific hyporesponsiveness at 6 weeks posttransplant in the experimental group.

SUMMARY POINTS:• Induction therapy to deplete the mononuclear cells, donor

BMT along with short term FK506 prolongs CTA survival across a strong MHC barrier.

• Sustained chimerism may be the mechanism for this prolongation.

• This protocol represents a clinically applicable strategy to reconstruct complex hand defects using CTA while minimizing complications due to chronic immunosuppression.

29


Use of Nerve Conduits as an Adjunct to Brachial Plexus Micro-Neurorraphy

u Scott W. Wolfe, MD, New York, NYRichard Cheng, BS, New York, NYHelene Strauss, BA, New York, NYJoseph Feinberg, MD, New York, NY

HYPOTHESIS: The use of nerve conduits in level I human trials showimprovement in sensory recovery when compared with directrepair. While primate studies on major mixed motor-sensorynerves have also documented significant improvements overdirect repair with nerve conduits, no human clinical dataanalyzing motor recovery following nerve conduit repair hasbeen reported. We hypothesize that the recovery of nervesrepaired with conduits surpasses that of nerves repaired withend-to-end neurorraphy.

METHODS: Over a three year study period, 17 patients had one ormultiple nerve-to-nerve transfers for adult traumatic brachialplexus palsy using the operative microscope. 7 transfers wereperformed by advancing the nerve ends into a semi-permeableType I cross-linked collagen conduit stabilized with 8-0 nylonsutures. 24 nerve transfers were performed utilizing standardend-to-end neurorraphy and 8-0 or 9-0 nylon sutures. No repairs involved interposition grafts. Postoperativerehabilitation and follow-up were identical between groups.Clinical evaluation using the Medical Research Council gradingscheme of muscle function was documented at one and two years postoperatively. Postoperative EMG was alsodocumented. Two-tailed unpaired t-tests were completed.

RESULTS/STATISTICS: 31 and 21 transfers were available for one- and two-yearfollow-up testing, respectively. For all three evaluation criteria,no statistically significant differences existed between thegroups. Notably, seven of seven transfers performed withnerve conduits demonstrated clinical and electromyographicreinnervation at one year and all 6 muscles with two yearfollow-up data demonstrated M3 or M4 clinical function.

SUMMARY POINTS:• Functional muscle recovery is equivalent for nerve transfers

performed with collagen nerve conduits and by traditional micro-neurroraphy.

• Successful conduit usage for motor neuron repair in humans as documented here and previous studies of conduit usage in animals and sensory neurons warrant continued investigation into conduit repair efficacy and potential improvements in operative time, precision of repair, and speed of nerve recovery.

30


Reappraisal of Traditional Medical Research Council Muscle Testing for the Flexor Pollicis Longus

u Michael C. MacAvoy, MD, South San Francisco, CA

HYPOTHESIS: The muscles controlling hand movement, in particular theflexor pollicis longus, are so powerful compared to the weightof the parts being moved, that the 0-5 Medical ResearchCouncil (MRC) scale is rendered meaningless as an outcomeassessment tool in the hand.

METHODS:29 normal thumbs in 15 healthy subjects (5 men, 10 women,mean age 39) were studied to determine key pinch strength,weight, volume, center of gravity, and length, distal to thecenter of IP joint rotation. Simple calculations were made todetermine the gravity torque necessary to move the distalphalanx of the thumb against gravity (grade 3/5 strength), and this was compared to peak voluntary key pinch strength(grade 5/5).

RESULTS/STATISTICS: Mean gravity torque with standard deviation is shown in Table1, and compared to mean peak voluntary flexor pollicuslongus torque, with standard deviation. The mean ratio ofgravity torque to peak flexor torque was 0.000305.

Table 1Gravity Torque Peak TorqueNm Nm

Mean 0.000778 2.553SD 0.000275 0.906

SUMMARY POINTS:• Regarding flexor pollicis longus strength, the grade “4/5”

is synonymous with the phrase “at least 0.03% strength but less than full strength” rendering the MRC scale nearlymeaningless.

• Grade 3/5 strength may be much weaker than is generally assumed

• Of the six grades, the single grade 4/5 strength encompasses 99.97% of the spectrum when describing flexor pollicis longus moving the IP joint of the thumb.

• Hand held dynamometry or another method for accuratelymeasuring force should be used when reporting results of motor nerve surgery rather than the MRC scale.

REFERENCES:1. MacAvoy MC, Green DP. Critical Reappraisal of Medical

Research Council Muscle Testing for Elbow Flexion. J Hand Surg (Am) 2007; 32A: 149-153

2. James MA. Use of the Medical Research Council Muscle Strength Grading System in the Upper extremity. J Hand Surg (Am) 2007; 32A: 154-156

3. O'Brien MD. Aids to the Examination of the peripheral nervous system. Philadephia: Elsevier Saunders, 2000: 1-2

4. Medical Research Council. Aids to the investigation of peripheral nerve injuries. War Memorandum No. 7. 2nd ed. 1943: 1-2

31


The Radial Nerve in the Brachium

u Douglas E. Carlan, MD, St. Petersburg, FLJeffrey A. Pratt, MD, Modesto, CAAndrew J. Weiland, MD, New York, NYMartin I. Boyer, MD, St. Louis, MORichard H. Gelberman, MD, St. Louis, MO

PURPOSE: To explore the course of the radial nerve in the brachium andidentify practical anatomical landmarks that can be used toavoid nerve injury during humerus fracture fixation.

METHODS: Data were collected from twenty-seven cadaveric specimens.Measurements were taken to define the relationship of theradial nerve and the posterior and lateral humerus. Theextremities were studied further in order to determine theassociation of the radial nerve and anatomical landmarks onboth longitudinal and cross sectioned specimens.

RESULTS: A 6.3 ± 1.7 centimeter segment of radial nerve was found tobe in direct contact with the posterior humerus from 17.1 ±1.6 to 10.9 ± 1.5 centimeters proximal to the lateralepicondyle, centered within 0.1 ± 0.2 centimeters of the levelof the most distal aspect of the deltoid tuberosity (Figure 1).The radial nerve lay in direct contact with the periosteum in all specimens, without evidence of a structural groove in thehumerus in any specimen (Figures 2a and 2b). The radial nervehad minimal mobility as it was interposed between theobliquely oriented lateral intermuscular septum and the lateralaspect of the humerus. The nerve coursed anterior to thehumerus and became protected by brachialis muscle at thelevel of the proximal aspect of the lateral metaphyseal flare.

SUMMARY POINTS:• The radial nerve is at risk with anterior operative fixation of

the humerus in the posterior mishaft region for a distance of 6.3 centimeters, centered at the distal aspect of the deltoid tuberosity.

• The deltoid tuberosity is a practical landmark that can be utilized to locate the radial nerve.

• There is a risk of radial nerve injury with medial operative fixation of the humerus secondary to penetration of the lateral cortex from 10.9 centimeters proximal to the lateral epicondyle, to the level of the distal metaphyseal flare.

Figure 1

Figure 2

32


Are Standardized Patient Self-Reporting Instruments ApplicableTo The Evaluation Of Ulnar Neuropathy At The Elbow?

lV Neal B. Zimmerman, MD, Lutherville, MDMarc Kaye, MD, Baltimore, MD, E. F. Shaw Wilgis, MD, Baltimore, MDRyan Zimmerman, BS, Baltimore, MDNorman Dubin, PhD, Baltimore, MD

HYPOTHESIS: The “Levine-Katz Self Administered Questionnaire for theAssessment of Severity of Symptoms (LK-S) and FunctionalStatus (LK-F) in Carpal Tunnel Syndrome” and the “Disabilitiesof the Arm, Shoulder & Hand Module” (DASH) have beenshown to be valid and reliable instruments for the evaluationof carpal tunnel syndrome. We hypothesize that both of thesequestionnaires are applicable to the evaluation of ulnarneuropathy at the elbow (UNE).

METHODS:Patients with UNE were evaluated clinically using a commonstaging system (stages 0-4) prior to and six months followingulnar nerve surgery. Synchronously, patients reported theirsymptoms using the LK and DASH questionnaires (totalevaluations = 146). Also a QuickDASH questionnaire consistingof an 11 question subset of the DASH was evaluated.Analysis of variance was used to determine if there was adifference between the patient’s questionnaire scores and the physician’s evaluation of clinical stage. If significance (p < 0.05) was found, ranges of non-significance were used to determine detailed differences between stages. Correlationcoefficients (r) were used to determine relationships betweenthe questionnaires.

RESULTS/STATISTICS:LK-S, LK-F, and DASH scores increased in relation to clinicalstage (p < 0.001). All questionnaires discriminated betweenclinical stages “0-1”, “2-3”, and “4” (ie: Figure 1). There wassignificant (p < 0.001) correlation between LK-S and LK-F (r =0.73), LK-S and DASH (r = 0.79), and LK-F and DASH (r=0.87).The QuickDASH was just as effective as the complete DASH (r = 0.97).

SUMMARY POINTS:• The self administered questionnaires preformed well in

differentiating between physician assigned clinical stages.• Either DASH or the LK questionnaires can be utilized to

evaluate ulnar neuropathy at the elbow.

• The fewer questions in the QuickDASH provide essentially the same information as the DASH in terms of staging UNE.

Figure 1: Relationship between DASH scores and clinical stage of UNE

REFERENCES:1. Szabo, RM. Outcomes Assessment in Hand Surgery: When

Are They Meaningful. J Hand Surg 2001; 26A: 993-10022. Kotsis SV, Chung KC. Responsiveness of the Michigan

Hand Outcomes Questionnaire and the Disabilities of the Arm, Shoulder and Hand Questionnaire in Carpal Tunnel Surgery. J Hand Surg 2005; 30A: 81-86

3. Gay RE, Amadio PC, Johnson JC. Comparative Responsiveness of the Disabilities of the Arm, Shoulder, and Hand, the Carpal Tunnel Questionnaire, and the SF-36to Clinical Change After Carpal Tunnel Release. J Hand Surg 2003; 28A: 250-254

4. SooHoo NF, McDonald AP, Seiler JG, McGillivary GR. Evaluation of the Construct Validity of the DASH Questionnaire by Correlation to the SF-36. J Hand Surg 2002; 27A: 537-541

lV This project was funded by an AFSH/ASSH ClinicalResearch Grant and and Intramural Grant from MedStarResearch Institute

33


Comparative Analysis of Holding Strength of Available “Nerve Glues”

l Jonathan E. Isaacs, MD, Richmond, VACandice McDaniel, MD, Richmond, VAJohn Owen, BS, Richmond, VAJennifer Wayne, PhD, Richmond, VA

HYPOTHESIS: A variety of potentially useful artificial and biological sealantsapplied to a sutured nerve decrease gapping at the repair site.

METHODS:Fifty-seven cadaveric nerve specimens were transected andrepaired with two 8-0 nylon epineural sutures placed 180degrees apart. The specimens were divided into five groups.Four groups received augmentation of the repair withapplication of either autologous fibrin glue, Tisseel fibrin glue(Baxter Healthcare Corporation), Evicel fibrin glue (Ethicon,Inc.), or DuraSeal polyethylene glycol based hydrogel sealant(Confluent Surgical, Inc.). Each nerve construct was mountedin a servohydraulic materials testing machine (InstronCorporation; MTS Systems Corporation) and stretched at a constant 5mm/min displacement rate until failure. A noncontact video analysis permitted normalization of stretchwithin the repair region. Statistical analysis was performed viaANOVA followed by Tukey-Kramer post-hoc pairwisecomparison, if indicated.

RESULTS/STATISTICS:There was no statistical difference for the peak load at failurebetween any of the groups (p>0.4, Fig. 1). Resistance togapping as measured through normalized stiffness(N/mm/mm) was greater for the Tisseel group (p<0.004), Evicel group (p<0.007), and DuraSeal group (p<0.003) versusthe no glue group only (Fig. 2). The stiffness of the autologousgroup approached significance versus the no glue group(p=0.071). There were no significant differences in stiffnessbetween any of the various nerve glue groups (p>0.6, Fig. 2).

Figure 1:Maximum load for each group.

Figure 2:Normalized stiffnessof each group.

SUMMARY POINTS:• Avoidance of gapping at the nerve repair site is crucial in

achieving successful nerve regeneration. Commercially available tissue sealants (Tisseel, Evicel, and DuraSeal), when used to augment sutured nerve repairs, help preventthis initial gapping.

• None of the tissue sealants tested, however, increased the ultimate load to complete failure of the repair.

• No prior studies have documented the differences betweenthese currently available nerve glues.

REFERENCES:1. Bento, R. F., et al: Ear Nose Throat J, 72(10): 663, 19932. Narakas, A.: Orthop Clin North Am, 19(1): 187-99, 19883. Martins, R. S., et al: Surg Neurol, 64 Suppl 1: S1:10-6;

discussion S1:16, 20054. Menovsky, T., et al: J Neurosurg, 95(4): 694-9, 20015. Feldman, M. D., et al: Arch Otolaryngol Head Neck Surg,

113(9): 963-7, 19876. Cruz, N. I., et al: Plast Reconstr Surg, 78(3): 369-73, 19867. Sames, M., et al: Physiol Res, 46(4): 303-6, 19978. Maragh, H., et al: J Reconstr Microsurg, 6(4): 331-7, 19909. Smahel, J., et al: J Reconstr Microsurg, 3(3): 211-20, 1987

l Received support from DePuy

34


Three Dimensional Carpal Kinematics After Carpal Tunnel Release

u Jonathan Schiller, MD, Providence, RIDouglas Moore, MS, Providence, RIJeffrey Brooks, MD, Providence, RIJoseph J. Crisco, PhD, Providence, RISharon Sonenblum, MS, Providence, REdward Akelman, MD, Providence, RI

HYPOTHESIS: Release of the transverse carpal ligament (TCL) alters thethree-dimensional kinematics of the carpus during wristflexion and extension.

METHODS:The in vitro kinematics of the carpus were studied in five freshfrozen cadaveric wrists before and after a mini-open CTR, viaserial computerized tomography (CT) scans and markerlessbone registration techniques.1 The specimens were positionedfor CT scanning in a custom design jig and evaluated in threepositions, neutral, 60º flexion, and 60º extension. Post-scandissections were conducted to ensure a complete release ofthe TCL. Before and after comparisons of centroid diastasisand rotation of the hamate and trapezium were made usingStudent t tests. Pisiform rotation and carpal arch width (CAW),defined as the distance from the hook of the hamate to thetrapezial ridge was also compared. P-values ≤ .05 wereconsidered statistically significant.

RESULTS/STATISTICS:CAW increased by an average of 1.08 ± 0.05 mm after CTR at all wrist positions (max p=0.02). In contrast, the distancebetween the trapezium and hamate centroids increased onlyby an average of 0.41 ± 0.19 mm (max p=0.035). After CTR,the hamate and trapezium rotated dorsally, away from themidline, by 4.46º ± 4.11º and 2.46º ± 1.58º, respectively, andthe pisiform rotated 3.83º ± 1.14º dorsally with respect to thetriquetrum (p 0.05)(Figure 1).

SUMMARY POINTS:Sectioning of the transverse carpal ligament alters theconformation and kinematics of the carpus. In particular, CTR:• Significantly increases CAW and trapezio-hamate interbone

spacing• Leads to small but significant outward rotation of both the

hamate and trapezium• Results in significant rotation of the pisiform with respect

to the triquetrum• Conformational and kinematic changes in the carpus may

contribute to the transient pillar pain and loss of grip strength after CTR.

REFERENCES:1. Crisco JJ, McGovern RD, Wolfe SW: Noninvasive technique

for measuring in vivo three-dimensional carpal bone kinematics. J Orthop Res 1999:17:96-100

35


Comparative Responsiveness of the Michigan Hand Outcomes Questionnaire and theBoston Carpal Tunnel Questionnaire to clinical change following Carpal Tunnel Release

u Justin Chatterjee, MBChB (Glasg), MRCSEd, MRCS (Glasg), MSc, Edinburgh, West Lothian, United KingdomPatricia Price, BA(Hons), PhD, CHPsychol, AFBPsS, FITL, Cardiff, United Kingdom

HYPOTHESIS: The responsiveness of the Michigan Hand OutcomesQuestionnaire (MHQ) (Chung et al 1998) and the BostonCarpal Tunnel Questionnaire (CTQ) (Levine et al 1993) have not been previously been directly compared followingcarpal tunnel surgery. This prospective study compared theresponsiveness of the MHQ and CTQ to clinical changefollowing carpal tunnel release (CTR), in order to determinewhich instrument is most sensitive.

METHODS:Patients diagnosed with Carpal Tunnel Syndrome (CTS) andscheduled for unilateral open carpal tunnel decompressionwere recruited and informed consent obtained followingethics approval. Inclusion criteria were primary procedure,history, clinical signs and conduction studies consistent withCTS. Forty-two patients completed both the MHQ and CTQ, pre-operatively and 6 months post-operatively. TheKolmogorov-Smirnov test showed responses in a number of domains for both the CTQ and MHQ were significantly(p<0.05) deviated from normal and so the non-parametricWilcoxon signed-rank test was used to assess change aftersurgery. The standardised response mean (SRM) was used to assess responsiveness.

RESULTS/STATISTICS:All domains of the MHQ and the CTQ showed significantpostoperative improvement (p<0.001). The overallresponsiveness of both MHQ and CTQ were large (SRM≥ 0.8), however the CTQ demonstrated increasedsensitivity to change after carpal tunnel decompressioncompared to the MHQ. Although the SRM of the MHQ was0.8, the SRM of the CTQ was 1.22. Both domains of the CTQ had an SRM well above 0.8, whereas half of the 6 MHQdomains had an SRM below 0.8 (Table.1, Figure.1). On thebasis of these results the CTQ has demonstrated greaterresponsiveness to clinical change following CTR than the MHQ.

Table 1.Standardised Response Means (SRM) for MHQ and CTQ

Scales Preop SD Postop SD Resp. Resp. SRM†

Mean Mean Mean SD

MHQ

Function 39.27 17.95 62.42 24.93 24.43 29.60 0.83

ADL 49.80 23.98 75.12 26.42 24.10 30.20 0.80

Work 45.25 23.37 68.23 29.10 22.82 28.79 0.79

Pain 66.89 16.77 29.64 27.99 37.24 28.86 1.30

Aesthetics 67.93 22.57 82.23 17.82 15.72 20.22 0.78

Satisfaction 31.82 29.75 67.94 29.25 34.17 43.50 0.79

Total MHQ 50.09 11.99 63.34 14.67 13.25 16.53 0.80

CTQ

Symptom

Severity 3.40 0.65 1.93 0.92 1.48 1.11 1.33

Functional

Status 3.05 0.87 1.99 0.94 1.06 1.08 0.98

Total CTQ 3.23 0.69 1.96 0.89 1.27 1.04 1.22

† SRM of 0.2 is considered small, 0.5 is medium and 0.8 is large.

Figure.1 Standardised Response Mean of the MHQ and CTQ domainsand totals.

36

Paper 17 continued

SUMMARY POINTS:• Both CTQ & MHQ produce a large response after CTR.• However the CTQ is more responsive and sensitive to

clinical change following CTR than the MHQ and this evidence may affect instrument choice for future CTS research.

REFERENCES:1. Chung KC, Pillsbury MS, Walters MR, Hayward RA, Arbor

A (1998) Reliability and Validity Testing of the Michigan Hand Outcomes Questionnaire. The Journal of Hand Surgery 23 (4) 575-582

2. Chung KC, Hamil JB, Walters MR, Hayward RA (1999) The Michigan Hand Outcomes Questionnaire (MHQ): Assessment of Responsiveness to Clinical Change. Annals of Plastic Surgery 42 (6)

3. Levine DW, Simmons BP, Koris MJ, Daltroy LH, Hohl GG, Fossel AH, Katz JN (1993) A Self-Administered Questionnaire for the Assessment of Severity of Symptoms and Functional Status in Carpal Tunnel Syndrome. The Journal of Bone and Joint Surgery 75 (11) 1585-1591

4. Amadio PC, Silverstein MD, Ilstrup DM, Schleck CD, Jensen LM (1996) Outcome Assessment for Carpal Tunnel Surgery: The Relative Responsiveness of Generic, Arthritis-Specific, Disease-Specific, and Physical Examination Measures. The Journal of Hand Surgery 21 (3) 338-346

5. Gay RE, Amadio PC, Johnson JC (2003) Comparative Responsiveness of the Disabilities of the Arm, Shoulder, and Hand, the Carpal Tunnel Questionnaire, and the SF-36to Clinical Change After Carpal Tunnel Release. The Journal of Hand Surgery 28 (2) 250-254

6. Kotsis SV, Chung KC, Arbor A (2005) Responsiveness of the Michigan Hand Outcomes Questionnaire and the Disabilities of the Arm, Shoulder and Hand Questionnaire in Carpal Tunnel Surgery. The Journal of Hand Surgery 30 (1) 81-86

7. Klein RD, Kotsis SV, Chung KC (2002) Open Carpal Tunnel Release Using a 1-Centimeter Incision: Technique and Outcomes for 104 Patients. Plastic and Reconstructive Surgery 111 (5) 1616-1622

8. Atroshi I, Gummesson C, Johnsson R, Sprinchorn A (1999)Symptoms, Disability, and Quality of Life in Patients with Carpal Tunnel Syndrome. The Journal of Hand Surgery 24 (2) 398-404

37


Sonography vs. NCV –Who Has The Upper Hand In The Diagnosis Of Carpal Tunnel Syndrome?

u Bong Cheol Kwon, MD, Kyeonggi-do, KoreaSeong Hye Ko, MD, Ahnyang, Kyeonggi-do, KoreaIk Kwang Chung, MD, Ahnyang, KoreaNam Kyu Lee, MD, Ahnyang, Kyeonggi-do, Korea

HYPOTHESIS: This study is to compare diagnostic accuracy of sonographywith nerve conduction study for the diagnosis of carpal tunnelsyndrome.

METHODS:PATIENTS - Reference standard for diagnosis of CTS based onpatient’s symptoms were: 1) paresthesias in hand in mediannerve or median and ulnar nerve distribution 2) which awakenpatient from sleep, 3) relieved by shaking hand, 4) positivePhalen sign.

CONTROL - After matching for age, sex and involved side,subjects with average 1 point on Boston Questionnaire andnegative on Phalen test were enrolled. Sonography -Sonography was performed by a musculoskeletal radiologistblinded to subject’s state. Transverse images of median nervewere scanned at three levels: at immediate proximal to carpalinlet (at the level of distal part of distal radioulnar joint), at thecarpal inlet (at the level of pisiform), and at carpal outlet (atthe level of hook of hamate). Cross sectional area at each levelwas measured by direct tracing with electric caliper around themargin of the median nerve.

NCS - NCS was performed by a physician of rehabilitationmedicine. Criteria of carpal tunnel syndrome are: 1) amplitudeof sensory action potential ≤15µV 2) distal latency?3.5ms 3)wrist to palmar conduction time?1.8ms 4) distal latency ofthenar compound muscle action potential ?4.0ms.

RESULTS:There were no significant differences in age, sex, and involvedside between case and control groups, which include 41hands of 29 patients respectively. Only CSA at inlet wassignificantly larger in case group than in control group (12.07mm2±3.20 mm2, 10.22 mm2±2.01 mm2 respectively; p=0.02), with area under the fitted ROC curve being 0.673. Thebest cut off value was 10.68 mm2 with sensitivity 67.5% andspecificity 63.4%. NCS showed 78.0% sensitivity and 82.9%specificity.

Table 1.Cross sectional area(CSA) at each level in patientsand control group.

Patients Control P valueCSA at carpal inlet (mm2) 12.07 ± 3.20 10.22 ± 2.01 0.002CSA at carpal outlet (mm2)10.91 ± 2.56 9.99 ± 1.92 0.069CSA at DRUJ (mm2) 11.77 ± 2.67 10.87 ± 2.25 0.105

Figure 1. Fitted ROC curve of cross sectional area of median nerve atcarpal inlet, at carpal outlet and at DRUJ level.

SUMMARY POINT: Sonography does not appear to be accurate enoughas a diagnostic test for carpal tunnel syndrome.

38


Actual Delivery Location of Carpal Tunnel Injections: A Cadaveric Study

u Joseph E. Robison, MD, Cleveland, OHJeffrey Lawton, MD, Cleveland, OHPeter Evans, MD, PhD, Cleveland, OH

HYPOTHESIS: A significant number of injections directed toward the carpaltunnel do not result in distribution of the solution freely into it.

METHODS:Thirty-four cadaveric specimens were injected with 1cc ofDepo-Medrol containing tissue dye (The Davidson MarkingSystem, Bradley Products, Inc., Bloomington, MN). A 5/8 inch25 gauge needle was inserted into the skin at the intersectionpoint of the wrist flexion crease and the midline of the ringfinger ray. The needle was directed distally at a 45 degreeangle in line with the ring finger ray until the hub of theneedle just touched the skin. The fingers were then passivelyflexed and extended, and any motion of the needle wasdocumented. The injection was then performed. The arm wasthen carefully dissected into the carpal tunnel from the mid-palm to the distal one third of the forearm, noting thelocation of the needle tip and distribution of the dye.

RESULTS/STATISTICS:Only 12 of 34 specimens had injection solution distributedfreely within the carpal tunnel. Of those 12, 10 did notdemonstrate motion of the needle with passive digitexcursion. Eighteen specimens showed solution deposited in the tenosynovium and/or sheaths of the flexor tendons. The remaining 4 specimens demonstrated solution in either a side wall of the carpal tunnel or the transverse carpalligament. The median nerve was not penetrated in any specimen.

SUMMARY POINTS:• The injection method utilized in this study is not likely to

put the median nerve at risk. • Although needle motion with passive digit excursion may

confirm that the needle tip is within the carpal tunnel, it indicates the injection is not likely to be freely dispersed into the carpal canal.

39


Carpal Tunnel Syndrome and Keyboard Use at Work: Population-Based Study

l Isam Atroshi, MD, PhD, Hässleholm, SwedenChristina Gummesson, PhD, Lund, SwedenEwald Ornstein, MD, PhD, Hässleholm, SwedenRagnar Johnsson, MD, PhD, Lund, SwedenJonas Ranstam, PhD, Lund, Sweden

HYPOTHESIS: There is no association between carpal tunnel syndrome andthe amount of keyboard use at work.

METHODS: We have previously performed a population-based study todetermine the prevalence of carpal tunnel syndrome in ageneral population [1]. As part of that study a health statusquestionnaire was mailed to 2,465 persons of working age(25 to 65 years), randomly selected from the generalpopulation of a representative region. The questionnaireinquired about presence and severity of pain, numbness andtingling in each body region, employment history, and workactivities including average time using keyboard during a usualworking day. The response rate to the quetsionnaire was82%. All persons who reported recurrent hand numbness ortingling in the median nerve distribution were asked to attendphysical examination and nerve conduction tests; 80%attended the examinations within 2 months after respondingto the questionnaire. In the present analysis, the prevalence ofcarpal tunnel syndrome, defined as symptoms plus abnormalnerve conduction test results, was compared between groupsthat differed in the intensity of keyboard use, adjusting forage, sex, body mass index, and smoking status.

RESULTS: The persons who had reported intensive keyboard use at workin the questionnaire were significantly less likely to bediagnosed with carpal tunnel syndrome than those who hadreported little keyboard use; prevalence 2.6% in the highestkeyboard use group (¡?4 hr/day), 2.9% (1 to <4 hr/day), 4.9%(<1 hr/day), and 5.2% (no keyboard use at work) (P for trend= 0.032). With 1 hr/day cut-off, the adjusted prevalence ratioof the high to low keyboard-use groups was 0.55 (95%confidence interval 0.32 to 0.96, P=0.035).

SUMMARY POINT: In a working-age general population, intensive keyboard useat work, measured with self-report, appears to be associatedwith lower risk of carpal tunnel syndrome defined assymptoms and abnormal nerve conduction tests.

REFERENCES1. Atroshi I, Gummesson C, Johnsson R, Ornstein E, Ranstam

J, Rosen I. Prevalence of carpal tunnel syndrome in a general population. JAMA 1999; 282: 153-58. +

l Received support from the Skane County Council’sResearch and Development Foundation and KristianstadUniversity, Sweden.

40


Revascularization of the Lunate in early Kienbock's Disease by Lunotriquetral Arthrodesis

u Martin A. Posner, MD, New York, NYSteve Green, MD, New York, NYAlon Garay, MD, San Diego, CA

HYPOTHESIS: To restore lunate circulation in early Kienbock’s disease by alunotriquetral (LT) arthrodesis. The rationale for the procedureis based on the surgical treatment of scaphoid non-unionswith avascular necrosis of the proximal fragment. Sinceautogenous bone grafts are usually successful in achievingscaphoid healing, LT fusions could potentially restorecirculation to the lunate in stage I and II Kienbock’s disease.The lunate is analogous to the proximal avascular scaphoidfragment and the triquetrum analogous to be the distalscaphoid.

METHODS:All patients who underwent surgery for early Kienbock’sdisease were treated with LT fusions. When radiographs wereinsufficient to accurately stage the condition, CT imaging wasobtained. At surgery, a deep trough was fashioned across thelunotriquetral joint; necrotic bone within the lunate wascuretted. The trough was then packed with a corticalcancelleous autogenous bone graft.

RESULTS/STATISTICS:The series comprises 18 patients with stage II Kienbock’sdisease treated since 1982 whose duration of symptomsaveraged 3.6 years. There were 11 males and 7 females andtheir ages ranged from 16-52 years (avg. 30.4 years). Ulnanegative variance was present in 10 patients, ulna neutral in 6,and ulna positive in 2. All patients were followedpostoperatively for a minimum of 3 years and in each casepostoperative radiograph showed no further collapse of thelunate. In the 10 cases treated since 1990, preoperative andpostoperative magnetic resonance imaging (MRI) was obtainedin addition to radiographs. In all of these cases, the post-operative MRI showed revascularization of the lunate. Allpatients in the series reported an improvement in theircondition and were pleased with the result. There were nocomplications.

SUMMARY POINT:Revascularization of the lunate in early Kienbock’s disease canbe achieved by a LT fusion.

41


Two Types of Vascular Bundles for Revascularization of Avascular Tissue

Martins Kapickis, MD, Louisville, KYu Sunil M. Thirkannad, MD, Louisville, KY

HYPOTHESIS: There are at least two types of blood vessel bundles – a)“parallel pipes” type which being ligated distally willeventually thrombose due to a lack of adequate venousoutflow because of inefficient or absent arterio-venouscommunications; b) “axial flap” type – which containnumerous arteriovenous communications and if ligated distallywill survive as an axial flap thus providing a source ofneovascularisation.

METHODS: Hori and Tamai’s technique is an accepted method for thetreatment of avascular necrosis (AVN) of carpal bones.Nevertheless, clinical results have been less encouragingcompared to experimental data. Our study suggests that oneof the possible reasons for failure is vessel bundle thrombosis.A prospective animal study was performed whereby surgicalligation of the femoral and epigastric vessels of a rat was used as the model for vessel transplantation.

Twenty rats were submitted to epigastric or femoral vesselbundle distal ligation and exploration at different timeintervals – 2 hours, 3, hours, 6 hours, 24 hours and 3 weeks.Silicone sheet wraparound was used for the 24 hour and 3week groups to simulate an avascular environment andpreclude any external vascular ingrowths. Opposite sides wereused as unligated controls. Specimens were evaluated clinicallyand histologically.

RESULTS: No thrombus was detected in the 8 out of 8 femoral vesselbundles that were ligated for 2, 3 and 6 hours. There wereclinically and histologically detectable thrombus in the 7 out of 9 femoral vessel bundles that were ligated 24 hours to 3weeks. There were no thrombus in the 9 distally ligatedepigastric vessels at any time interval up to 3 weeks.

SUMMARY POINT: There are at least two vascular bundles in a rat model. Thefemoral bundles were thrombosed in 78% of cases, but noepigastric bundles were thrombosed. Epigastric bundlesdisplayed remarkable revascularization potential compared to femoral bundles.

42


Long Term Clinical Outcome Of Vasculaized Pedicled Bone Graft For Scaphoid Nonunion.

u Nash H. Naam, MD, Effingham, ILPatrick Stewart, MD, Effingham, IL

HYPOTHESIS: Treatment of scaphoid nonunion with vascularized pedicledbone grafts has been shown to have good to excellent shortterm results. The purpose of this study is to evaluate the longterm outcome of this procedure.

MATERIALS AND METHODS:Between 1989 and 2000, 28 patients with nonunitedscaphoid fractures were treated with vascularized bone graftsfrom the distal radius using the 1,2 intercompartmentalsupraretinacular vessels. Patients’ age averaged 38 years (15 to63). There were 19 males and 9 females. The dominant handwas involved in 17 patients. Fractures involved the waist in 19 patients (68%); proximal pole in 8 (28%) ;distal pole in 1 (3%). Fifteen patients (54%) did not receive any treatmentbefore; six (21%) had a cast immobilization and 7 (25%) had previous ORIF. Time from injury to surgery averaged 43months (3-260). Internal fixation was achieved with K-wires.

RESULTS/STATISTICS:Follow up averaged 7.5 years (5 to 17 years). All fractureshealed. Average time to healing was 11 weeks (5-24).Sixteen patients (57%) had no pain; 8 (29%) had minimalpain ; 3 (11%) had moderate pain and 1 (3%) had persistentpain. Range of motion averaged 89% of the contralateralside. Grip strength averaged 91% of contralateral side. Onlyone patient had to change his job when ho took an earlyretirement. The rest of the patients went back to their originaljobs. Mayo scoring system: Excellent 17 (61%); Good 7(25%); fair 3 (11%); poor 1 (3%). 86% of the patients weresatisfied with the outcome. The three patients who hadmoderate and persistent pain were found to have arthriticchanges in the radioscaphoid and lunocapitate joints.

SUMMARY POINT:Treatment of scaphoid nonunion with vascularized bone graftis associated with good to excellent long term outcome.

REFERENCES:1. Steinmann SP, Bishop AT, Berger RA. Use of the 1,2

intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difficult scaphoid nonunion. J Hand Surg [Am]. 2002 May;27(3):391-401

2. Straw RG, Davis TR, Dias JJ. Scaphoid nonunion: treatment with a pedicled vascularized bone graft based on the 1,2 intercompartmental supraretinacular branch of the radial artery.J Hand Surg [Br].2002 Oct;27(5):413

43


Treatment of Scaphoid Waist Nonunion with Associated Avascular Necrosis of theProximal Pole with Carpal Collapse: A Comparison of Three Vascularized Bone Grafts

u Alexander Y. Shin, MD, Rochester, MNDavid Jones, MD, Rochester, MNHeinz Buerger, MD, Klagenfurt, AustriaAllen T. Bishop, MD, Rochester, MN

HYPOTHESIS: Treatment of scaphoid waist non-unions with carpal collapseand proximal pole avascularity requires both correction ofdeformity and introduction of blood supply to the proximalpole. We hypothesize there are no differences between threetypes of vascularized bone grafts (1,2-intercompartmentalsupraretinacular artery (1,2-ICSRA) pedicle distal radius graft;iliac crest wedge (ICW) graft with implanted arteriovenousbundle; free vascularized medial femoral condyle (MFC) graft)with respect to union rates, time to union and complications.

METHODS: A retrospective review was conducted to identify all patientstreated at two institutions who had scaphoid waist nonunionsassociated with proximal pole avascularity and carpal collapse.Carpal angles, time to union, union rates, and complicationswere recorded. ANOVA and Kaplan-Meier analysis wasperformed.

RESULTS/STATISTICS: Between January 1994 and February 2006, 24 patients (24nonunions) were treated: 10 with 1,2 ICSRA grafts, 3 withvascular bundle ICW grafts, and 11 with free vascularizedMFC grafts. Patient characteristics were similar for the groupsand follow-up averaged 12 months. Overall, 18 scaphoid non-unions united at an average of 19 weeks after surgery. The1,2-ICSRA grafts achieved union in 4/10 fractures at a mediantime to healing of 6.9 months; the ICW grafts achieved unionin 3/3 fractures at a median time to healing of 6.3 months;and the MFC grafts achieved union in 11/11 fractures at amedian time to healing of 3.5 months. Median time to healingwas significantly shorter for the MFC grafts compared to the1,2 ICSRA (p<0.001) and ICW (p=0.01) grafts.

SUMMARY POINTS: • Non-unions treated with vascularized wedge grafts from

the iliac crest or femoral condyle achieve higher rates of union than 1,2-ICSRA grafts.

• Free vascular MFC grafts achieve union more rapidly than vascular bundle ICW grafts.

• MFC vascularized bone grafts demonstrated superiority in the treatment of scaphoid waist non-unions with proximal pole avascularity and carpal collapse.

44


Donor Site Evaluation after Autologous OsteochondralMosaicplasty for Capitellar Osteochondritis Dissecans

u Norimasa Iwasaki, MD, Sapporo, JapanHiroyuki Kato, MD, Matsumoto, JapanJyunichi Ishikawa, MD, Sapporo, JapanTatsuya Masuko, MD, Sapporo, JapanNaoki Suenaga, MD, Sapporo, JapanAkio Minami, MD, Sapporo, Japan

HYPOTHESIS: No adverse effects of osteochondral graft harvests on donorknee function are found following mosaicplasty for capitellarosteochondritis dissecans (OCD) in young athletes.

METHODS:Eleven male competitive athletes with advanced lesions ofcapitellar OCD underwent mosaicplasties. Their mean age atthe time of surgery was 14 years (11 to 22). The surgicaltechnique involves obtaining small-sized cylindricalosteochondral grafts from the non weight-bearing peripheryof the lateral femoral condyle at the level of thepatellofemoral joint, and transplanting them to osteochondraldefects in the capitellum. Assessment at follow-up includedlocal findings of the donor knees, a Lysholm knee scoringscale, International Knee Documentation Committee (IKDC)standard evaluation form, and MRI evaluation. The quality ofthe donor site repair was semiquantitatively assessed from MRIfindings according to the scoring system of Henderson et al (1)(0, normal to 20, no repair).

RESULTS/STATISTICS:At a mean follow-up of 26 months, all patients returned to acompetitive level of their previous sports without any donorsite disturbances. Based on the Lysholm knee score and IKDCevaluation form, all knees were graded as excellent andnormal, respectively. MRI scans were available for 9 of 11patients at follow-up. The MRI showed 50 to 100% defect fillin 6 of 9 patients and normal or nearly normal signals in 4patients at the donor sites. All patients except 1 showed nojoint effusion. The overall MRI score was 6.7 points (4 to 9).

SUMMARY POINT:(1) The current results suggest no unfavorable effect of graftharvest on the donor knee in young athletes with capitellarOCD treated with mosaicplasty. (2) MRI findings indicate thatthe empty site after harvesting osteochondral grafts isresurfaced with fibrous or fibrocartilaginous tissue.

REFERENCES:Reference 1: Henderson IJP, et al. Prospective clinical study ofautologous chondrocyte implantation and correlation with MRIat three and 12 months. J Bone Joint Surg [Br]. 2003;85-B:1060-1066

45


Treatment of Scapholunate Instability Using a Resorbable Plate

u Walter H. Short, MD, Syracuse, NYFrederick W. Werner, MME, Syracuse, NYLevi G. Sutton, BS, Syracuse, NY

HYPOTHESIS: Attachment of a bioresorbable plate to the dorsal surface ofthe scaphoid and lunate following scapholunate ligament (S-L)repair improves the short term outcome compared to patientswho underwent S-L repair and dorsal capsulodesisaugmentation for the same condition.

METHODS: Between June 2004 and December 2005 eight patients witharthroscopically documented scapholunate instability and apositive “drive through” sign were treated with openreduction of the instability with K-wires and direct repair ofthe S-L ligament with bone anchors. This was augmented witha four hole resorbable plate (polylactic acid, PLA) screwed ontothe dorsal non-articular surface of the reduced scaphoid andlunate. This group was compared to a randomly selectedcontrol group treated by S-L repair and dorsal capsulodesis.Comparison was done using the modified Mayo wrist score.Statistical analysis was done using Student’s t-test. Theestimated power was 80% for p < .05. The PLA plate is madeprimarily from the D and L isomers of lactic acid. It degradesto 70% strength at 8 weeks and gradually weakens over 6-9months. It is eventually converted to CO2 and H20. Initially ithas strength characteristics similar to titanium plates except intorsion. When warmed to 60ºC it is malleable. The plates areFDA approved for hand surgery and are used extensively incraniofacial surgery.

RESULTS/STATISTICS: All patients were followed for one year. There was one failurein the PLA group and two failures in the capsulodesis group.Using the modified Mayo wrist score the PLA average score of83 was statistically greater than the dorsal capsulodesis groupscore of 71.

SUMMARY POINT:The addition of a PLA plate improves the short term outcomeof S-L repair compared to dorsal capsulodesis. The authorsbelieve that the PLA plate maintains S-L reduction after K-wireremoval. As the ligament regains strength the plate graduallyresorbs.

46


Scapholunate Interosseous Ligament Reconstruction:Results with a Modified Brunelli Technique versus Four-Bone Weave

u Annie C. Links, MD, Seattle, WAThomas Trumble,MD, Seattle, WAThanapong Waitayawinyu, MD, Seattle, WASimon Chin, MD, Seattle, WA

HYPOTHESIS: To compare clinical and radiographic outcomes in patientswith chronic scapholunate dissociation treated with a modifiedBrunelli technique versus a four-bone tendon weave.

METHODS:Twenty-one patients presented with chronic scapholunatedissociation and were treated with the modified Brunellitechnique as described by Van Den Abbeele et al. Twenty-three were treated with the four-bone tendon weavetechnique as described by Almquist. All patients hadpreoperative stress-view radiographs demonstratingscapholunate ligament disruption and positive MRarthrograms. Prospective evaluation included radiographicchanges, pain and DASH scores, grip strength and range ofmotion. Data was analyzed using the student’s t-test (p=0.05).

RESULTS/STATISTICS:Ages of patients were comparable (modified Brunelli groupmean age 30.2 years (range 19 to 44), 15 males; four-bonetendon weave group 29.0 years (range 24 to 40) with 17 malepatients). The scapholunate angle decreased in both groups(mean 14.5 degree decrease for the Brunelli group, standarddeviation 4.9 degrees, 10 degree decrease in the four-bonetendon weave group, standard deviation 3.9 degrees). Meanpain and DASH scores pre and postoperatively showed moreimprovement for the modified Brunelli group (pain scoresrated on 1 to 10 visual analogue scale, mean differenceBrunelli group=4.8 points, four-bone weave=3.2 points,mean difference 1.6 points, p<0.001; DASH scores with meandifference Brunelli group=2.2 points versus 0.9, mean increase1.5 points, p<0.001). Postoperative range of motion as apercentage of preoperative range of motion also increasedmore for the Brunelli group (mean 86%, standard deviation7.2 versus 60%, standard deviation 11.6, p<0.001).Differences in grip strength were greater in the Brunelli group(mean 2.2 kg versus 0.9 kg, increase of 1.2 kg, p<0.001).

SUMMARY POINT:The modified Brunelli technique for scapholunate interosseousligament reconstruction as compared with the four-bonetendon weave has improved outcomes in pain relief, DASHscores, range of motion and grip strength.

Figure 2 A. Diagramillustrating the four-bonetendon weave techniqueas described by Almquistand B. the modifiedBrunelli technique asdescribed by Van DenAbbeele et al.

Figure 2. Postoperative radiographs of patient treated withmodified Brunelli technique

47


Simulated Radioscapholunate Fusion Alters Lunotriquetral and Midcarpal Kinematics

l Ryan P. Calfee, MD, Cincinnati, OHEvan Leventhal, BS, Providence, RIJoseph Crisco, PhD, Providence, RIJim Wilkerson, BA, Providence, RIDouglas Moore, MS, Providence, RIEdward Akelman, MD, Providence, RI

HYPOTHESIS: As midcarpal degeneration is well documented followingradioscapholunate fusion, this study was designed to test thehypothesis that radioscapholunate fusion alters the kinematicbehavior of the remaining lunotriquetral and midcarpal joints.

METHODS:Simulated radioscapholunate fusions were performed on 6unembalmed cadaveric wrists in an anatomically neutralposture. Two 0.060” carbon fiber pins were placed fromproximal to distal across the radiolunate and radioscaphoidjoints respectively. Wrists were positioned in a custom jig forCT imaging. The wrists were passively positioned toward a fullrange of motion along the orthogonal axes as well as obliquemotions, with additional intermediate positions along the dartthrower’s path. Positioning was limited to the first appreciableresistance. Utilizing a markerless bone registration technique,each carpal bone’s 3-D rotation was defined as a function of wrist flexion/extension from the pinned neutral position.Kinematic data obtained was analyzed against data collectedon the same wrist prior to fixation using hierarchical linearregression analysis and paired Student’s t-tests.

RESULTS/STATISTICS:Following simulated fusion, wrist range of motion wasrestricted to an average flexion-extension arc of 47.9°,reduced from 77.2°, and an ulnar-radial deviation arc of 19.3°,from 32.6°. The overall remaining motion was maximallypreserved along the plane from radial-extension toward ulnar-flexion (Figure 1). The simulated fusion significantly increasedrotation through the scaphotrapezial joint (p<0.01),scaphocapitate joint (p<0.01), triquetrohamate joint (p<0.01),and lunotriquetral joint (p<0.01) (Figure 2). For example, in the pinned wrist, the rotation of the hamate relative to thetriquetrum increased 85%. Therefore, during every 10° oftotal wrist motion, the hamate rotated an average of 7.6°relative to the triquetrum after pinning versus 4.1° in thenormal state.

48

Figure 1.Plot of wrist positionsdemonstrating limitedmotion followingsimulatedradioscapholunatefusion with thegreatest preserved arefrom radial-extensiontoward ulnar-flexion.

Figure 2.Regression linesdemonstratinggreater rotation ofthe hamate relative to the triquetrumfollowing simulatedradioscpholunatefusion.

Paper 28 continued

SUMMARY POINTS:1. Simulated radioscapholunate fusion produces altered

kinematic behavior through the lunotriquetral and midcarpal joints.

2. Wrist motion following simulated radioscapholunate fusionwas primarily preserved along the dart thrower’s path fromradial-extension toward ulnar-flexion.

REFERENCES:1. Bach AW, Almaquist EE, Newman DM. Proximal row fusion

as a solution for radiocarpal arthritis. J Hand Surg 1991;16A:424-431

2. Nagy L, Buchler U. Long term results of radioscapholunate fusion following fractures of the distal radius. J Hand Surg 1997;22B:705-710

3. Krakauer JK, Bishop AT, Cooney WP. Surgical treatment of scapholunate advanced collapse. J Hand Surg 1994;19A:751-759

4. Garcia-Elias M, Lluch A, Ferreres A, Papini-Zorli I, Rahimtolla ZO. Treatment of radiocarpal degenerative osteoarthritis by radioscapholunate arthrodesis and distal scaphoidectomy. J Hand Surg 2005;30A:8-15

5. Crisco JJ, McGovern RD, Wolfe SW. Noninvasive technique for measuring in vivo three-dimensional carpal bone kinematics. J Orthop Res 1999;17:96-100

l Received support from NIH-HD052127

49


Restoration of Forearm Rotational Stability by Directly Anchoring the Triangular FibrocartilageLigamentum Subcruentum to the Ulna Fovea: An Anatomic Study, Provocative Maneuvers, and Clinical Correlation

William B. Kleinman, MD, Indianapolis, INu Jedediah Jones, MD, Las Vegas, NV

HYPOTHESIS: The biomechanical advantage of the deep fibers of thetriangular fibrocartilage (TFC) in controlling forearm rotation is based on the angle of attack of these well-vascularizedfibers from the fovea of the ulna to the medial radius. Injury only to the deep portion of the TFC (Ligamentumsubcruentum) should result in painful, functionally-incapacitating forearm instability, even with intact superficialTFC components. Contrast MRI is inconsistent in establishing a definitive diagnosis. Direct arthroscopy has essentially novalue, since integrity of an uninjured superficial TFC precludesarthroscopic examination of injured deeper tissues.

METHODS: Between 2002 and 2005, ten patients with chronically-painfuldisruption of only the foveal attachment of the TFC weretreated by open repair. Provocative physical examinationtechniques of the deep components of the TFC proved precise in making definitive diagnoses of destabilizing injuries.At arthroscopy, each patient had intact superficial TFCcomponents, with a normal “trampoline effect.”

RESULTS: Once diagnosed, these unique TFC injuries were treated by re-attaching the injured Ligamentum subcruentum back to theulna fovea using bone-anchoring techniques, in an effort torestore painless forearm rotation under load. Following tenweeks of immobilization, aggressive rehabilitation led torestoration of full painless pronosupination in eight, andrestricted forearm rotation in two. These complications weretreated by distal radio-ulna joint capsulectomy and immediaterehabilitation. Recovery of full rotation was achieved in both.

SUMMARY POINT: This paper emphasizes the biomechanical significance of theLigamentum subcruentum, describes provocative maneuversand a clinical approach to identifying these unusual TFCinjuries, describes a surgical technique to restore stableforearm rotation, and provides long-term outcomes in tenpatients.

REFERENCES:1. af Ekenstam F, Hagert CG: Anatomic studies on the

geometry and stability of the distal radio-ulna joint. ScandJPlastReconstrSurg 19: 17, 1985

2. Hermansdorfer JD, Kleinman WB: Management of chronic peripheral tears of the triangular fibrocartilage complex. JHandSurg 16A: 340, 1991

3. Schuind F, An KN, Bergland L, et al.: The distal radioulna ligaments: A biomechanical study. JHandSurg 16A: 1106, 1991

4. Hagert, CG: Distal radius fracture and distal radioulna joint- anatomical considerations. HandchirMikrochirPlastChir 26: 22, 1994

5. Chou KH, Sarris IK, and Sotereanos DG: Suture anchor repair of ulnar-sided triangular fibrocartilage complex tears.JHandSurg 28B: 546, 2003

50


In Vivo Length Change of the Ulnocarpal Ligaments during Radiocarpal Motions

u Hisao Moritomo, MD, PhD, Suita-shi, Osaka, JapanTsuyoshi Murase, MD, PhD, Suita-shi, Osaka, JapanSayuri Arimitsu, MD, Suita-shi, Osaka, JapanHiroyuki Tanaka, MD, PhD, Suita-shi, Osaka, Japan

HYPOTHESIS: One of the pathomechanisms of a foveal triangularfibrocartilage complex (TFCC) tear can be an excessive tractionof the ulnocarpal ligament by wrist hyperextension.

METHODS:We noninvasively investigated in vivo, 3-dimensionalkinematics of the wrist joint using a markerless boneregistration technique(1). Magnetic resonance images of the wrists of 5 healthy volunteers were acquired in 6 positionseach during wrist flexion-extension motion, radioulnardeviation, and the so called dart-throwing motion (radialextension / ulnar flexion motion). We created 3-dimensionalanimations of the ulnocarpal motions and computed 3-dimensional ligament lengths of the ulnotriquetrum,ulnolunate, and palmar radioulnar ligaments as shortest pathsbetween the fovea and insertion point of each ligament(Figure 1). We used a method which was reported by Marai,et al.(2) to model ligament path to avoid bone penetration.

Figure 1Ulnar view of flexion-extension motion of the right wristshowing 3-dimensional ligament paths of the ulnocarpal and palmar radioulnar ligments.

RESULTS/STATISTICS:From wrist neutral to extension, the length of ulnolunateligament increased by 5.2 mm+/-1.6 mm and the length of ulnotriquetrum ligament increased by 1.4 mm+/-1.5 mm.

From wrist neutral to radial deviation the length ofulnotriquetrum ligament increased by 1.2 mm+/-0.4 mm but that of ulnolunate ligament decreased by 0.3 mm+/-1.2mm. From wrist neutral to radial extension, the length ofulnotriquetrum and ulnolunate ligaments increased by 3.0mm+/-1.7 mm and 1.8 mm+/-1.7 mm, respectively. Thepalmar radioulnar ligament seldom changed in any motion.

Figure 2Volar view of A) the normal TFCC and B) hypthesized fovealTFCC tear by hyperextension in the right wrist.

SUMMARY POINTS:• The ulnocarpal ligaments were taut most in wrist

extension. • This study supports a hypothesis that one of the

pathomechanisms of foveal TFCC tear can be an excessive traction of the ulnocarpal ligament by wrist hyperextension(Figure 2).

REFERENCES:1. Goto A, Moritomo H, Murase T, et al. In vivo three-

dimensional wrist motion analysis using magnetic resonance imaging and volume-based registration. J Orthop Res 23:750-756. 2005

2. Marai GE, Laidlaw DH, Demiralp, et al. Estimating joint contact areas and ligament lengths from bone kinematics and surfaces. IEEE Trans Biomed Eng 51:790-799, 2004

51

Paper 31Friday, September 28, 2007, 1:00 - 1:07 PM

Adeno-Associated Virus-2 Mediated bFGF Gene Transfer to Digital FlexorTendons Significantly Increases Healing Strength: An In Vivo Study

u Jin Bo Tang, MD, Nantong, JS, ChinaYi Cao, MD, Nantong, JS, ChinaBei Zhu, MD, Nantong, JS, ChinaXin,Ke-Qin Xin, PhD, Nantong, JS, China

HYPOTHESIS: The central issue underlying the unsatisfactory outcomes ofintrasynovial flexor tendon repairs is the lack of sufficienthealing capacity. Transfer of genes critical to healing may offera promising way of strengthening the repairs. We hypothesizethat transfer of basic fibroblast growth factor (bFGF) genethrough the adeno-associated viral-2 (AAV2) vector to injureddigital flexor tendons increases healing strength of the tendon.

METHODS: 132 long toes from 66 chickens were used. The flexordigitorum profundus tendons were cut completely in zone 2and were repaired surgically. In group 1 (AAV2-bFGF group), atotal of 2 x 109 particles of AAV2-bFGF were injected to bothends of the cut tendon. In group 2 (AAV2-luciferase group),the same amount of AAV2 carrying the luciferase gene wasinjected. In group 3 (non-injection control), the tendons weresutured without any injection. At the end of 2, 4, 8, and 12weeks, the tendons were tested for the load-to-failurestrength and the energy required to flex the toes. Themorphology regarding healing status and peritendinousadhesions were assessed.

RESULTS/STATISTICS: The ultimate strength of repaired tendons treated with AAV2-bFGF was significantly greater than that of tendons treatedwith the sham-vector or non-injection during the early healingperiod (at 2 and 4 weeks, p < 0.001) and a later period (8weeks, p < 0.05)(Fig. 1). Statistically, the grading of adhesionswas the same among three groups at 4 and 8 weeks, but wassignificantly less severe after AAV2-bFGF treatment than non-injection controls at 12 weeks (p < 0.001)(Fig. 2). Energy ofdigital flexion after AAV2-bFGF treatment was significantlydecreased at 12 weeks compared with non-injection controls(p < 0.001).

SUMMARY POINT: bFGF gene transfer to digital flexor tendons mediated by AAV-2 vectors significantly increases healing strength duringthe critical tendon healing period, but does not increaseadhesion formation.

52


Gene Therapy Manipulation of Tendon Healing:Reduction of Adhesions While Maintaining Tensile Properties

u Patrick Basile, MD, Rochester, NYTulin Dadali, BS,Rochester, NYEdward Schwarz, PhD, Rochester, NYDavid Mitten, MD, Rochester, NYWarren Hammert, DDS, MD, Rochester, NYHani Awad, PhD, Rochester, NY

HYPOTHESIS: Adhesions at the site of tendon repair often limits functionalrecovery. We investigated the role of growth/differentiationfactor-5 (Gdf5), a known determinant in tendon healing, todecrease adhesions but maintain tensile strength in a mousetendon allograft model compared to a control expressing noknown growth factors.

METHODS:Using recombinant adeno-associated virus (rAAV) mediatedgene therapy as a vehicle for delivery, lyophilized mouse FDL(flexor digitorum longus) allografts seeded with rAAV-Gdf5(n=9) or rAAV-LacZ (n=9) were microsurgically inserted into 3mm gap defects in the distal FDL of C57BL/6 mice. Tendonswere harvested 14 days later, evaluated non-destructively foradhesions and tested biomechanically for repair tensilestrength, stiffness, and toughness.

RESULTS/STATISTICS: All animals survived the surgery and post-op period. Genedelivery via the allograft was verified using bioluminescent and histological markers. Adhesion testing showed that mice receiving the Gdf5 tendon allograft had a statisticallysignificant (p<0.05) decrease in adhesions compared to theLacZ group. Biomechanical testing at this time point showedthat there is no statistical difference (p>0.05) in repairstrength, stiffness, and toughness between the LacZ and Gdf5 groups.

SUMMARY POINT:This study demonstrates that application of rAAV-Gdf5 coatedtendons decreases adhesions while preserving tensile strengthcompared to controls, suggesting that Gdf5 can selectivelymodulate healing at the tendon-tendon interface. Thesefindings may lead to clinical strategies that improve outcomesin tendon healing.

53


Early Active Motion after Transfer of the Extensor Indicis Proprius Tendon - A Randomized Prospective Trial

u Kai O. Megerle, MD, Ludwigshafen, GermanyMirko Przybilski, MD, Ludwigshafen, GermanyGuenter Germann, MD, PhD, Ludwigshafen, GermanyMichael Sauerbier, MD, PhD, Ludwigshafen, GermanyGoetz Giessler, MD, Ludwigshafen, Germany

HYPOTHESIS: There is no difference in early clinical outcomes andcomplications following two postoperative treatment protocols(dynamic motion vs. early active motion) after transfer of theextensor indicis proprius tendon.

METHODS:In a prospective trial, twenty-one patients (10 female, 11male) were randomly assigned to two treatment protocolsafter transfer of the extensor indicis proprius tendon. In onegroup of patients (“dynamic”) the reconstructed tendon wasextended passively with a rubber band-system, in the otherstudy group (“active”) early active extension of the thumb wasinitiated. Active range of motion in the interphalangeal (IP)and metacarpophalangeal joints (MP) as well as grip and pinchstrength were evaluated after the third, fourth, sixth andeighth postoperative week. All complications during the firstpostoperative year were noted. Statistical analysis wasperformed with chi-square- and Mann-Whitney-U-tests.

RESULTS/STATISTICS:After the eighth postoperative week in the IP joint an averagerange of motion of 69° (45°–110°) was found in the dynamicstudy group and 58° (40°-75°) in the active study group. Afterthree weeks patients treated with the dynamic treatmentprotocol demonstrated significantly (p=0,03) greater ranges ofmotion, during the further treatment course no significantdifferences between the two groups were detected. Aftereight weeks the average grip and pinch strength was66%/73% of the contralateral side in the dynamic studygroup and 63%/71% in the active study group.

SUMMARY POINTS:• With respect to the small groups of patients both

treatment protocols demonstrate comparable clinical results during the first 8 weeks.

• Early active motion does not result in a higher rate of complications but fails to speed up rehabilitation.

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Bioactive Sutures for Tendon Repair:Assessment of a Novel Method of Delivering Mesenchymal Stem Cells

u Jeffrey Yao, MD, Palo Alto, CAJonathan Riboh, BS, Palo Alto, CAJames Chang, MD, Palo Alto, CAR. Lane Smith, PhD, Palo Alto, CA

HYPOTHESIS: Pluripotential mesenchymal stem cells (MSCs) may be seededon to sutures intended for tendon repair. These cells may beinfluenced to adhere to suture material and furthermore,remain in culture attached to those sutures. These cell-impregnated sutures may be useful for promoting healing of tendon repairs.

METHODS:10 cm segments of 4-0 Fiberwire (Arthrex, Naples FL),Ethibond and Vicryl (both Ethicon, Somervile, NJ) sutures werecoated for 16 hours with 10 f Y g/mL fibronectin, 10 f Y g/mLpolylysine (both Sigma-Aldrich, St Louis, MO) or PBS. Thesutures were placed in sterile dishes and covered with a 1 million cells / mL suspension of C3H10T1/2 cells (murinemesenchymal line) for 24 hours. The sutures were then placedinto low adhesion polypropylene tubes with DMEM and 10%FBS for 7 days. The presence of viable cells on these sutureswas assessed by methylene blue vital staining of cellsmigrating off the suture on to a fresh culture dish into formedcolonies (Figure 1) and by the colorimetric Alamar Blue cellproliferation assay. Spectrophotometry was utilized to quantifythe relative amount of cell proliferation across theexperimental groups (Figure 2). All experiments wereperformed in duplicate.

Figure 1: Cell colony formation off of Ethibond, Fiberwire andVicryl sutures.

Figure 2:Alamar Blue

RESULTS/STATISTICS:The largest number of viable cell colonies resulted fromseeding of Fiberwire sutures (13 colonies/dish), followed byEthibond sutures (9 colonies/dish) and Vicryl sutures (2colonies/dish). Coating Fiberwire suture with fibronectinincreased the number of viable cells present by 65% whencompared to control (PBS). Coating the suture with polylysineincreased the cell number by 18% compared to control.

SUMMARY POINTS:• MSCs may be seeded onto sutures and adhere and survive

in culture.• Fiberwire is the most promising suture for cell seeding.• Fibronectin coating of sutures offers significant

improvement in retention of viable cells.• Standard suture coated with MSCs may augment tendon

repairs. Further study will elucidate this.

REFERENCES:1. Towler DA, Gelberman RH. The alchemy of tendon repair:

a primer for the (S)mad scientist. J Clin Invest. 2006 Apr;116(4):863-6

2. Rohrich RJ, Trott SA, Love M, Beran SJ, Orenstein HH. Mersilene suture as a vehicle for delivery of growth factors in tendon repair. Plast Reconstr Surg. 1999 Nov;104(6):1713-7

3. Rickert M, Jung M, Adiyaman M, Richter W, Simank HG.A growth and differentiation factor-5 (GDF-5)-coated suture stimulates tendon healing in an Achilles tendon model in rats. Growth Factors. 2001;19(2):115-26

55


Growth Differentiation Factor-5 Induced Tendon Repair and Regeneration

l Trevor Starnes, MD, PhD, Charlottesville, VAGirish Kesturu, PhD, Charlottesville, VARoshan James, MS, Charlottesville, VALance M. Brunton, MD, Charlottesville, VAGary Balian, PhD, Charlottesville, VAA. Bobby Chhabra, MD, Charlottesville, VA

HYPOTHESIS: The aim of this study is to determine the spatial and temporaleffects of growth differentiation factor–5 (GDF-5) expression in both normal and healing tendon and the action ofrecombinant human growth differentiation factor–5 (rhGDF-5)in a tendon repair model. We hypothesize that GDF-5treatment will increase tendon collagen and proteoglycancontent, enhance tendon diameter and strength, and showlocalized expression to the site of injury and repair.

METHODS: In vivo tendon repair was completed using a rat Achillestendon model. The Achilles tendon was transected,lengthened, and repaired using a modified Kessler’s technique.The tendons were then harvested en bloc at different timepoints and used for biochemical analysis, histology,biomechanical testing, and immunolocalization studies.

RESULTS/STATISTICS: Using a rat Achilles tendon repair model, rhGDF-5 treatmentupregulated the production of proteoglycan, increased tendondiameter and improved collagen fibril organization ascompared to control specimens. Biomechanical testingrevealed an increase in tensile strength with increasingdosages of GDF-5 protein. GDF-5 immunolocalization to thesite of tendon repair was biphasic with the highest levelsdetected early after repair and again increasing at day 10.

SUMMARY POINTS: Tendon repair and regeneration following injury is asuboptimal process controlled by multiple growth factors and cytokines. • These results indicate that GDF-5 protein treatment

increases tendon proteoglycan content and improves collagen orientation and strength which may enhance tendon healing.

• The clinical significance of this study is manifested by the timely upregulation of GDF-5 – induced metabolic activity, since surgically repaired tendon lacerations are weakest approximately 10-14 days postoperatively.

• This data suggests that either administration of GDF-5 intothe tendon at the time of injury or repair of the tendon with a GDF-5 eluting scaffold may shorten the required period of immobilization to allow for safe, early active range of motion of an injured digit.

REFERENCES:1. Aspenberg P, Forslund C. Enhanced tendon healing with

GDF 5 and 6. Acta Orthop Scand 1999; 70 51-42. Chhabra A, Tsou D, Clark RT, et al. GDF-5 deficiency in

mice delays Achilles tendon healing. J Orthop Res 2003; 21 826-35

3. Rickert M, Jung M, Adiyaman M, et al. A growth and differentiation factor-5 (GDF-5)-coated suture stimulates tendon healing in an Achilles tendon model in rats. Growth Factors 2001; 19 115-26

l Received support from NIH-NIAMS

56


Flexor Tendon Tissue Engineering: Preservation of BiomechanicalProperties in Acellularized and Reseeded Tendon Constructs

l Alphonsus K. Chong, MD, Palo Alto, CAJonathan Riboh, BS, Palo Alto, CADerek Lindsey, MS, Palo Alto, CAHung Pham, BS, Palo Alto, CAJeffrey Yao, MD, Palo Alto, CAJames Chang, MD, Palo Alto, CA

HYPOTHESIS: Tissue engineering of flexor tendons requires scaffold materialwith adequate biomechanical strength. We hypothesized thattreatments for acellularization and reseeding of flexor tendonswould not significantly decrease the tensile stress and elasticmodulus compared to normal tendons.

METHODS:Rabbit forepaw and rearpaw flexor tendons were acellularizedusing an optimized protocol. Acellularization of the tendonsamples was assessed by histology and by cell viability assay.Reseeded constructs were obtained by incubating acellularizedtendons in a tenocyte cell suspension. Tensile testing wasperformed to compare the ultimate tensile stress and elasticmodulus of acellularized tendons (n=24), reseeded tendonconstructs (n=24), and fresh flexor tendons (n=32).Comparison across groups was done using ANOVA andcomparisons of means between acellularized and reseededconstructs versus normal controls were performed using theStudent t-test.

RESULTS/STATISTICS:Complete acellularization was achieved as evidenced by theabsence of cells within the tendon and the lack of viable cellsobtained in culture. Acellularized tendons were successfullyreseeded with tenocytes. Acellularized tendon had the sameultimate stress and elastic modulus as normal tendons.Reseeded constructs had the same elastic modulus as normaltendons but rearpaw tendon constructs showed a decrease inultimate stress compared to normal tendons (50.09 MPa vs66.01 MPa, p = 0.026). Forepaw tendons had similar ultimatestress compared to normal tendons. The study has 90%power to detect a difference of 18N in ultimate tensilestrength between groups.

Representative H&E section of flexor tendons:A. Normal flexor tendon – note flat tenocytes

and crimp pattern.B. Acellularized tendon – absence of tenocytes and

loss of crimp.C. Reseeded tendon construct – arrow points to single

cell on surface of tendon. (Original magnification 40x).

SUMMARY POINTS:• The treatment protocol can consistently acellularize flexor

tendons. • Acellularized tendons retain the biomechanical properties

of normal flexor tendons. • Acellularized tendons can be successfully reseeded to form

tendon constructs. • Reseeded constructs retain the elastic modulus of normal

tendons, but show a decrease in ultimate stress in the caseof rearpaw tendons.

• Acellularized flexor tendons are potential high strength scaffolds for flexor tendon tissue engineering.

57

Paper 36 continued

REFERENCES:1. Boyer MI, Strickland JW, Engles D, et al. 2003. Flexor

tendon repair and rehabilitation: state of the art in 2002. Instr Course Lect 52: 137-61

2. Leversedge FJ, Zelouf D, Williams C, et al. 2000. Flexor tendon grafting to the hand: an assessment of the intrasynovial donor tendon-A preliminary single-cohort study. J Hand Surg [Am] 25: 721-30

3. Seiler JG, 3rd, Chu CR, Amiel D, et al. 1997. The Marshall R. Urist Young Investigator Award. Autogenous flexor tendon grafts. Biologic mechanisms for incorporation. Clin Orthop Relat Res 239-47

4. Gelberman RH, Seiler JG, 3rd, Rosenberg AE, et al. 1992. Intercalary flexor tendon grafts. A morphological study of intrasynovial and extrasynovial donor tendons. Scand J Plast Reconstr Surg Hand Surg 26: 257-64

5. Chong AK and Chang J 2006. Tissue engineering for the hand surgeon: a clinical perspective. J Hand Surg [Am] 31: 349-58

6. Ng BH, Chou SM, Lim BH and Chong A 2005. The changes in the tensile properties of tendons after freeze storage in saline solution. Proceedings of the Institution of Mechanical Engineers 219: 387-92

7. Cartmell JS and Dunn MG 2004. Development of cell-seeded patellar tendon allografts for anterior cruciate ligament reconstruction. Tissue Eng 10: 1065-75

8. Awad HA, Boivin GP, Dressler MR, et al. 2003. Repair of patellar tendon injuries using a cell-collagen composite. J Orthop Res 21: 420-31

9. Kryger G, Chong AK, Costa MA, et al. In Press. A comparison of tenocytes and mesenchymal stem cells for use in flexor tendon tissue engineering. J Hand Surg [Am]

10.Webb K, Hitchcock RW, Smeal RM, et al. 2006. Cyclic strain increases fibroblast proliferation, matrix accumulation, and elastic modulus of fibroblast-seeded polyurethane constructs. J Biomech 39: 1136-44

11.Abousleiman RI and Sikavitsas VI 2006. Bioreactors for tissues of the musculoskeletal system. Adv Exp Med Biol 585: 243-59

l Received support from VA Merit Review, American Society for Surgery of the Hand and American Association of HandSurgery

58


Locally Delivered IGF-1 During Nerve Regeneration in Aged Rats

l Peter J. Apel, MD, Winston-Salem, NCJianjun Ma, MD, PhD, Winston-Salem, NCZhongyu Li, MD, PhD, Winston-Salem, NC

HYPOTHESIS: Age is known to negatively impact functional recovery afternerve repair. The hypothesis of this study was that locallydelivered insulin-like growth factor (IGF) would improve thequality of nerve regeneration in aged rats.

METHODS:Twenty-four Brown Norway/Fischer 344 rats were divided intotwo groups: young (8 months) and aged (24 months). Allanimals underwent tibial nerve transection leaving a 4 mmgap. The nerve was repaired using a semi-porous T-tubeapparatus. The nerve stumps were placed in the ends of the T-tube, and the middle arm attached to a mini-pump. Half ofthe animals in each age group received IGF-1 at 0.025micrograms per hour. The other half received vehicle at thesame rate. Three months after the initial transection, theregenerated nerve was tested for compound motor actionpotential (CMAP). The tibial nerve was exposed above therepair site and stimulated with increasing current (0.5mA-3.0mA). The depolarization of the gastrocnemius wasrecorded. The motor neurons were double-labeled withfluorescent tracers to quantify neurons that survived the nervetransection and crossed the repair site. After testing, theregenerated nerve was harvested for histological analysis, and the muscle was processed for phenotype changes.

RESULTS/STATISTICS: For control animals, 83% of young animals showed electricalevidence of regeneration vs. 50% of aged animals. Foranimals treated with IGF-1, 100% of animals in both groupsshowed electrical evidence of regeneration. In addition,average muscle mass in the affected limb improved with IGF-1treatment in aged animals from 0.84g to 1.01g. Younganimals did not show a difference in muscle mass recoverywith IGF-1 treatment. Preliminary results from histologicalanalysis support this trend.

SUMMARY POINT: These preliminary results suggest that IGF-1 may amelioratethe age-related impairment of peripheral nerve regeneration.

Figure 1:T-tube apparatus on the tibial nerve. Proximal is to the right ofthe photo.

Figure 2:Compound motor action potential (CMAP) tracing from atreated animal. Tracing C and D are from the normal,contralateral nerve.

l Received support from the Orthopaedic Research andEducation Foundation

59


A Decellularized, Enzyme Processed Nerve Allograft Provides BetterRecovery of Function than Isografts in Rat Sciatic Nerve Repair

l David Muir, PhD, Gainesville, FL

HYPOTHESIS: Nerve regeneration after repair with a decellularized, enzyme-processed, sterile nerve allograft is comparable to autograftingin the rat.

METHODS: Donor nerve grafts from Sprague-Dawley rats were recovered,frozen and then decellularized using a series of detergents asdescribed by Hudson et al. (2004). The decellularized nerveswere then treated with chondroitinase ABC as described byKrekoski et al. (2001). The nerve grafts were frozen, gamma-irradiated, and then thawed and trimmed before use. A 0.5cmgap in the sciatic nerves of adult Fischer rats was repaired witha 1.0cm processed allograft (n=6). Live isografts (from Fischerrat donors) were transplanted into Fisher rat hosts within 30minutes of harvest (n=6). All grafts were coapted by epineurialsutures and secured with fibrin glue. Recovery of sciatic nervefunction (sensory and motor) was assessed every 2 weeksfrom 4 through 24 weeks after grafting.

RESULTS/STATISTICS:Five behavioral function tests were compiled as a single index.Ten weeks after repair, animals receiving isografts recovered39% of preoperative function while those with processedallografts showed 52% recovery (P<0.05, Likelihood ratiotest).

SUMMARY POINTS: • A detergent decellularized rat nerve allograft was

developed that retains the essential 3-dimensional nerve sheath structures and supports regeneration without immunosuppression, but decellularized grafts are limited in terms of regeneration potential.

• We developed means to enhance the growth-promoting properties of decellularized nerve grafts by treatment with chondroitinase to selectively remove inhibitory chondroitin sulfate proteoglycan, to unmask endogenous growth promoting factors and to potentiate the regenerative properties if the endoneurial scaffold.

• Decellularized, chondroitinase-treated, sterile nerve allografts provided superior results to live isografts and may represent a major breakthrough for clinical nerve repair.

REFERENCES:1. Hudson TW, Zawko S, Deister C, Lundy S, Hu CY, Lee K,

Schmidt CE (2004) Optimized acellular nerve graft is immunologically tolerated and supports regeneration. Tissue Eng 10:1641-1651

2. Krekoski CA, Neubauer D, Zuo J, Muir D (2001) Axonal regeneration into acellular nerve grafts is enhanced by degradation of chondroitin sulfate proteoglycan. J Neurosci21:6206-6213

l Received support from AxoGen Corp.

60


Glial Derived Growth Factor (GDNF) to Gene TherapyModulates Neuronal Phenotype after Chronic Nerve Injuries

l Ranjan Gupta, MD, Irvine, CAErika Strandberg, BS, Irvine, CAMona Tafti, BS, Irvine, CAOswald Steward, PhD, Irvine, CA

HYPOTHESIS: Chronic nerve compression (CNC) injuries are commonafflictions affecting quality of life. Previous work hasdemonstrated that there are numerous cellular changes thatoccur prior to distinct electrophysiologic changes after CNCinjury. It was our hypothesis that small-diameter nerve fibersare preferentially affected and account for pain or nociceptionand that the local up-regulation of glial-derived neurotrophicfactor (GDNF) by Schwann cells (SCs) may modulate theneuronal phenotypic response secondary to chronic nerve injury.

METHODS: A CNC animal model was created by atraumatically placing a biologically inert tube around the sciatic nerve with thecontralateral nerve mobilized as a control. The phenotypic shiftwas determined by assessing fluorogold and fluoro rubyuptake and immunohistochemical colocalization with specificmarkers for DRG phenotype. GDNF and growth associatedprotein 43 (GAP-43) expression was assessed usingimmunohistochemistry and western blot analysis.

RESULTS/STATISTICS: Injured neurons are known to uptake Fluororuby from the siteof injury. Fluororuby uptake colocalized with calcitonin generelated peptide (CGRP) and isolectin B-4 (IB-4) bindingneuronal profiles in the L4 and L5 ipsilateral DRG, indicative of damage to small diameter neurons. Additionally, DRGsexhibited a marked reduction in neurofilament-200 (NF-200)positive neurons, concurrent with an increase in number of IB-4 binding and CGRP positive neurons, indicating that aphenotypic shift had occurred. At six months post injury DRG phenotype had returned to normal. GDNF protein levelstemporally correlated with these findings as they increased inL4 and L5 DRG early in injury, followed by return to baselineat six months.

SUMMARY POINT: Patients with CNC injuries often present with pain andsymptoms prior to positive electrophysiologic findings. These data demonstrate that there are changes to the smallerdiameter neurons/fibers that are responsible for these clinicalfindings. This altered neuronal phenotype after CNC injurylikely occurs secondary to the local increased expression ofGDNF by Schwann cells. Small diameter fibers are generallyless myelinated and therefore have a slower conductionvelocity. As such, changes to these neuronal fibers would not be detected with standard electrophysiologic techniques.Sophisticated electrophysiology techniques, including nearnerve studies, may be able to identify damage to smalldiameter neurons early in the disease course. Moreover, it ispossible that with modern techniques, including gene therapy,that we may be able to modulate the response to chronicnerve injuries and abate symptoms of pain with non-operativetherapeutic strategies.

REFERENCES:1. Gupta R et al. Exp Neuro 200(2): 418-29, 20062. Gupta R et al. J Neurotrauma 23(2): 216-226, 20063. Hoke A et al. J Neuroscience 26(38): 9646-55, 2006

l Received support from NIH-NINDS 5R01 NS049203

61


Atrogin-1 Levels and Axonal Integrity Are Maintained AfterChronic Nerve Compression-Induced Nerve Sprouting

l Erika Strandberg, BS, Irvine, CAKazuko Abe, BA, Irvine, CATahseen Mozaffar, MD, Irvine, CARanjan Gupta, MD, Irvine, CA

HYPOTHESIS: Demyelination of the nerve occurs early after chronic nervecompression (CNC) injury and is followed by axonaldegeneration with loss of sensation and muscle atrophy.Clinically, there is a gradual decline in nerve conductionvelocity (NCV) with no early changes in compound motoraction potential (CMAP). We hypothesize that the axonaldegeneration is not required to induce an early Schwann cellresponse after CNC injury.

METHODS:A CNC animal model was created by atraumatically placing an inert tube around the sciatic nerve with the contralateralmobilized as a control (1,2). The sciatic nerve was transectedat its proximal stump and returned to the bed to degeneratefor two weeks as a positive control. We chose to study thesoleus muscle because of its early and severe involvement indenervation, and harvested nerve and muscle at multiple time-points. Motor unit number estimation (MUNE) andneurodiagnostic studies (NDX) determined functional axonal integrity. Quantitative real-time PCR (QRT-PCR) andImmunohistochemistry were used to assess for muscle atrophyand integrity of the neuromuscular junction (NMJ),respectively. Additionally, muscle fiber cross-sectional area(CSA) was determined. Statistical analysis was performedusing Students t-tests and one-way ANOVA with Newman-Keuls multiple comparison post-test.

RESULTS/STATISTICS: There was a progressive decline (NCV) with no changes inCMAP, MUNE, or other NDX. There was no change in Atrogin-1 mRNA levels, which is robustly expressed in mostmuscle atrophy paradigms (3). Immunohistochemistry showedevidence for sprouting from the nodes of Ranvier. The NMJremained intact in CNC injury and soleus muscle fibers on the compressed side had slightly decreased CSA.

SUMMARY POINT: Our original hypothesis that axonal degeneration is notrequired to induce axonal sprouting is supported by this data.We conclude that CNC injury does not initially induce motoraxon loss and that the early changes in CNC are likelySchwann cell-mediated.

REFERENCES:1. Gupta et. al. Exp Neuro 2006 Jun 72. Gupta R and Steward O. JCN 461(2):174-86, 2003 3. Bodine SC, Latres E, Baumhueter S et. al. Science

294:1704-1708, 2001 +

l Received support from PHS-5K08NS002221 and5R01NS049203

62


Erythropoeitin for Traumatic Peripheral Nerve Injury

l John C. Elfar, MD, Rochester, NYJustin Jacobson, MD, Rochester, NYMichael Zuscik, PhD, Rochester, NYRandy Rosier, MD, PhD, Rochester,NY

HYPOTHESIS: Erythropoetin is neuroprotective and can show actualfunctional benefit in standard animal models of peripheralnerve injury. Such functional benefit is relevant to the practiceof hand surgery.

METHODS:Mice underwent recovery surgery in three experimentsdesigned to illustrate the effects of EPO. Mice wererandomized to groups including those subjected to crushinjuries, EPO treatment (5000 U/Kg), neurectomy and shamsurgery. In separate experiments mice randomly received EPOtreatment at different times after injury during the naturalrecovery period. Mice were then evaluated with functionalwalking track analysis and results were correlated withhisptopathological specimens from mice sacrificed as part ofthe experimental design. Finally, immunolocalization forrelevant markers of EPO signaling was undertaken to evaluatethe presence or absence of the EPO receptor (EPO-R) at thesite of injury.

RESULTS/STATISTICS:Mice exposed to a standard crush injury recovered slower thanidentical mice treated with EPO after the injury. Sham andneurectomized mice behaved predictably as positive andnegative controls. Specific immunohistochemical analyses ofmice revealed EPO-R expression that was related to injury andEPO administration. When mice were exposed to a moreextensive injury, untreated mice recovered reliably but moreslowly than identical mice exposed to EPO and treatmentbenefit was largely independent of the time of EPOadministration up to one week after injury. Histologicalanalyses directed toward spinal cord and ganglia showedpositive staining for EPO-R confirming the presence of thisreceptor in both the cord and peripheral nerve neurons andsupportive tissue. Mice treated with EPO after sciatic nervetransection and repair, failed to recover function but revealedintense staining for EPO-R at the repair sites.

SUMMARY POINT:EPO treatment in the setting of nerve injury improves functionin a predictable way. Taken together these data suggest animportant role for EPO in peripheral nerve recovery after injury.

l Received support from the University of Rochester.

63


The Pain of Chronic Nerve Injuries May Be Mediated By Schwann Cells

l Laura S. Rummler, MS, Irvine, CAWinnie Palispis, BS, Irvine, CARanjan Gupta, MD, Irvine, CA

HYPOTHESIS: Pain is induced early after chronic nerve compression (CNC)injury. In this study we sought to understand the source of thispain. We hypothesized that, like the human condition, the in-vivo model induces pain in the early stages of injury. As CNCinjury produces a distinct pathology and painful symptomsfrom acute nerve injuries(1), we further hypothesized that thispain is non-inflammatory.

METHODS:To create the model, biologically-inert silastic tubes werewrapped atraumatically around sciatic nerves of Sprague-Dawley rats. Contralateral nerves were mobilized as controls.Pure Schwann cell cultures were established using themodified Brockes technique. Western blot andimmunohistochemistry were performed according to standard protocols.

RESULTS/STATISTICS:c-fos is upregulated in the spinal cord in response to painfulperipheral stimuli.(2) Using immunohistochemistry, we foundincreased c-fos expression that peaks 2 weeks post-injury.Western blot for the pro-inflammatory cytokines TNF-αand IL-6 showed no change in expression from intact nerves at5-days and 2-weeks. Voltage-gated sodium channels can alterthe excitability of sensory neurons and produce chronic pain.Two weeks post-injury, NaV1.8-immunoreactive Schwann cellsappear in the periphery of longitudinal nerve sections andprotein expression is upregulated. Teased nerve fibers analysisconfirmed that these cells are myelinating. Imunolabeledpurified Schwann cell cultures demonstrated that most cellsexpress low levels of NaV1.8.

SUMMARY POINT:While there is an upregulation of c-fos 2-weeks post-injurythat suggests activation of a pain-inducing pathway,expression of pro-inflammatory cytokines that are crucial toinflammatory pain pathways remain stable. An alternate non-inflammatory source of pain may involve upregulation ofNaV1.8 by Schwann cells within the nerve. This is consistentwith earlier studies which showed that CNC injury is likely aSchwann cell-mediated disease. As Schwann cells appear toplay a pivotal role in CNC injury-related pain, futuretreatments may be possible using Schwann cell-targetedtherapies.

REFERENCES:1. Gupta, R. Exp Neuro (2006)2. Hunt, SP. Nature (1987)3. Akopian, AN. Nat Neurosci (1999)

l Received support from NIH NINDS-5R01 NS049203.

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Paper 43Saturday, September 29, 2007, 8:45 - 8:52 AM

Impact of Posttraumatic Stress Disorder (PTSD) and Depressionon Functional Status in Patients with Hand Injuries

Allison Williams, ND, PhD, Denver, COJustin Newman, III, MS, Denver, COu Kagan Ozer, MD, Denver, COAmanda Laufer, BS, Denver, COSteven Morgan, MD, Denver, COWade Smith, MD, Denver, CO

HYPOTHESIS: Posttraumatic stress disorder (PTSD) and depression have anegative impact on functional status in hand injury patients.

METHODS:A prospective, epidemiological study was conducted ofpatients who sustained a hand injury. Patients with adocumented history of chronic mental illness, or cognitiveimpairment were excluded. Psychological status was assessedusing the Revised Civilian Mississippi Scale for PTSD (RCMS)and the Beck Depression Inventory (BDI). Functional status wasevaluated with the SF-36. Demographics and injurycharacteristics were obtained from the patient charts. Mann-Whitney, Fisher Exact, and Chi-square tests were performed toanalyze functional status in relation to psychological status.

RESULTS/STATISTICS:Sixty-eight patients (24 female, 44 male) were included. Themean age was 40.6 (range 18-79). Mechanism of injury forthe majority of injuries was a fall (n = 22, 32.4%) followed bylacerations (n = 10, 14.7%). Responses to the RCMS indicatedthat 24 persons (35.4%) were positive for PTSD. BDI responsesidentified 19 (27.9%) patients with depression. Fifteen(22.1%) patients were positive for both PTSD and depression.The association between PTSD and depression was significant(p < 0.01). Persons with PTSD had significantly lower scoresfor all SF-36 subscales (p < 0.05) except physical functioning(p = 0.051). Patients with depression had significantly lowerscores on all SF-36 subscales (p < 0.05). Depression andmeasures on the SF-36 general health subscale had asignificant negative correlation (r = -0.73, p < 0.01)

SUMMARY POINTS:• PTSD and depression affect a notable percentage of

persons who experience a hand injury. • Presence of PTSD and/or depression has a significant

negative impact on functional status following hand injury. • Depression is significantly correlated with perceptions of

general health in hand injured patients. • Psychological status should be addressed when caring for

patients with hand injuries.

65


Psychological Distress and Idiopathic Arm Pain

l Ana-Maria Vranceanu, PhD, Boston, MAMeijuan Zhao, MD, Boston, MAChaitanya Mudgal, MD, Boston, MAJesse Jupiter, MD, Boston, MASteve Safren, PhD, Boston, MADavid Ring, MD, PhD, Boston, MA

HYPOTHESIS: The psychological disorders that associate with idiopathic armpain and correlate with perceived disability may overlap andinteract to some degree. This study tested the hypothesis that,controlling for other psychological diagnoses, psychologicaldistress (depression and anxiety) predicts idiopathic vs. discretearm pain.

METHODS:Forty-one patients with idiopathic arm pain and 40 withdiscrete arm pain completed the Patient Health Questionnaire(PHQ; a validated measure of somatoform disorder,depression, anxiety disorder, and disorders of lifestyle copingfactors), a measure of post-traumatic stress disorder (PTSD),and a measure of arm-specific perceived disability (TheDisabilities of the Arm, Shoulder, and Hand questionnaire;DASH).

RESULTS/STATISTICS:Compared to patients with discrete arm pain, patients withidiopathic arm pain were younger, more often single, had hada greater number of prior diagnostic tests, were more likely tobe taking psychiatric medication, and reported greaterdisability (higher DASH). According to validated quantitativemeasures, patients with idiopathic arm pain were significantlymore likely than patients with discrete arm pain to bediagnosed with somatoform disorder (34% vs. 7% p < 0.01),anxiety disorder (29% vs. 10% p < 0.05), and PTSD (24% vs.7%; p < 0.05). In multivariate analyses, somatoform disorderwas the sole predictor of 1) idiopathic vs. discrete pain; and, 2)perceived disability (DASH score).

SUMMARY POINT:While psychological distress (anxiety in particular) is commonamong patients with vague, diffuse, non-specific, medicallyunexplained (idiopathic) arm pains, somatoform disorder is abetter predictor of idiopathic vs. discrete pain and is thedominant determinant of perceived disability.

l Received support from the AO Foundation, Small BoneInnovations, Smith and Nephew Richards, Wright Medical,Joint Active Systems, and Biomet

66


Negative Misconceptions about Pain Predict Perceived Disability

l Ana-Maria Vranceanu, PhD, Boston, MAJames Cowan, BA, Boston, MADavid Ring, MD, PhD, Boston, MA

HYPOTHESIS: Negative misconceptions about pain (as measured by a newlyvalidated quantitative scale—The Negative Pain ThoughtsQuestionnaire; NPT) predict perceived disability independent of depression.

METHODS:100 new patients with various complaints of arm paincompleted measures of arm-specific perceived disability (The Disabilities of the Arm, Shoulder, and Handquestionnaire; DASH), depression (The CESD questionnaire),and the NPT questionnaire, which assesses 11 commoncognitive errors associated with chronic pain. The NPT wasvalidated with Principal Component Factor Analyses and inter-item correlations. Univariate and multivariate analyses wereused to determine predictors of perceived disability (DASH).

RESULTS/STATISTICS:The internal consistency of the NPT was high, .92, with all

inter-item correlations with rs > .5. The Principal ComponentAnalyses of the 11-item scale identified one factor withEigenvalue greater than 1, which explained 67 % of the totalvariance. Univariate regression linear regression analysesshowed that NPT significantly predicted disability (r = .504, p = .001) and depression (r = .330, p = .05). In multivariatelinear regression, NPT predicted disability even after controllingfor depression (b = 0.52, p < 0.01). NPT was found to explain55% and depression 34% of the variance in DASH scores.

SUMMARY POINT: The NPT represents an internally consistent measure ofmisconceptions about pain. Pain related misconceptionspredict perceived disability independent of depression.Cognitive behavior therapy (CBT) can help replace negativemisconceptions about pain with more positive illness conceptsand thereby reduce perceived disability. The NPT may prove tobe a useful screening tool for identifying patients that maybenefit from CBT.

l Received support from AO Foundation, Small BoneInnovations, Smith and Nephew Richards, Wright Medical,Joint Active Systems, and Biomet

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The Importance of Recognizing, Validating, and TreatingPsychosocial Symptoms in Chronic Limb Pain Patients

l Jose J. Monsivais, MD, El Paso, TXKris Robinson, MD, El Paso, TX

HYPOTHESIS: Recognizing and treating psychosocial symptoms improvessurgical outcomes.

METHODS:We conducted an archival review of records from 91 patientstreated for neuropathic pain over a ten-year period in aspecialty clinic. Inclusion criteria included individuals withproven nerve dysfunction experiencing pain > 3 months.Diagnosis was established by history, physical examination,electrodiagnostic studies and imaging. Surgical candidateswere determined by severity of sensory-motor abnormalitiesand had no evidence of untreated or uncontrolled depressionor other psychological distress. Surgical procedures includednerve decompressions, reconstruction, neurolysis, and excisionof neuromas. Medical treatment included analgesics,adjuvants, and neuroleptic medications. Psychosocialtreatment included a prescription to return to work on apredetermined date and psychological evaluation withdiagnosis and testing (Oswestry Pain Questionnaire, GAF, and PSS). Participants received periodic clinical evaluation of sensory and motor function, and assessment of pain.Statistician conducted analysis which consisted of correlationsand Chi Square using SAS statistical program.

RESULTS/STATISTICS:Over 93% (85/91) of patients returned to work and reportedlower levels of pain up to 5 years after onset of nerve injury/condition. Return to work date was determined by sensoryand motor recovery. In addition, no differences were notedbetween groups on a variety of psychosocial measures aftertreatment including pain level (p=.2), litigation status (p > .5),and return to work (p>.05). The majority of individualsexpected total relief of pain with surgical treatment. Reporteddrug and alcohol abuse was lower than that of the generalpopulation and did not differ between groups.

SUMMARY POINT:With psychosocial assessment, support, and adequate paintreatment, there seems to be no difference in functionaloutcomes on several levels between those patients receivingsurgical and non-surgical treatment. Patients' expectations ofsurgery are unrealistic and must be addressed prior totreatment. In summary, recognizing, validating, and treatingpsychosocial symptoms in chronic limb pain patients improvessurgical outcomes.

l Received support from The University of Texas at El Paso

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Idiopathic Arm Pain is a Somatoform Disorder

l Ana-Maria Vranceanu, PhD, Boston, MAMeijuan Zhao, MD, Boston, MAJames Cowan, BA, Boston, MASteven Safren, PhD, Boston, MADavid Ring, MD, PhD, Boston, MA

HYPOTHESIS: Prior research has established that idiopathic arm pain (alsoreferred to as nonspecific or medically unexplained pain) iscommon, disabling, and associated with ineffective copingskills. This study tested the hypothesis that patients withidiopathic arm pain score higher on measures ofhypochondriasis (a somatoform disorder) than control patientswith a discrete painful hand condition.

METHODS: Forty patients with idiopathic arm pain and 26 patients with atrigger finger completed the DASH, a pain intensity scale, andthree validated measures hypochondriasis. Univariate andmultivariate analyses were performed to compare patientswith idiopathic pain and patients with a trigger finger.

RESULTS/STATISTICS: Patients with discrete pain were older, more likely to bemarried, rated themselves less disabled, and had lower painintensity ratings. In univariate analysis, idiopathic arm pain wasassociated with significantly greater hypochondriasis thantrigger finger on all three measures. In multivariate analysis,age, marital status and one of the measures ofhypochondriasis (somatic focus) were the most importantpredictors of idiopathic vs. discrete arm pain.

SUMMARY POINT: When subjective complaints are disproportionate to physicalpathology, the treating physician should be confident to admitpuzzlement and uncertainty, and apply a nonspecificdiagnosis. There is strong and growing evidence baseestablishing that nonspecific chronic pains are associated withineffective coping and psychological distress and mayrepresent a type of somatoform disorder. Cognitive behavioraltherapy may prove more effective than standard treatment inthis setting, and invasive treatment may be inappropriate.

l Received support AO Foundation, Small Bone Innovations,Smith and Nephew Richards, Wright Medical, Joint ActiveSystems, and Biomet

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Oxygen Saturation/Perfusion Measurement in the Evaluationof Patients with Suspected Thoracic Outlet Syndrome

u Richard M. Braun, MD, San Diego, CADavid Sahadevan, BA, San Diego, CAMark Rechnic, MD, San Diego, CA

INTRODUCTION: The clinical diagnosis of a patient with Thoracic OutletSyndrome (TOS) often lacks objective verification. Clinicaloutcomes can be expected to improve if significantmeasurement and data enters the medical decision makingprocess. Vascular flow/perfusion abnormalities may beresponsible for disabling symptoms in TOS suspected patients.

HYPOTHESIS:Significant abnormalities in vascular flow and perfusion may differentiate symptomatic TOS patients from a normalasymptomatic cohort.

METHODS:Pulse oximetry perfusion studies were performed on a normalcontrolled group and on a group of patients with symptomssuggesting TOS. Provocative exercises were performed by each monitored group. Data was collected and analyzed forpossible significant differences in upper limb oxygen saturationand pulse rate experienced during provocation.

This is considered a Level One Evidence Study.

Figure 1b.Pulse oximetry measurement during provocative exercise.

RESULTS/STATISTICS:Oxygen saturation, at rest, for normal controls and TOSsuspects was similar and unremarkable. Provocative exerciseswith the shoulder abducted resulted in a statistically significant(p<0.001) drop in oxygen saturation and associated pulseelevation in patients suspected for a diagnosis of TOS.

SUMMARY POINTS:• Significant abnormalities in vascular flow and perfusion

do separate symptomatic TOS patients from a normal asymptomatic cohort.

• Objective, statically significant limb perfusion data can be used to assist diagnosis in patients suspected for TOS.

• A Mechanism of intermittent claudication may explain subjective complaints, previously considered obscure in TOS suspects.

• Objective data may be used for medical management decisions related to the diagnosis, evaluation and treatment of TOS patients.

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The Risk of Adverse Outcomes in Extra-articular Distal Radius Fractures Are Increasedwith Mal-alignment In Patients of all Ages, But Mitigated in Older Patients

u Ruby Grewal, MD, FRCSC, London, ON, CanadaJoy MacDermid, BScPT, MSc, London, ON, Canada

HYPOTHESIS: The purpose of this study was to determine if mal-alignmentafter extra-articular distal radius fractures influenced patientreported pain and disability at 1-year, and to investigate howthis relationship changes with age.

METHODS:216 subjects with Colles’ fractures were prospectivelyfollowed. The influence of specific radiographic parametersand the overall ‘acceptability’ of alignment on PRWE andDASH scores were assessed. The relative risk (RR) of a pooroutcome in the presence of mal-alignment of the distal radiusat various ages was calculated; the RR was then used tocalculate a number needed to harm (NNH).

RESULTS/STATISTICS:Mal-alignment of the distal radius was associated with higherreports of pain and disability in patients <65 (PRWE: p =0.001, DASH: p< 0.001). In patients aged >65, no isolatedradiographic parameter was found to significantly affect PRWE(p= 0.224) or DASH (p = 0.386) scores however there was anincreased risk of having a poor outcome in fractures with mal-alignment when compared to fractures with acceptablealignment in all age groups. The RR of a poor outcome with mal-alignment showed a decreasing trend with theprogression of age, with a significant reduction after 65 years.In patients >65, 8 mal-aligned distal radii require correction toprevent 1 poor outcome (based on DASH, 9 based on PRWE);in younger patients only 2 mal-aligned radii need correction toavoid 1 poor outcome (based on DASH, 3 based on PRWE).

SUMMARY POINT:Although no radiographic variable correlated with DASH orPRWE scores in patients >65, the risk of poor outcome washigher in the presence of mal-alignment, similar to youngerpatients. The relationship between outcome and alignment of the radius should not be considered as an all or nonephenomenon, but rather considered as a decreasing gradientof risk, with the most significant change seen after patientsreach 65 years of age.

Figure 1Relative Risk of pooroutcome (based onDASH score) andMal-alignment ofthe Distal Radius

Figure 2Number Need toHarm – Based onDASH score

REFERENCES:1. Chang HC, Tay SC, Chan BK, and Low CO. Conservative

Treatment of Redisplaced Colles Fractures in Elderly PatientsOlder than 60 Years Old - Anatomical and Functional Outcome. Hand Surg 6(2):137-144, 2006

2. Kelly AJ, Warwick D, Crichlow TPK, and Bannister GC. Is Manipulation of a Moderately Displaced Colles' fracture worthwhile? A prospective randomized trial. Injury 28(4):283-287, 1997

3. Young BT, Vernal UT, Ghazi M, and Rayan MD. Outcome Following Nonoperative Treatment of Displaced Distal Radius Fractures in Low-Demand Patients Older Than 60 Years. J Hand Surg [Am] 25A:19-28, 2000

4. Anzarut A, Johnson JA, Rowe BH, Lambert RG, Blitz S, and Majumdar SR. Radiologic and Patient-Reported Functional Outcomes in an Elderly Cohort With Conservatively TreatedDistal Radius Fractures. J Hand Surg [Am] 29(6):1121-1127, 2004

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5. Beharrie AW, Beredjiklian PK and Bozentka DJ. Functional Outcomes After Open Reduction and Internal Fixation for Treatment of Displaced Distal Radius Fractures in Patients Over 60 Years of Age. J Orthop Trauma 18:680-686, 2004

6. Beumer A, McQueen MM. Fractures of the distal radius in low-demand elderly patients Closed reduction of no value in 53 of 60 wrists. Acta Orthop Scand 74(1):98-100, 2003

7. McQueen M, Caspers J. Colles fracture: does the anatomical result affect the final function? J Bone Joint Surg Br 1988;70:649–51

72


Sagittal Rotational Malunions of the Distal Radius

u Francisco del Piñal, MD, Santander, SpainFrancisco Garcia-Bernal, MD, Santander, Spain Javier Regalado, MD, Santander, SpainHiginio Ayala, MD, Santander, SpainLeopoldo Cagigal, MD, Santander, SpainAlexis Studer, MD, Santander, Spain

HYPOTHESIS: To present a group of malunited distal radius fractures, whosemain deformity is malrotation in the sagittal plane. Despiteradius shortening and dorsal tilt, correction of both can beachieved by simple derotation of the distal fragment, withoutthe need of any interpositional wedge graft to lengthen theradius.

METHODS: This subgroup can be recognized by two facts on the lateralradiogram: 1) Presence of a “hinge” point on the volar cortex,without translocation of the distal fragment, and 2) Ulnarhead shorter than the most distal edge of the anterior lip ofthe radius (irrespective of the ulnar variance on the PA view).The procedure consists of preplating, incomplete volarosteotomy through the “hinge” point, and derotation of thedistal fragment. The defect was filled with cancellous bonegraft from the olecranon. Range of motion was startedimmediately. Five patients were identified as having a purerotational malunion and treated with the above protocol: fourwere dorsal and one volar malrotations. Preoperatively all hadsevere pain (8 over 10 in a VAS) and limitation of motion andgrip strength less than 50% of the healthy side. DASH av. 59.

RESULTS/STATISTICS: All osteotomies healed primarily. One patient sustained a falland broke her ulna donor site. All improved to 90% of thenormal ROM and grip strength. Significant improvement inDASH in all (Delta DASH>10). Radiologically sagittal tiltimproved, in the dorsal malunited group, from -25.2º to+5.2º. Ulna variance improved 3.5 mm, from +2 to -1.5mm.

SUMMARY POINT:In spite of not using a structural corticocancellous interpositionwedge graft to lengthen the radius, a pure derotationalosteotomy corrects radius shortening and dorsal tilt in thissubgroup of patients. Our study questions the accuracy ofmeasurements in distal radius malunion using classiclandmarks.

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Sensitivity of Fluoroscopy in Determining Screw Position in the Distal Radius

l Jeffrey A. Greenberg, MD, Indianapolis, INAndrew Thomas, MD, St. Paul, MN

HYPOTHESIS: During volar plating of distal radius fractures accurateintraoperative assessment of screw position is essential toavoid iatrogenic complications, specifically extensor tendonrupture. This study evaluates the sensitivity of fluoroscopy for detecting screw positioning in the dorsal distal radius.

METHODS: Cadaveric distal radii were used. Standard 2.4 mm screwswere placed from volar to dorsal in the radial, central, andulnar thirds of the distal radius. Screws were placed 1 mm shy of cortex, flush to bone, 1 or 2 mm proud of cortex.

Fluoroscopic images were then produced, intentionally makingthe screw appear as proud as possible. Hard copies were thenprovided to practicing hand surgeons with different years ofexperience. Evaluators were then asked to assess screwposition.

RESULTS:Results were stratified by the position of the screw in the distalradius and by the evaluators' experience. Combining allevaluators, fluoroscopy was found to be 72% sensitive atdetecting screw overshoot in the radial-most position, 75%sensitive in the central position and 54% sensitive in the ulnarposition. Evaluators with greater than three years of practiceexperience determined screw position with 100%, 94% and78% sensitivity in the radial, central, and ulnar positions,respectively. Evaluators with less than three years of experiencewere less accurate, predicting screw position with 63%, 60%,and 56% sensitivity in the radial, central and ulnar positions,respectively.

SUMMARY POINT: Fluoroscopy is a less sensitive method for determining screwovershoot in the ulnar aspect of the dorsal distal radius,particularly with less experienced hand surgeons. Based on thedata presented here, surgeons, and particularly those with lessexperience, should have a low threshold for screw exchangewhen presented with possible screw overshoot in the dorsaldistal radius. A technique in which the dorsal cortex is notpenetrated is recommended.

l Full- or part-time employment or consulting arrangementwith Stryker

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Determinants of Health Status and Wrist Functionafter Operative Fixation of Distal Radius Fractures

u John-Sebastiaan Souer, MD, Boston, MASantiago Lozano-Calderon, MD, Boston, MAJesse Jupiter, MD, Boston, MADavid Ring, MD, PhD, Boston, MA

HYPOTHESIS: This aim of this study was to identify the most importantdeterminants of physician-based and patient-based scoringsystems for the wrist and upper extremity after operativetreatment of a fracture of the distal radius. Our specifichypothesis was that pain is the strongest determinant of bothtypes of scores

METHODS: Eighty-four patients were evaluated a minimum of six monthsafter operative fixation of an unstable distal radius fractureusing two physician-based evaluation instruments (The MayoWrist Score and the Gartland and Werley Score) and an upperextremity specific health status questionnaire (Disabilities ofthe Arm, Shoulder and Hand). Multivariate analysis of varianceand multiple linear regression modeling were used to identifythe degree to which various factors affect variability in thescores derived with these measures.

RESULTS/STATISTICS: The physician-based scoring systems showed moderatecorrelation (r=-0.32, P=0.003) with each other and with DASHscores (r[GW] = 0.41, p<0.001; r[Mayo] = -0.32; p=0.003).The results of multiple linear regression modeling were asfollows (percent variability accounted for by the best fit model/model with top factor alone): Mayo score--54% grip andflexion arc/ 47% grip alone; Gartland and Werley: ¬¬70%pain, flexion arc, radiocarpal arthritis, and duration of follow-up/ 53% pain alone; DASH: 71% pain, forearm arc, and typeof fracture/ 65% pain alone.

SUMMARY POINT: Pain dominates the patient’s perception of function afterrecovery from a distal radius fracture as measured by theDASH score and the physician-based rating according to thesystem of Gartland and Werley. The Mayo score is determinedby grip strength rather than pain. Because the perception ofpain and strength of grip are influenced by psychosocialfactors, both patient-based and physician-based measures ofwrist function after fracture of the distal radius may reflectillness behavior as much as objective pathology.

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Volar Shearing Fractures of the Distal Radius Are UsuallyComplete Articular (AO/OTA Type C) Fractures

u John-Sebastiaan Souer, MD, Boston, MADavid Ring, MD, PhD, Boston, MALaurent Audige, PhD, Dubendorf, SwitzerlandJesse Jupiter, MD, Boston,MA

HYPOTHESIS: Fractures of the volar articular margin of the distal radius withvolar radiocarpal subluxation (volar shearing fractures) can beaccompanied by fracture of the dorsal metaphyseal cortex. We hypothesized that, among volar shearing fractures, injurieswith a dorsal cortical break (AO/OTA Type C fracture) are morecommon than isolated volar marginal articular fractures(partial articular or Type B fractures). We also compared wristfunction and perceived disability after both types of fractures.

METHODS: In a prospective cohort study of plate and screw fixation of thedistal radius, 58 patients with a volar marginal shearingfracture of the distal radius and volar radiocarpal subluxation(volar Barton’s fracture) were followed for at least one year.Thirty-eight patients that also had a dorsal metaphysealcortical fracture (Type C fracture) were compared with 20patients with a true (Type B) fractures in terms ofdemographics, injury circumstances, and outcomes accordingto motion, grip strength, pain, Gartland/Werley Score, DASHand SF-36 scores at 6, 12, and 24 months follow-up.

RESULTS: There were no differences in baseline characteristics betweenType B and C fractures. Patients with Type C fractures hadsignificantly less motion forearm rotation (163 vs. 174degrees; p=0.05), grip strength (72% vs. 85% of oppositearm; p=0.03), and significantly more pain (2.2 vs. 0.6; p=0.01)than patients with Type B fractures at the early (6 month)follow-up, but not at later (12 and 24 month follow-ups).There were no significant differences in Gartland and Werley,DASH, or SF-36 scores at any time point.

SUMMARY POINTS:Volar shearing fractures are usually complete articular, Type Cfractures. Type C volar shearing fractures take longer torecover, but ultimately do as well as true Type B volar shearingfractures.

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Osteoporosis Screening and Treatment following Fractures of the Distal Radius

l Tamara D. Rozental, MD, Boston, MAEric Makhni, BS, Boston, MACharles Day, MD, Boston, MAMary Bouxsein, PhD, Boston, MA

HYPOTHESIS: Osteoporosis screening and treatment rates following fragilityfractures of the distal radius (DRF) remain low. An interventionin the outpatient clinic can improve osteoporosis screeningand treatment.

METHODS:Aim 1: The records of 298 consecutive patients treated forfragility DRF were reviewed. Patients over the age of 50, with>6month follow-up were included. Aim 2: Patients with DRF were prospectively randomized into2 interventions.Intervention 1): the orthopaedic surgeonordered a bone mineral density test (BMD) and forwardedresults to the primary care physician (PCP). Intervention 2): Abrief letter was sent to the PCP outlining guidelines forosteoporosis screening.

RESULTS/STATISTICS:Aim 1: Following DRF, 21.3% of patients had a BMD and78.7% were never screened. Osteopenia was the mostcommon diagnosis among those screened(56.9%). Afterinjury, 72.5% of patients received no medication, 6.7% wereon Ca/Vitamin D, 11.3% were on biphosphonates, 2.5% wereon HRT and 7.1% were on a combination regimen. Patientswith a BMD had a treatment rate of 52.9% compared to20.6% of patients without a prior BMD (p<0.001). Aim 2: 26 patients have been enrolled in this study. InIntervention 1 (n=14), 13 patients(93%) obtained a screeningBMD compared to 4 (33%) patients in Intervention 2(p=0.003). 14 (100%) patients in Intervention 1 discussedtreatment with their PCP and four (33%) patients fromIntervention 2 had a similar discussion (p<0.001). 12 (85.7%)of patients in Intervention 1, were treated with medicationcompared to 4 (33%)in Intervention 2 (p=0.01).

SUMMARY POINTS:• At 21.3% and 27.5% respectively, screening and

treatment rates for osteoporosis after fragility fracture remain alarmingly low.

• Patients with a BMD are more likely to be treated for osteoporosis.

• Osteopenia is the most common diagnosis after DRF.• A simple intervention in the orthopaedic clinic can

dramatically improve osteoporosis screening and treatment rates.

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Paper 54 continued

REFERENCES:1. Riggs BL, Melton LJ III. The prevention and treatment of

osteoporosis. New England J Med 1992; 327: 620-6272. Hosam KK, Hussain MS, Tariq S, Perry HM III, Morley JE.

Failure to diagnose and treat osteoporosis in elderly patients hospitalized with hip fractures. Am J of Medicine 2000; 109; 326-28

3. Torgerson DJ, Dolan P. Prescribing by general practitioners after an osteoporotic fracture. Ann Rheum Dis 1998; 57: 378-79

4. National Commoitte for Quality Assurance.The state of health care quality 2004. www.ncqa.org/communications/somc/sohc2004.pdf

5. Solomon DH, Finkelstein JS, Polinski JM, Arnold M, Licari A, Cabral D, canning C, Avorn J, Katz JN. A randomized controlled trial of mailed osteoporosis education to older adults. Osteoporos Int. 2006;17(5):760-7

6. Freedman K, Kaplan F, Bilker W, Strom B, Lowe R. Treatment of Osteoporosis: Are Physicians Missing an Opportunity? J Bone Joint Surg 2000; 82-A: 1063-1070

l Received support from Procter & Gamble

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Paper 55Saturday, September 29, 2007, 10:05-10:12 AM

A Prospective Randomized Controlled Trial of Dynamic vs. StaticProgressive Elbow Splinting for Post-Traumatic Elbow Stiffness

l Anneluuk Lindenhovius, MSc, Boston, MAJob Doornberg, PhD, Amsterdam, NetherlandsJesse B. Jupiter, MD, Boston, MAChaitanya Mudgal, MD, Boston, MADavid C. Ring, MD, PhD, Boston, MA

HYPOTHESIS: Both dynamic and static progressive (turnbuckle) methods ofsplinting are used to help regain motion after elbow trauma.There are advocates of each method, but no comparativedata. Our null hypothesis was that there is no difference inimprovement of motion and DASH scores between staticprogressive and dynamic splinting.

METHODS:Fifty-two patients with post-traumatic elbow stiffness wereenrolled in a prospective randomized trial: thirty-one in thestatic progressive and twenty-one in the dynamic cohort.Patients were evaluated according the Mayo ElbowPerformance Index and the DASH questionnaire at enrollmentand 3, 6, and 12 months later. This abstract is based onpreliminary data of twenty-two patients in the staticprogressive cohort and sixteen in the dynamic cohort thatcompleted at least 6 months follow-up. One dynamicallysplinted patient and six statically splinted patients had surgery(to address stiffness in five). Two patients asked to be switchedto static progressive splinting. The analysis was according tointention-to-treat principles.

RESULTS:There were no significant differences in flexion arc and DASHat any time point. The arc of flexion (dynamic vs. static)averaged 55° vs. 53° at enrollment, 86° vs. 85° at threemonths, 100° vs. 93° at six months, and 102° vs. 105° twelvemonths after initiating splinting. The average DASH score(dynamic vs. static) was 55 vs. 47 at enrollment, 34 vs. 24 atsix months, and 26 vs. 23 points twelve months afterenrollment.

SUMMARY POINTS: • Post-traumatic elbow stiffness can improve with exercises

and dynamic or static splinting over a period of 6 to 12 months and patience is warranted

• There were no significant differences between static progressive and dynamic splint protocols, and the choice can be left to patients and their physicians.

l Received support from Joint Active Systems, AOFoundation, Small Bone Innovations, Smith and Nephew,Wright Medical, and Biomet

79


Bone Allografts in Reconstructive Surgery of the Hand

u Marco Innocenti, MD, Florence, ItalyRoberto Adani, MD, Modena, ItalyLuca Delcroix, MD, Florence, ItalyLuigi Tarallo, MD, Modena, Italy

HYPOTHESIS: Frozen allografts may be used in in the bone reconstruction ofthe hand with encouraging results. Such a procedure is able toprovide an effective alternative to prosthesis and autologousbone grafts in case of bone defects involving the hand.

METHODS:Between January 2000 and January 2006, 12 patients receiveda frozen bone allograft to treat a bone defect resulting fromtraumatic loss or tumor resection. In 3 cases an intercalaryreconstruction was performed (two metacarpal bone and oneproximal phalanx ) and in 9 cases a joint was reconstructed (five M.P.J. and four PIPJ). In 8 cases also the extensorapparatus have been reconstructed using the allogenictendon. The bone fixation has been as stable and rigid aspossible in order to allow an early mobilization and it has beenachieved by titanium plates in the vast majority of cases.

RESULTS/STATISTICS:Seven patients with a follow up longer than 2 years have been controlled both clinically and radiographically withencouraging results. All the allografts but one healed with the host bone, and the functional recovery was good in themajority of cases. One patient at 6 years postoperativelydeveloped a Charcot joint in the transplanted PIP joint. A reduction of active ROM has been the most frequentcomplication in those cases where also the extensor apparatuswas transplanted.

SUMMARY POINT:Massive bone allograft have been extensively used inorthopaedic surgery: they are very popular in large defectsreconstruction, but few reports are available on their use insmall segments. Our findings seem to pont out that thecreeping substitution healing process is able to fullyincorporate small allografts and that the ROM in case of jointtransplant is quite acceptable. However, concerns still remainabout the long term survival of the articular cartilage and onthe tendons management.

REFERENCES:1. Patradul A,Kitidumrongsook P,Parkpian V,Ngarmukos C.

Allograft replacement in giant cell tumour of the hand Hand Surg, 2001 Jul;6(1):59-65

2. Bury Tf, Stassen L.P.Van Der Werken C. Repair of the proximal interphalangeal joint with homograft J Hand Surg 1989 14: 657

3. Mankin Hj, Gebardt Mc,Jenninigs Lc, Springfield D.S., Tomford Ww., Long-term results of allograft replacement in the management of bone tumorsClin. Orthop 1996:324:86-97

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Locked, Flexible Intramedullary Nail versus K-wire Techniques forFixation of Metacarpal Shaft Fractures: A Biomechanical Study

u Kevin Lutsky, MD, St. Louis, MONader Paksima, DO, MPH, New York, NYEric Strauss, MD, New York, NY

HYPOTHESIS: This biomechanical study sought to determine if there is adifference in stiffness between the Small Bone Fixation System(SBFS) a proximally locked, flexible intramedullary nail device(Hand Innovations, LLC, Miami, FL) and 3 traditional stainlesssteel K-wire fixation methods – crossed 0.045-inch K-wires, 2 intramedullary 0.045-inch K-wires, and 1 intramedullary0.062-inch K-wire. Our hypothesis is that the lockingmechanism and curved, flexible design of the SBFS nail wouldimpart greater stability in fixation of a transverse metacarpalshaft fracture.

METHODS:11 frozen cadaveric metacarpals, index through small fingers,were osteotomized to create a transverse, midshaft metacarpalfracture model. The metacarpals were then fixed with each ofthe 4 constructs. Each construct was then tested formechanical stiffness in a cantilever bending model.

RESULTS/STATISTICS:The mean stiffness of the SBFS was 11.57 N/mm. The meanstiffnesses of the 0.045-inch intramedullary K-wires, crossed Kwires, and the 0.062-inch K wire were, respectively, 2.73N/mm, 4.78 N/mm, and 2.78 N/mm. There was a statisticallysignificant difference in stiffness between the SBFS and eachof the other three constructs (p<.01). There was no significantdifference among the three stainless steel K-wire constructs.

SUMMARY POINT :The SBFS, a proximally locked flexible intramedullary naildevice, is significantly stiffer in a transverse, midshaftmetacarpal fracture model than crossed 0.045-inch K wires,two 0.045-inch intramedullary K wires, or a single 0.062-inchintramedullary K wire.

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Nonunion of Scaphoid in Children: A Clinical Studyof 21 Patients Undergoing Operative Treatment

u Tobias Lutz, MD, Bad Neustadt, Saale, GermanyThomas Pillukat, MD, Bad Neustadt, Saale, GermanyKarl-Josef Prommersberger, MD, Bad Neustadt, Saale, GermanyJörg van Schoonhoven, MD, Bad Neustadt, Germany

HYPOTHESIS: The management of the exceedingly rare problem of scaphoidnonunion in children is essentially based on experience inadults and at least a few published paediatric cases. Westudied history, pathology and long-term results of 21 childrenwho were operated on for a scaphoid nonunion to evaluatethe benefit of operative treatment in this setting.

METHODS:21 patients (19 boys, 2 girls) with a mean age of 12,3 years(range 5-15) were treated operatively for scaphoid non-union.In 20 patients a primary diagnosis was missed. The non-unionwas localized at the waist in 12 patients, in the proximal thirdin 6 patients, and in 3 patients nonunion was localized indistal third of the scaphoid. 17 patients were treated withbone grafting and Herbert-Screw fixation. Vascularized bonegraft, Matti-Russe-Procedure,resection of the proximalscaphoid pole with or without bone grafting was done each in one patient. The mean follow-up was 71,9 month (range12-180). Follow-up included clinical (range of motion, gripstrength, DASH score) and radiographic evaluation. Clinicaloutcome was correlated with the fracture morphology.

RESULTS/STATISTICS:Bony healing was found in 17 patients. Nonunion persisted in 4 patients. There was no evidence for advanced carpalcollaps.Radiocarpal osteoarthritis was seen in 3 patients. Themean value for the DASH-Score was 8,3 points (range 0-59).The mean deficiency of range of movement compared withthe opposite wrist amounted to 15° in the dorso-palmar plane and 10° radioulnar. There was no limitation found for pronation or supination. Measured with the JamarDynamometer, the avarage score of grip strength came to37,9 kg for the injured hand and 43,0 kg for the oppositehand. Patients with multifragment fracture of the proximalpole had unsatisfactory results.

SUMMARY POINT: Operative treatment of scaphoid non-union in children leads to good clinical and radiological results. Clinical andradiological outcome correlate with the initial fracturemorphology.

REFERENCES:1. Müssbichler, H Acta radiol. 1961 Nov;56:361-8.2. Grundy,M Br J Surg. 1969 Jul;56(7):523-43. Southcott R J Bone Joint Surg Br. 1977 Feb;59(1):204. Fabre O Acta Orthop Belg. 2001 Apr;67(2):121-55. De Boeck H J Orthop Trauma. 1991;5(3):370-26. Stuart, HC Onset, Completions and Spans of Ossification

Pediatrics February 1962 7. Greene, MH J Hand Surg 19848. Jupiter, J Ring, C AO Manual Hand and Wrist9. Christodoulou, AG J Pediatr Orthop198610.Wilson-MacDonald, J J Hand Surg 1987 12A 520-52211.Adey, L J Hand Surg [Am]. 2007 Jan;32(1):61-6

82


Functional Outcome Following Open Reduction and Internal Fixationof Intraarticular Distal Humerus Fractures in the Elderly

u Jerry I. Huang, MD, Cleveland, OHMichael Paczas, MD, Cleveland, OHHarry Hoyen, MD, Cleveland, OHHeather Vallier, MD, Cleveland, OH

HYPOTHESIS: Intra-articular distal humerus fractures are challenging to treat,especially in the elderly population with osteopenic bone andassociated fracture comminution. The purpose of this studywas to evaluate the results and functional outcomes aftersurgical treatment of intra-articular distal humerus fractures inthe elderly.

METHODS:Between 1997 and 2005, 23 consecutive patients with meanage of 76.8 years (range 65 to 89), with intra-articular distalhumerus fractures (OTA type 13-C1: n=9; C2: n=9, C3: n=5)were identified. All underwent open reduction internalfixation. None had primary total elbow arthroplasty. Aretrospective review of charts and radiographs was performed.Serial radiographs were analyzed for alignment, healing, andheterotopic ossification. Patients were clinically evaluated by atrained examiner not involved in their care, and functionaloutcomes were assessed with Musculoskeletal FunctionAssessment (MFA), Disabilities of the Arm, Shoulder, and Hand(DASH), and Mayo Elbow Performance (MEP) scores.

RESULTS/STATISTICS:The mean elbow flexion contracture was 20„a, and meanelbow flexion was to 112„a. There was no loss of forearmsupination (58„a vs. 77„a, p>0.05) or pronation (71„a vs.78„a, p>0.05), and no difference in grip strength (32.6 vs.34.0 lbs, p>0.05) between the injured and uninjured arms.MFA scores demonstrated disability with a mean total score of 52.1 (normative 9.3), hand score of 55.1 (normative 3.7),self care score of 56.4 (normative 1.7), and emotionaladjustment/life score of 61.1 (normative 15.6). The meanDASH score was 49.0, while the mean MEP score was 74.3.

SUMMARY POINT: Intra-articular distal humerus fractures are severely disablinginjuries, particularly in the elderly population. Despitereasonable range of motion, patient-directed questionnairesrevealed persistent pain and functional limitations. Primarytotal elbow arthroplasty may be a better alternative in elderlypatients with intra-articular distal humerus fractures witharticular comminution and osteopenic bone.

83


Technical Considerations and Outcome Assessment of Complex Forearm Injuries

u S. Raja Sabapathy, MS, MCh, DNB, FRCS, Coimbatore, IndiaSaranjeet Singh, MD, Coimbatore, IndiaHari Venkatramani, MD, Coimbatore, IndiaJ. Dheenadhayalan, MD, Coimbatore, IndiaS. Rajasekaran, MD, Coimbatore, India

HYPOTHESIS: 1. It is worth salvaging complex forearm injuries (open fracturewith extensive multiple tissue injury/loss) 2. Injury to nerves is the determinant factor to the ultimatefunctional outcome.

METHODS:Charts of 13 patients with complex forearm injuries treatedbetween 1999 and 2005 were reviewed. Age range:22-50(Ave-36), 10/13 dominant hands, MESS score:4-12, 4patients had MESS score >7. 10 had fracture both bones and3 had DRUJ disruption. 3 had associated hand injuries. 7patients had nerve injuries and 4 required revascularisation. All patients had radical debridement, ORIF of fractures orstabilisation of DRUJ(2), wrist arthrodesis(1), revascularization,nerve repair when possible and early skin cover (8 pedicleabdominal, 2 free, 3 skin grafts). 5 had secondary bonyprocedures. 2 had tendon transfers. Patients were recalled and assessed by DASH score

RESULTS/STATISTICS:All 13 were salvaged. Occupational status: same-8, change-3,no job-2. None had severe pain. 8/10 patients had primarybone union. 3 patients developed infection, 2 deep and 1superficial. There was no infection in 4 patients who hademergency flap cover. 1 superficial infection among the threewho had early flap cover and 2 deep infection of the 3 whohad delayed flap cover. DASH score: range-1.47 to 76.4 (Ave38). See table for details.

SUMMARY POINTS:• MESS score >7 is no contraindication for salvage. • Emergency or early flap cover results in less infection.

Infection rate not related to the type of flap cover (pedicled or free).

• Fracture pattern, fixation technique and single muscular compartment loss does not result in increased DASH score.

• Double compartment injury in the absence of nerve injury still gives good functional outcome. (Case 7, 8).

• Patient with nerve injuries had an average DASH score of 62 and this group has the most functional disability.

• Salvage better than amputation in all combinations of injuries.

Case 13 – MESS Score-10, DASH-62.5Please see table for injury details

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Table – Details of the Injuries and ResultsNo Bone Compartment Nerve Vessels MESS DASH

score score

1. #BB E _ _ 6 4.6

2. #BB F UN UA 6 58.3

3. #BB E _ _ 4 1.6

4. DRUJ E _ _ 4 1.47

5. #BB E _ _ 4 2.27

6. #BB, MC, Ph E+F MN+UN RA+UA 11 69.8

7. DRUJ E+F MN* _ 5 38.33

8. #BB E+F _ RA+UA 7 38.97

9. #BB F MN+UN RA+UA 12 52.5

10 DRUJ #Ph E+F UN UA 6 75

11. #BB F UN UA 5 76.4

12. #BB F _ _ 5 13.3

13. #BB E+F MN+UN R+U 10 62.5

#BB- Fracture both bone forearm, MC- metacarpal, Ph-Phalangeal, E- Extensor compartment , F- Flexor compartment,UN- Ulnar nerve, MN- Median nerve, RA- Radial artery, UA- Ulnar artery, * partial injury

REFERENCES:1. Bray PW, Boyer MI, Bowen. Complex Injuries of the

Forearm - Coverage Consideration. Sorft Tissue Management of Complex Upper Extremity Wounds. Hand Clinics 1997;13:(2):263-278

2. Togawa S, Yamami N, Nakayama H, Mano Y, Ikegami K, Ozeki S. The Validity of the Mangled Extremity Severity Score in the Assessment of Upper Limb Injuries. J Bone Joint Surg;2005;87B:1516-1519

3. Jester A, Harth A, Wind. G, Germann G, and Sauerbier M, Disability of the arm, shoulder and hand (DASH) questionnaire; Determining functional activity profiles in patients with upper extremity disorders. J Hand Surg; 2005; 30B: 23- 28

4. Graham B, Adkins P, Tsai TM, Firrell J, Breidenbach WC. Major Replantation Versus Revision Amputation and Prosthetic Fitting in the Upper Extremity: A Late Functional Outcomes Study; 1998;23:783-791

85


Reconstruction of the Distal Radius Facet by a Free VascularizedOsteochondral Autograft: Anatomic Study and Report of Three Cases

u Francisco del Piñal, MD, Santander, SpainFrancisco Garcia-Bernal, MD, Santander, SpainHiginio Ayala, MD, Santander, SpainJavier Regalado, MD, Santander, SpainLeopoldo Cagigal, MD, Santander, SpainAlexis Studer, MD, Santander, Spain

HYPOTHESIS: Large chondral defects after fractures present a phenomenalreconstructive challenge. The purpose of this study is tointroduce the concept of vascularized osteochondral graft, to present the anatomical findings in the cadaver of avascularized osteochondral autograft appropriate forreconstructing the distal radius articular facet, and to presentthree patients in whom this technique was used.

METHODS: The base third metatarsals were studied in the feet of 20cadavers. The size and shape of the cartilage were measured.Additionally, vessels distribution was recorded and thediameter of vascular foramina were measured with Juch’smethod.

RESULTS/STATISTICS: The base of the third metatarsal is pear shaped wider dorsally(12.6 mm) than plantarly (7.9 mm), and 19.2 mm maximumlength on its main axis. Its cartilaginous surface is minimallyconcave or flat, and it is slightly slanted proximal-dorsal todistal-plantar and proximal-peroneal to distal-tibial. Nutrientforamina were found in every case in the dorsum and bothsides of the proximal shaft. At least one nutrient vessel couldbe tracked back to the dorsalis pedis in every dissectedspecimen.

Case Reports: Three patients (33-56yo) have been operated toreconstruct major osteochondral defects on the distal surfaceof the radius after fractures, by a vascularized osteochondralgraft taken form the base of the third metatarsal. In all cases a skin monitor was taken with the flap. No postoperativecomplications occurred. At a minimum follow-up of one year(1-2.5 years) all patients reported improvement in ROM(Average 90º) and decreased in pain (from 9 preop to ave 1.5 postop in a VAS). No complaints from the donor site were referred.

SUMMARY POINT:The procedure is indicated for irreparable chondral defects ofthe radius and it is a reasonable alternative to partial or totalarthrodeses.

86


Effect of Cooling on Vascular Alpha-Adrenergic Receptor-MediatedResponses in Primate Digital Arteries

u Delrae M. Eckman, PhD, Winston-Salem, NCMichael F. Callahan, PhD, Winston-Salem, NCJanice D. Wagner, DVM, Winston-Salem, NCThomas L. Smith, PhD, Winston-Salem, NCL. Andrew Koman, MD, Winston-Salem, NC

HYPOTHESIS: Few studies have specifically assessed isolated primate digitalartery vasoconstriction with cooling. The intent of this studywas to determine: (1) the response of primate (human andnon-human) digital arteries to cooling, (2) the contribution ofalpha-AR activation to cooling-induced vasoconstriction inprimate (human and non-human) digital arteries, and (3)compare our findings in primate digital arteries to murinedistal tail arteries so as to demonstrate our ability to replicatethe observations and address the results of currentexperiments in context with those made by other investigatorsstudying this vascular bed.

METHODS:After assessing vascular smooth muscle and endothelialintegrity, we determined the effect of cooling from 37°C to 23°C on (1) K+-induced constrictions, and (2) alpha-1(phenylephrine), alpha-1/alpha-2 (norepinephrine), and alpha-2(UK-14,304) AR activation on vascular tone in isolated,cannulated primate digital and murine tail arteries.

RESULTS/STATISTICS: Cooling of primate (human and non-human) digital andmurine tail arteries to 23°C had no effect on resting arterialtone. Vascular smooth muscle depolarization-inducedconstrictions to 50 mM KCl were significantly attenuated at23°C as compared to 37°C in primate digital arteries (p<0.05).Furthermore, we observed attenuation of both alpha-1 andalpha-2 adrenergic agonist-induced constrictions with coolingin primate digital arteries (p<0.05). In contrast, the constrictionto 50 mM KCl in murine tail arteries was comparable at 37°Cand 23°C. Additionally, we observed no difference in theconstriction of murine tail arteries to alpha-1 AR stimulationbut observed enhanced constriction to UK-14,304, an alpha-2AR agonist, with cooling from 37°C to 23°C.

SUMMARY POINT: These data demonstrate that, in contrast to murine distal tailarteries, human and non-human primate digital arteriesdemonstrate attenuated constrictions to elevated [K+]o andalpha-AR stimulation when cooled to 23°C. These data alsosuggest that previously published reports demonstratingaugmented alpha-2 AR signaling with cooling (37°C to 28°C)may by species- and/or vascular bed-dependent.

87


The Tibial Second Toe Vascularized Neurocutaneous Free Flap For Major Digital Nerve Defects

u Francisco del Piñal, MD, Santander, SpainFrancisco Garcia-Bernal, MD, Santander, SpainHiginio Ayala, MD, Santander, SpainJavier Regalado, MD, Santander, SpainAlexis Studer, MD, Santander, SpainLeopoldo Cagigal, MD, Santander, Spain

HYPOTHESIS: Our purpose is to introduce a method of 1-stagereconstruction of complex neurocutaneous defects in thefingers and to report the results and clinical effectiveness at aminimum 1 year follow-up.

METHODS:From 1997 to 2005 there were 6 consecutive patients whohad a combined soft tissue and digital nerve defectreconstructed by a vascularized neurocutaneous flap from thetibial side of the second toe. Three were acute and 3 chroniccases. One flap was used for the ulnar side of the thumb, 2for the radial aspect of the index, 1 the radial of the small,and 2 the ulnar side of this same finger. The nerve gapaveraged 4.2 mm, and flap size averaged 3.2x2.1cm. The flapswere revascularized with standard microsurgical techniques tolocal vessels in the fingers. The nerves were sutured withepineural stitches. A split-thickness skin graft was used toclose the toe’s donor site.

RESULTS/STATISTICS:All flaps survived without complications. At the latest follow-up (av. 4.3 years) s2PD averaged 7.5mm on the pulp. Half thepatients had a normal sensation when tested with Semmes-Weinstein filaments. Subjective feeling was 78% of thenormal side. Five patients felt their feeling was excellent on asubjective scale. DASH averaged 4.90.

SUMMARY POINT:The tibial neurocutaneous second toe free flap is suitable toreconstruct a missing nerve and soft tissue defect in the finger.We found good functional recovery and high satisfaction inthis group of patients. The donor site morbidity has beenminimal, although delayed healing is common.

88


Functional Assessment After Successful Isolated Thumb Replantation

u Matthew J. Trovato, MD, San Francisco, CA,Jayant P. Agarwal, MD, San Francisco, CACharles K. Lee, MD, San Francisco, CADarrell Brooks, MD, San Francisco, CARudolph F. Buntic, MD, San Francisco, CAGregory M. Buncke, MD, San Francisco, CA

HYPOTHESIS: The thumb is responsible for 40% of hand function; its role iscritical in prehension and grasping. The purpose of this studywas to perform a retrospective analysis of isolated thumbreplantations with respect to their function. We hypothesizethat thumb replantation is associated with a very high survivalrate and functional outcome.

METHODS: Age, hand dominance, mechanism of injury, level ofamputation, use of vein or nerve grafts, use of soft tissuecoverage or skin grafting, and number of secondaryprocedures (tenolyses, soft tissue rearrangements, etc.) werereviewed in twenty-nine (29) consecutive isolated thumbamputation/replantations over a four and a half year period(7/4/01 - 1/19/06) at the California Pacific Medical Center andcorrelated with survival rate and functional outcome at anaverage follow-up of 9.2 months after the initial injury.

RESULTS/STATISTICS: The overall survival rate was 89.7%. Follow-up ranged from 2 - 21 months (9.2 average) Two of the three unsuccessfulreplants were zone III injuries. The average key-pinch strengthwas 58.8% of the contralateral hand. The average gripstrength was 69.5% of the contralateral hand. Poor key-pinchand grip strength results were associated with interphalangealfusion and flexor pollicis longus reconstruction at time ofreplantation. 46.2% of successful replants required one ormore subsequent operative procedures (tenolyses, soft tissuerearrangements, etc).

SUMMARY POINT: We achieved a high survival rate with attempted isolatedthumb replants. With the most important goal in thereplantation of an amputated thumb being useful function,clinicians and patients can expect 58.8% and 69.5% of thekey-pinch and grip strengths of the contralateral hand,respectively; 46.2% of successful replant patients shouldexpect secondary operative procedures to improve function.These findings should be of value to the clinician involved inmanaging similar traumatic thumb amputations andunderstanding functional outcomes.

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Paper 65Saturday, September 29, 2007, 2:15-2:22 PM

Results of Revision Metacarpophalangeal Joint Surgery inRheumatoid Patients Following Previous Silicone Arthroplasty

u Scott D. Burgess, MD, Grand Rapids, MIMichiyuki Kono, MD, Anahiem, CAPeter J. Stern, MD, Cincinnati, OH

HYPOTHESIS: We suspect the results of revision siliconemetacarpophalangeal joint arthroplasty in patients withrheumatoid arthritis will be inferior to primary arthroplasty due to deficient soft tissue support from repeat surgery anddisease progression.

METHODS:Twenty hands in 18 patients (62 implants) underwent revisionsilicone MCP arthroplasties between 1986 and 2005 and hadgreater than 1 year follow-up (mean 5.4 years). Aretrospective chart review was performed to collectpreoperative and intraoperative data. Patients were then re-examined for range of motion and ulnar drift, x-rays wereobtained, and a questionnaire was administered, addressingsubjective outcome and satisfaction. Pre- and post-operativemeasures were compared using student's t-test.

RESULTS/STATISTICS: Intraoperatively, 76 percent of the implants were fractured.Preoperatively, the average arc of motion was from 16° to50°and ulnar drift was 24°. Postoperatively, the average arc ofmotion was from 20° to 54° (p>0.1) and ulnar drift was 13°(p=0.003). Follow-up x-rays on 14 hands revealed that 15 of44 (34%) revised implants had fractured. Sixteen patients (18hands) were available to complete a questionnaire. Twelvepatients (14 hands) were satisfied and 3 were dissatisfied.Five of 16 patients would not have the revision again.These patients had worse average postoperative ulnar drift(30° vs. 9°) than the other 11 patients. All patients except onewho had preoperative pain had at least moderate pain relief,and all patients except one who listed pain as their primaryreason for revision were satisfied.

SUMMARY POINT: Revision silicone arthroplasty provides excellent pain relief, and the majority of patients were pleased with their results.Objective results, however, were generally poor. Soft tissuereconstruction is more difficult to achieve than the primaryprocedure, as evidenced by minimal improvement in ulnardrift, a high rate of implant fracture, and no change in arc ofmotion.

REFERENCES:1. Swanson AB. Flexible implant arthroplasty for arthritic

finger joints: rationale, technique, and results of treatment.J Bone Joint Surg Am. 1972;54:435-55

2. Trail IA, Martin JA, Nuttall D, Stanley JK. Seventeen-year survivorship of Silastic metacarpophalangeal joint replacement. J Bone Joint Surg Br. 2004;86B:1002-6

3. Bechenbaugh RD, Dobyns JH, Linsheid RL, Bryan RS. Review and analysis of silicone-rubber metacarpophalangeal implants. J Bone Joint Surg Am. 1976;58:483-7

4. Goldfarb CA, Stern PJ. Metacarpophalangeal joint arthroplasty in rheumatoid arthritis. A long-term assessment. J Bone Joint Surg Am. 2003;85:1869-78

90


Osteochondral Resurfacing of Capitate Chondrosis in Proximal Row Carpectomy

u Joseph E. Imbriglia, MD, Wexford, PAPeter Tang, MD, MPH, Pittsburgh, PA

HYPOTHESIS: Osteochondral resurfacing of capitate chondrosis in proximalrow carpectomy (PRC) can give equal results to standard PRC.

METHODS:Patients undergoing PRC who had grade 2 - 4 capitatechondrosis, underwent osteochondral resurfacing of thecapitate with grafts harvested from resected carpal bones.(Fig. 1-6) Demographic information, pre- and post-operativepain, employment status, ROM, grip strength and modifiedMayo wrist scores were assessed. MRI’s were done to evaluategraft incorporation.

RESULTS/STATISTICS:• N = 8 patients, average age 53.1 years, follow-up

17.7 mos• Pain – Pre-op - 87.5% moderate to severe; Post-op -

87.5% mild to no pain (p=0.0005)• Employment - Pre-op - 62.5% regular employment; Post-

op - 75.0% regular employment (p>0.05)• ROM – Pre-op - 84 degrees (74.0% of the contralateral);

Post-op - 75 degrees (66% of the contralateral) (p>0.05)• ROM in previous studies – DiDonna 72 deg, Imbriglia 84

deg, Jebson 77 deg, Tomaino 74 deg (1-4)• Grip Strength – Pre-op - 65 lbs or 62% of the

contralateral; Post-op - 74 lbs or 71% of the contralateral (p>0.05)

• Grip Strength in previous studies – DiDonna 91%, Imbriglia80%, Jebson 83%, Tomaino 79%. (1-4)

• Mayo wrist score – Pre-op – 51 = poor result; Post-op - 68 = fair result (p=0.01)

• Radiographic degeneration - 75% of patients had mild to no degeneration.

• MRI’s showed graft incorporation (Fig. 7)

SUMMARY POINT :Our results compare favorably to the literature on PRC,showing that osteochondral grafting in PRC performs as well

as standard PRC in terms of pain relief, employment status,ROM and grip strength. Autogenous osteochondrondralgrafting is a proven technique which we have applied to thePRC wrist for the first time. If this procedure proves effective,the hand surgeon will have another option to treat wristarthritis, specifically PRC when there is capitate chondrosis.

Fig. 1 Capitate chondrosisafter PRC

Fig. 2 Capitate preparation

Fig. 3 Capitate prepared

Fig. 4 Graft harvest

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Fig. 5 Graft next to lunate

Fig. 6 Graft in place

Fig. 7 MRI showinggraft incorporationin the capitate

REFERENCES:1. DiDonna ML, Kiefhaber TR, Stern P. Proximal Row

Carpectomy Study with a Minimum of Ten Years of Follow-Up. J Bone Joint Surg 2004;86A:2359-2365

2. Imbriglia JE, Broudy AS, Hagberg WC, McKernan D. Proximal Row Carpectomy: Clinical Evaluation. J Hand Surg1990;15A:426-430

3. Jebson PJL, Hayes EP, Engber WD. Proximal Row Carpectomy: A Minimum 10-Year Follow-Up Study. J Hand Surg 2003;28A:561-569

4. Tomaino MM, Delsignore J, Burton RI. Long-Term Results Following Proximal Row Carpectomy. J Hand Surg 1994;19A:694-703

92


Pyrolytic Carbon Implants for the Treatment of Trapezialmetacarpal Arthritis

u Steven L. Moran, MD, Rochester, MNJavier Martinez de Aragon, MD, Rochester, MNMarco Rizzo, MD, Rochester, MNRobert Beckenbaugh, MD, Rochester, MN

HYPOTHESIS: Pyrolytic carbon implants have produced some success in thetreatment of osteoarthritis of the metacarpalphalangeal joints.Recently pyrolytic carbon heimarthoplasties have been usedfor the treatment of osteoarthritis of the carpometacarpal(CMC) joint of the thumb. We wished to review our short-term outcomes for this device in the treatment of CMCarthritis.

METHODS:Fifty-four Trapeziometacarpal joints (49 patients) with a meanpatient age of 59 years at primary surgery were treated with a pyrolytic carbon hemiarthroplasty. Underlying diagnosisincluded osteoarthritis in 44 thumbs, rheumatoid arthritis in 8,psoriatic arthritis in 1 and juvenile rheumatoid arthritis in 1.The patients were followed clinically as well as radiologicallyfor an average of 14 months postoperatively.

RESULTS/STATISTICS:The overall 14 month survival rate excluding STT arthritis was76% according to a Kaplan–Meier analysis. Elevensubluxations were observed. A total of 15 re-operations wererequired in this cohort. Joint salvage was obtainable in 9patients simply by deepening the trapezial cup. Nocomplications were seen in the patients with inflammatoryarthritis. Thirty-one patients were pain free at the latestfollow-up and 10 reported mild occasional pain, the overallsatisfaction rate was 70%. Despite the subjectiveimprovements, strength and ROM remained less than thecontra lateral hand.

SUMMARY POINT:Although a high complication rate has been observed in thiscohort many cases of subluxation could be attributed to aninitial shallow trapezial cup. With proper patient selection,pyrolytic carbon remains a promising material for thetreatment of CMC arthritis.

93


Early Results of Pyro-carbon Proximal Interphalangeal Joint Replacement

u Edward Powell-Smith, MBBS BSc MRCS, Basingstoke, United KingdomJonathon Hobby, Basingstoke, United KingdomDavies Neville, Swindon, United KingdomSophie Phillips, Portsmouth, United KingdomIan Lowdon, Swindon, United Kingdom

HYPOTHESIS: Proximal Interphalangeal Joint Replacement has becomeincreasingly popular over the last five years; however, there isvery little clinical data available, apart from small studies andthose from the originators of the prostheses

METHODS:We present a review of our initial experience with theAcension © Pyro-carbon PIP joint replacement. We havecollated pre-op data and patients have been recalled forindependent clinical and radiographic review; including rangeof movement, functional outcome scores, patient satisfactionand grip strength.

RESULTS/STATISTICS:Between 2002 and 2006 we treated 57 PIP joints in 37patients, using the Acension © implant. There were 40 inwomen and 17 in men with an average age of 61.6 yrs. Themean follow-up is 23 months (range 10-51). We experienceda number of complications: 4 implants (7%) have been revised(1 for dislocation and 3 for component mal-position). Therehave been 5 further re-operations for tenolysis. One implanthas migrated and may be loose. Three superficial infectionsresolved with short courses of oral antibiotics. There havebeen no deep infections. Overall patients have shown asignificant improvement in range of joint movement (Pre-opflexion 53o, post-op flexion 76o). Grip strength was 94% ofthe contra-lateral hand. Pain and functional scores haveimproved, and the large majority of the patients (76%) aresatisfied with the results of surgery

SUMMARY POINT:We have found this to be a technically demanding procedure,and have experienced difficulty with instability, stiffness andimplant migration in some patients. However overall we havefound our early results encouraging, and believe this givesbetter short-term clinical results than arthrodesis of the PIPJ or silastic replacement. We intend to continue with thistechnique, but believe that the patients must be kept under review.

94


Capitellar Resurfacing Arthroplasty: A Case Report of Three Patients

u Andras Heijink, MD, Rochester, MNBernard Morrey, MD, Rochester, MNWilliam P. Cooney, MD, Rochester, MN

BACKGROUND: There is currently no acceptable treatment for symptomaticradiocapitellar arthritis. However, with the increasing use ofmetal radial head prostheses, this condition might be anincreasingly frequent occurrence. The purpose of this abstractis to report preliminary results of metal capitellar resurfacingarthroplasty as new treatment modality for painfulradiocapitellar arthritis. It was hypothesized that capitellarresurfacing arthroplasty improves postoperative pain andfunction in patients with painful radiocapitellar arthritis.

METHODS:Three patients have been treated at our institution withcustom metal capitellar resurfacing arthroplasty. In all casesthe radiocapitellar arthritis had developed in the setting ofchronic longitudinal radioulnar dissociation. Since all threepatients required metallic radial head replacement to restoreforearm stability, the capitellar resurfacing arthroplasty wasperformed in combination with polyethylene, metal-backedradial head replacement. Medical records and radiographs ofthe elbow were reviewed. Elbow function was evaluated usingthe Mayo Elbow Performance Score (Table1). The averageclinical follow-up was 87 months (range, 25-173 months).

Pain, 45 pointsNone 45Mild 30Moderate 15Severe 0Motion, 20 pointsArc > 100 degrees 20Arc 50 to 100 degrees 15Arc < 50 degrees 5Stability, 10 pointsStable 10Moderate instability 5Gross instability 0Daily function, 25 pointsCombing hair 5Feeding oneself 5Hygiene 5Putting on shirt 5Putting on shoes 5

RESULTS/STATISTICS:Pain had resolved in all three patients after treatment. The postoperative Mayo Elbow Performance Score was 100points in two patients, an excellent result, and 80 points inanother, a good esult. All three were satisfied with thetreatment. Two returned to work; one was restricted to lightwork due to unrelated disease. On radiographic examinationall capitellar prostheses appeared well seated with no signs ofloosening (Figure 1). In one patient there were reactivechanges at the lateral epicondyle, likely due to unloading dueto the capitellar prosthesis.

SUMMARY POINT:No good treatment is currently available for symptomaticradiocapitellar arthritis. The outcomes in those three patientssuggest capitellar resurfacing arthroplasty may address thistreatment deficiency. No reports of capitellar resurfacingarthroplasty are available in the literature.

95


Suprafascial Compared with Subfascial Harvest of the Radial Forearm Flap: An Anatomic Study

u Michel Saint-Cyr, MD, Dallas, TXMark Schaverien, MD, Dallas, TX

HYPOTHESIS: Suprafascial harvest of the radial forearm flap creates asuperior wound bed for skin grafting with a low rate of graftfailure compared with subfascial harvest. This study examinesthe changes in flap perfusion when the deep fascia ispreserved. We hypothesize that sub-fascial and supra-fascialharvest of the radial forearm flap yields similar vascularity.

METHODS:Twenty-four radial forearm flaps were harvested from twelvefresh cadavers. Paired suprafascial and subfascial flaps wereharvested from ten cadavers, the radial arteries werecannulated, and 10ml methylene blue dye followed by aMicrofil/lead oxide mixture were injected. The dye stainingpattern was traced and the area measured, the flaps weredigitally radiographed and area was measured using computersoftware, and helical CT scans were performed.

RESULTS/STATISTICS:No difference could be demonstrated in the vascularity of the flap when harvested using the subfascial or suprafascialtechnique. Flap dissection studies confirmed that thesubfascial plexus is poorly developed in the volar forearm, and does not contribute to flap vascularity.

SUMMARY POINT:The deep fascia does not contribute to the vascularity of the radial forearm flap, and therefore does not need to be included in the flap harvest.

Legend:

Figure 1. CT-angioof subfascialyharvested radialforearm flapinjected withbarium sulfate.

Figure 2. CT-angioof suprafascialyharvested radialforearm flapinjected withbarium sulfate.

REFERENCES:1. S Chia-Ning Chang, G Miller, CF Halbert, Kuo-Hui Yang,

Wen-Chi Chao and Fu-Chan Wei, Limiting donor site morbidity by suprafascial dissection of the radial forearm flap. Microsurg 17 (1996), pp. 136–140

2. OM Fenton and JO Roberts, Improving the donor site of the radial forearm flap. Br J Plast Surg 38 (1985), pp. 504–505

3. D Richardson, SE Fisher, ED Vaughan and JS Brown, Radial forearm flap donor-site complications and morbidity: a prospective study. Plast Reconstr Surg 99 (1997), pp. 109–115

4. HR Webster and DW Robinson, The radial forearm flap without fascia and other refinements. Eur J Plast Surg 18 (1995), pp. 11–13

96


The Fascial Pedicled Quaba Island Flap

Sandeep Sebastin, MCh (Plastic Surgery), Singapore, Singaporeu Aymeric Lim, FRCS, Singapore, SingaporeDavid Tan, MRCS, Singapore, SingaporeRomina Mendoza, MD, Singapore, Singapore

HYPOTHESIS: The fascial pedicled Quaba island flap provides quick andreliable coverage of proximal digital defects.

METHODS:30 fascial pedicled Quaba island flaps were done between2004 to 2006. The details of the flaps are summarized in Table1. All flaps were raised as a distally based island from theintermetacarpal space, relying on a fascial pedicle based onthe dorsal perforating branch of the palmar metacarpal artery.Technical refinements developed include using a fascial pediclewhich minimized scarring over the dorsum and allowed moreproximal dissection thus increasing reach of the flap andorienting the skin island obliquely which decreased the torsionon the pedicle.

Table 1S. No. Parameter Details1. Number of patients

Male 28Female 02

2. Etiology of defectPost-infective 16Post-traumatic 14

3. Location of defectDorsum Digit 22Palmar digit 04Lateral digit 02Web space 02

4. Involved digitsIndex finger 11Middle finger 10Ring finger 06Little finger 03

5. Flap pedicle2nd inter-space 113rd inter-space 144th inter-space 05

6. Flap donor site Primary closure 27Skin grafting 03

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RESULTS/STATISTICS:The dorsal perforating branch of the palmar metacarpal arterywas present in all cases. The flap took on an average 45minutes to raise and inset. One flap was completely lost in adiabetic patient with persistent infection. Superficialepidermolysis of the distal third of the flap was seen in twopatients and the resulting wounds healed secondarily. Themaximal reach of the flap was upto the proximal third of themiddle phalanx for dorsal digital defects; the proximalinterphalangeal joint for lateral defects and the proximalphalanx for volar defects. Flaps greater than 3 cm wideneeded a skin graft.

SUMMARY POINTS: • The Quaba flap provides reliable coverage of defects over

the proximal digit. • It is easy to raise, provides thin pliable skin, has minimal

donor site morbidity and allows early mobilisation. • The alternative options include the reverse dorsal

metacarpal artery flap and flaps from adjoining digits. The former is bulkier and complicated by variant anatomy and difficult dissection towards the ulnar digits, while the latternecessitates damaging an uninjured digit and always needsa skin graft.

REFERENCES:1. Quaba AA, Davison PM. The distally-based dorsal hand

flap. Br J Plast Surg. 1990; 43:28-392. Gerard F, Obert L, Pem R, Tropet Y. Use of distally based

intermetacarpal flaps to cover dorsal traumatic defects of the middle fingers. Chir Main. 2001; 20:138-43

3. Valenti P, Mascquelet AC, Begué T. Anatomic basis of a dorso-commissural flap from 2nd, 3rd and 4th intermetacarpal spaces. Surg Radiol Anat 1990; 12: 235-9

4. Keramidas E, Rodopoulou S, Metaxotos N, Panagiotou P, Iconomou T, Ioannovich J. Reverse dorsal digital and intercommissural flaps used for digital reconstruction. Br J Plast Surg. 2004; 57:61-5

5. Yang D, Morris SF. Reversed dorsal digital and metacarpal island flaps supplied by the dorsal cutaneous branches of the palmar digital artery. Ann Plast Surg. 2001; 46:444-9

6. Pelissier P, Casoli V, Bakhach J, Martin D, Baudet J. Reverse dorsal digital and metacarpal flaps: a review of 27 cases. Plast Reconstr Surg. 1999; 103:159-65

7. Dautel G, Merle M. Dorsal metacarpal reverse flaps. Anatomical basis and clinical application. J Hand Surg. 1991;16 B:400-5

8. Braga-Silva J. Anatomic basis of dorsal finger skin cover. Tech Hand Up Extrem Surg. 2005; 9:134-41

9. Vuppalapati G, Oberlin C, Balakrishnan G. Distally based dorsal hand flaps": clinical experience, cadaveric studies and an update. Br J Plast Surg. 2004; 57:653-67

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Treatment of Neuromas Using Skin Island Flaps

u Ryosuke Kakinoki, MD, PhD, Kyoto, JapanRyosuke Ikeguchi, MD, PhD. Kyoto, JapanKen Nakayama, MD, Kyoto, JapanTomoyuki Yamakawa, MDYoshihide Morimoto, MD, Kyoto, JapanTakashi Nakamura, MD, PhD, Kyoto, Japan

HYPOTHESIS: Our hypothesis is that an injured skin can be a target organ ofsmall nerve fibers regenerated from a transected nerve stumps(ref1). We treated nine patients with nine painful neuromas at the tips of their digits using reverse pedicled island flapscontaining subcutaneous nerves that were connected to thedigital nerve stumps after removal of the neuromas.

METHODS:There were nine patients (seven men and two women) withpainful cutaneous neuromas at the tip of the digits. The ageof the patients at the time of the surgery was 21-66 years(mean; 46 years). All neuromas were formed by the palmardigital nerves. In each patient, scarred skin at the tip of theinjured digit where Tinel’s sign had been found was discarded.A reverse dorsal cutaneous skin island including asubcutaneous nerve was harvested from the base of eachhomodigit. Any neuroma formed in a digital nerve wasexcised, and the digital nerve stump remaining after removalof the neuroma was sutured to the proximal stump of thesubcutaneous nerve included in the skin island. The skindefect created by removal of the scarred skin over theneuroma was then covered by the skin island. The surgicaloutcomes of the neuromas were assessed using a modifiedHerndon’s grade. Recovery of sensation in the transplantedskin islands was assessed using the Semmes–Weinsteinmonofilament (SW) test and the two-point discrimination(2PD) test.

RESULTS/STATISTICS:The preoperative status of neuromas of the patients belongedto the severe grade (seven) or moderate grade (two). Tinel’ssign disappeared completely in six of the nine patients.According to a postoperative assessment grade of neuromas,six patients showed “excellent” results and the other threepatients were “good”. (Table 1)

SUMMARY POINT:This skin island-approach provided us with good pain controland recovery of hand function following resection of painfulneuromas.

REFERENCES:1. Mackinnon SE, Dellon AL, Hudson AR, Hunter DA.

Alteration of neuroma formation by manipulation of its microenvironment. Plast Reconstr Surg 1985; 76(3):345-53

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Skeletal Muscle Response to Ischemia-Reperfusion Injury in Mice Deficient for Egr-1

u Michael W. Neumeister, MD, Springfield, ILBradley Medling, MD, Springfield, ILChristopher Chambers, PhD, Springfield, IL

HYPOTHESIS: The transcription factor early growth response protein-1 (Egr1)is a crucial mediator of inflammatory gene expression and hasbeen shown to regulate IR injury in various organ models of IRinjury. We hypothesize that Egr1 is a key molecular regulatorof skeletal muscle IR injury.

METHODS:The lower hind limb of wild-type, Egr1 heterozygous (+/-) or knockout (-/-) mice were made ischemic for 2 hours byapplication of a rubber ligature; reperfusion occurred for 1 or 24 hours. Muscles between the knee and ankle wereharvested and processed for RNA/protein isolation orbiochemical assays. PCR data is presented as average foldchange versus shams; statistical significance was determinedby one-way ANOVA at p≤0.05. Furthermore, we havedemonstrated increased Egr1 mRNA expression in isolatedmuscle (gracilis) preparations following 15 minutes to 4 hours of ischemia. Increased Egr1 expression was a potentinflammatory‚associated with elevated levels of IL1 mediator.

RESULTS/STATISTICS:Previous microarray data showed a 100-fold increase in Egr1mRNA after 2 hr. ischemia and 1 hr. reperfusion. Our currentresults confirm this by quantitative PCR (>200 fold increase in WT vs. shams; p<0.05). Several inflammatory modulators(IL1beta, MIP2 and Rad) showed less induction in Egr1 -/- and+/- than in WT mice following 1 hour of reperfusion. Edemawas less pronounced in Egr1 deficient mice (-/-<+/-≈WT) following 24 hours of reperfusion. We willanalyze muscle viability and neutrophil infiltration for bothtime points and mRNA levels for inflammatory modulators at24 hours of reperfusion

SUMMARY POINT :Egr-1 is upregulated by ischemia in skeletal muscle. Egr1 may regulate key inflammatory modulators following skeletalmuscle IR injury and provide a unique therapeutic target forthe reconstructive surgeon.

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Digital Artery Island Flap for Reconstruction after Volar/Lateral Oblique Fingertip Amputation

u Shohei Omokawa, MD, Yao, JapanRyotaro Fujitani, MD, Yao, JapanHiroshi Yajima, MD, Kashihara, Japan

HYPOTHESIS: Reconstruction of a painless and stable fingertip is expected toproduce cosmetic and functional results following adequateflap selection.

METHODS: Between 1996 and 2005, 232 patients who had volar/lateraloblique fingertip amputation were treated with digital arteryisland flap. Of the 66 patients who had thumb amputation,we constructed 48 orthograde flow flaps (27 neurovascularisland flaps from the long finger, 19 volar advancement flapsand 2 oblique triangular flaps) and 18 retrograde flow flaps(10 Brunellli dorsal thumb flaps and 8 radial thenar flaps). Ofthe 166 patients who had digital amputation, we constructed129 reverse digital artery island flaps and 37 orthograde flowflaps (28 oblique triangular flaps, 7 volar advancement flapsand 2 neurovascular island flaps). Donor sites of the 129reverse digital artery flaps involved the palmer-lateral aspect of the proximal phalanx in 98 patients, midpalm in 15patients, and hypothenar area in 16 patients.

RESULTS/STATISTICS:From the total of 232 flaps, 228 showed complete survivaland 4 resulted in partial/complete necrosis due to infection orvenous congestion. Postoperative complications occurred in 26 patients: deep infections in 2, flexion contractures (>20degrees) of the PIP joint in 17, and cold intolerance in 7.Additional procedures were required for 38 patients, including8 Z-plasties, 17 full thickness skin grafts, 13 nail plasties, and5 bone resections.

SUMMARY POINT: Digital artery island flap is a safe anduseful tool when the size and location of the defect isconsidered, particularly in cases of volar/lateral obliquefingertip amputation in which the germinal matrix of the nail remains intact.

Fig 1: (a) Post-injury hand appearance (b, c) Oblique triangular

advancement flap for thumb reconstruction and neurovascularisland flap for index finger resurfacing (d,e) Postoperative handview

Fig 2: (a) The degloved thumb was necrotized (b) Brunelli’sdorsal thumb flap innervated with radial sensory nerve waselevated (c) Sensory recovery demonstrated was 5 mm ofmoving two point descrimination

REFERENCES:1. Omokawa S, Takaoka T, Shigematsu K, Tanaka Y, Inada Y,

Yajima H, Takakura Y: Reverse-flow island flap from the thenar area of the hand. Journal of Reconstructive Microsurgery 18-8: 659-663, 2002

2. Omokawa S, Tanaka Y, Ryu J, Clovis N: Anatomical consideration of reverse-flow island flap transfers from the midpalm for finger reconstruction. Plast Reconstr Surg 108, 2020-2025, 2001

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Paper 74 continued

3. Omokawa S, Mizumoto S, Fukui A, Inada Y, Tamai S: Innervated radial thenar flap combined with radial forearmflap transfer for the thumb reconstruction. Plast Reconstr Surg 107:152-4, 2001

4. Omokawa S, Yajima H, Inada Y, Fukui A, Tamai S: A reverse ulnar hypothenar flap for finger reconstruction. Plast Reconstr Surg 106 : 828-833 , 2000

5. Omokawa S, Mizumoto S, Iwai M, Tamai S, Fukui A: Innervated radial thenar flap for sensory reconstruction of fingers. J Hand Surg. 21-A:373-80, 1996

6. Omokawa S, Ryu J, Tang JB, Han JS: Vascular and neural anatomy of the thenar eminence of the hand. Plast Reconstr. Surg. 99, 116-121, 1997

7. Omokawa S, Ryu J, Tang JB, Han JS: Anatomical basis for anew fasciocutaneous flap from the hypothenar eminence of the hand. British Journal of Plastic Surgery. 49, 559-563,1996

8. Omokawa S, Tanaka Y, Ryu J, Kish VL: The anatomical basis for reverse first to fifth dorsal metacarpal arterial flaps. J Hand Surg . 30B:40-4, 2005

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Brachial Plexus Birth Palsy Associated Shoulder Deformity: A Rat Model Study

l Zhongyu J. Li, MD, PhD, Winston-Salem, NCJianjun Ma, MD, PhD, Winston-Salem, NCThomas L Smith, PhD, Winston-Salem, NCKathy Carlson, PhD, St. Paul, MN L. Andrew Koman, MD, Winston-Salem, NC

HYPOTHESIS: Brachial plexus birth palsy (BPBP) often leads to shoulderdeformity due to the muscle imbalance. The aim of this studywas to establish an animal model to study BPBP associatedshoulder deformities.

METHODS:A right side C5, C6 axotomy was performed under themicroscope in 5 day old Sprague Dawley rats (n=9). Thecontralateral side served as a control. The development ofshoulder deformity and range of motion were followedlongitudinally. Animals were euthanized 4 months aftersurgery. Both shoulders were harvested, decalcified in formicacid, and transected in the axial plane for glenohumeralversion measurement and joint histology.

RESULTS/STATISTICS:All animals developed right shoulder internal rotationdeformities within 4 weeks after the C5,6 axotomy. Theaverage shoulder external rotation was 68%, 60% and 54%of the control side 1, 2 and 4 months after axotomy,respectively (p<0.0001). Glenoid version changed from2.2±2.3° of retroversion (control) to 8.0±2.7° of anteversion(P<0.0001). Five shoulders (55.6%) were subluxed clinicallywith a pseudoglenoid formation on radiographic image (Figure 1). Histological study demonstrated glenoid cartilagethickening and biconcave deformity (Figure 2).

Figure 1

Figure 2

SUMMARY POINT:This rat model clearly demonstrated typical shoulderdeformities after Erb's palsy. Use of this model will provide amethod for studying the mechanism and natural history ofBPBP-related shoulder deformity and for the development ofnew approaches in the prevention and treatment of thesecondary shoulder deformity after BPBP.

l s Received support from ASSH/AFSH, OREF

103


The Effect of Tendon Transfers and Open Capsulorraphyon Glenohumeral Deformity in Brachial Plexus Birth Palsy

l Donald S. Bae, MD, Boston, MAPeter Waters, MD, Boston, MA

HYPOTHESIS: Tendon transfers, musculotendinous releases, and openglenohumeral capsulorraphy result in remodeling ofglenohumeral deformity in children with brachial plexus birthpalsy (BPBP) and pre-existing glenohumeral dysplasia.

METHODS: Twenty-three patients who underwent subscapularis andpectoralis major musculotendinous lengthenings, latissimusdorsi and teres major tendon transfers to the rotator cuff, andopen glenohumeral capsulorraphies for brachial plexus birthpalsy underwent pre- and post-operative clinical andradiographic evaluation. Average age at the time of surgerywas 27 months. Shoulder function was prospectively assessedusing the Mallet Classification (MC), Toronto Test Score (TTS),and Hospital for Sick Children Active Movement Scale (AMS).Glenoid version and humeral head translation were quantifiedaccording to standard techniques. Average clinical andradiographic follow-up was 19 months.

RESULTS/STATISTICS: Global shoulder function improved significantly followingsurgery. Mean aggregate MC scores increasing from 10 pre- to18 post-operatively (p<0.01). Mean TTS and aggregate AMSscores similarly improved from 7.8 to 8.8 and 88 to 98,respectively. Mean MC scores for external rotation improvedfrom 2 to 4. Mean MC scores for hand-to-spine motionimproved from 1 to 2. Mean AMS external rotation scoreimproved from 2.7 to 6.3. Mean AMS internal rotation scorechanged from 6.4 to 6.1. Glenohumeral deformity improvedin 17 patients (74%) at most recent follow-up. Meanglenohumeral deformity classification improved from 3.4 to2.0, according to the classification of Waters et al. (p<0.01)

SUMMARY POINTS:• Open glenohumeral reduction and capsulorraphy, when

combined with tendon transfers and musculotendinous lengthenings, significantly improves both global shoulder function and glenohumeral deformity in the majority of children with BPBP and pre-existing joint dysplasia.

• No clinically significant loss of internal rotation was seen.• Consideration for earlier soft-tissue procedures must be

made in young children with limitations in shoulder function and radiographic evidence of mild-to-moderate glenohumeral dysplasia.

REFERENCES:Reference 1: Waters PM, Smith GR, Jaramillo D. Glenohumeraldeformity secondary to brachial plexus birth palsy. J Bone JointSurg Am 1998; 80: 668-77

l Received support from American Society for Surgery of theHand Outcome Studies Grant and the Pediatric OrthopaedicSociety of North America Clinical Trials Network

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Arthroscopic Anterior Release, Partial Subscapularis Tenotomy, Glenohumeral Reduction, +/-Tendon Transfers to Maintain Shoulder Joint Alignment in Children with Brachial Plexus Palsy

u Scott H. Kozin, MD, Philadelphia, PAMatt Boardman, DO, Philadelphia, PARoss Chafetz, DPT, MPH, Philadelphia, PAGerald Williams, MD, Philadelphia, PA

HYPOTHESIS: The purpose of the study was to assess the ability ofarthroscopic anterior release, partial subscapularis tenotomy,glenohumeral reduction, +/- tendon transfers to maintainshoulder joint alignment in children with brachial plexus palsy.In addition, a secondary goal was to correlate joint reductionwith clinical parameters of shoulder function. This study is anongoing prospective study with IRB approval.

METHODS:Over a 4-year period, 77 children underwent arthroscopicanterior release, partial subscapularis tenotomy, glenohumeralreduction, +/- tendon transfers to realign a dysplasticglenohumeral joint in children with brachial plexus palsy.Thirty-five children underwent 1 year clinical and MRI follow-up. Fourteen children underwent concomitant tendontransfers and 16 children underwent isolated release. Therewere 21 girls and 14 boys. MRI measurement and clinicalmeasurements, including Mallet parameters, were used toassess outcome.

RESULTS/STATISTICS:Preoperative glenoscapular angle averaged minus 36°, whichimproved to minus 18° at follow-up. Preoperative posteriorhumeral humeral head anterior to the midglenoid meaasured20%, which improved to 32% at follow-up. Passive externalrotation improved from minus 27° to +52° (p<. 01). Activeabduction improved from 112° to 134° (p<. 01). Abductionimprovement was greater in the cohort that underwentconcomitant tendon transfers. These improved measurementscorrelated with better Mallet parameters for abduction,external rotation, hand to mouth, and hand to neck. However,improvements in external rotation correlated with declines ininternal rotation and midline function.

SUMMARY POINT:Arthroscopic anterior release, partial subscapularis tenotomy,glenohumeral reduction, +/- tendon transfers can realign thedysplastic glenohumeral joint in children with brachial plexuspalsy. These results are maintained at 1-year follow-up. Theimprovements in joint reduction correlate with improvedabduction and external rotation, however, there is a decline ininternal rotation that may interfere with midline function.

REFERENCES:1. Waters PM, Bae DS Effect of tendon transfers and extra-

articular soft-tissue balancingJ Bone Joint Surg Am (2005 Feb) 87(2):320-5

2. Pedowitz DI, Gibson B, Williams GR, Kozin SH Arthroscopic treatment of posterior glenohumeral joint subluxationJ Shoulder Elbow Surg (2007 Jan-Feb) 16(1):6-13

105


Early Treatment with Botulinum Toxin-A and Shoulder Spica Casting to Prevent PosteriorShoulder Instability in Patients with Neonatal Brachial Plexus Palsy: A Preliminary Report

u Richard J. Harrison, Jr., MD, New York, NYMilan Patel, MD, New York, NYJanith Mills, PA-C, Dallas, TXScott Oishi, MD, Dallas, TXPeter Carter, MD, Dallas, TXMarybeth Ezaki, MD, Dallas, TX

HYPOTHESIS: The early administration of Botulinum Toxin-A (BTX-A) to theinternal rotators of the shoulder with external rotation spicacasting in patients with persistent neonatal brachial plexuspalsy with “at risk” shoulders decreases posterior shoulderinstability and reduces the need for open reductionprocedures.

METHODS:From January 1, 2001 to February 28, 2006, 31 “at risk”shoulders in 31 consecutive patients were treated with ourprotocol. One of the cases was not included in the study dueto concomitant neurolysis and pectoralis major lengtheningleaving, 30 patients. We retrospectively reviewed the need forrepeat BTX-A injection and for open reduction procedures.The shoulder internal rotators (pectoralis major, teres majorand subscapularis) were injected with BTX-A in the operatingroom under general anesthesia followed with shoulderexternal rotation stretching and shoulder spica cast applicationin external rotation. All patients were followed for at least oneyear to evaluate the need for further procedures.

RESULTS/STATISTICS:Of the 30 patients included in the study, four (13%) requiredrepeat injection due to persistent tone and decreased passiveexternal rotation. Six patients (20%) later went on to requireopen reduction procedures, but none of the patients whorequired repeat BTX-A injection later required an openprocedure.

SUMMARY POINT:At our institution, the majority of “at risk” shoulders go on todevelop posterior shoulder instability, posterior subluxation ordislocation, posterior glenoid dysplasia, and associatedimpaired upper extremity function. The injection of BTX-Adecreases the tone of the internal rotators, which increasesthe time interval for the external rotators to potentially regainfunction. The administration of BTX-A with shoulder spicacasting decreases the need for open shoulder procedures in“at risk” shoulders in patients with neonatal brachial plexuspalsy.

106


Simple Rotational Wedge Osteotomy at the Shaftof the Radius for Congenital Radioulnar Synostosis

u Yumiko Kanauchi, MD, Yamagata, JapanToshihiko Ogino, MD, Yamagata, JapanMasatoshi Takahara, MD, Yamagata, JapanHideo Kashiwa, MD, Yamagata, Japan

HYPOTHESIS: We developed a simple method of correction of the forearmposition in which osteotomy is only done at the shaft of theradius in 1994. Our new technique for simple rotationalwedge osteotomy of the radius is both easy and reliable.

METHODS:The osteotomy is performed at the insertion of the pronatorteres to the shaft of the radius, and the periosteum is tightlyrepaired without internal fixation. The pronation position wasthen manually corrected to allow 90 degrees supination at thepalm with compensatory rotation around the wrist and a castapplied. Twenty limbs in fourteen patients, average age 6.5years, underwent surgery by this method and were followed-up for 3.8 years.

RESULTS/STATISTICS:Prior to operation, the forearm fixation averaged 49 degreesof pronation ( range, 30-90). Post operatively, the forearm wasfixed at an average of 4.3 degrees of supination ( range, 0-20). Bone union occurred at 6 to 9 weeks after surgerywithout any complications. Patient?fs ability to perform dailyactivities showed remarkable improvement, and all weresatisfied with the operative outcome.

SUMMARY POINT:Different from osteotomy at the fusion site, circulatorycompromise or neural entrapment did not occur. Becauserotation takes place between the distal radioulnar joint andthe osteotomy sites, excessive soft-tissue tightness dose notoccur or cause complications. This method is a simple, easyand safe technique to rotate the forearms of the patients withcongenital radioulnar synostosis that are fixed in pronation.

107


Adjuvant Radiation of the Hand for Soft Tissue Sarcomas Increases Risk of Complications

u Rachel S. Rohde, MD, Southfield, MICarol D. Morris, MD, New York, NYKaled M. Alektiar, MD, New York, NYKaren D. Schupak, MD, Basking Ridge, NJJohn H. Healey, MD, New York, NYEdward A. Athanasian, MD, New York, NY

HYPOTHESIS: Risks of adjuvant radiation therapy (RT) to improve localcontrol and hand sparing surgical options in the treatment ofsoft tissue sarcoma of the hand (STSH) are not wellcharacterized. We hypothesized that there is an increased riskof hand-specific complications, that there exist predictivefactors associated with complications, and that risk is relatedto radiation timing following treatment of STSH with RT.

METHODS: A retrospective chart review of 55 patients treated surgicallyfor STSH was performed. Data regarding presentation,comorbidities, diagnosis, treatment, and outcome includingcomplications were analyzed.

RESULTS: Twenty-six of the 55 patients had undergone RT. Twenty-ninetreatment-related complications occurred in 19 of thesepatients who had received RT (73%) compared to 3/29patients treated without RT (10%). All who receivedbrachytherapy (100%) and 14/23 (61%) treated with externalbeam irradiation alone had complications. Preoperative andpostoperative RT complication rates were 75 and 72%,respectively. Parameters were examined to determineassociation of complications with various patient, tumor andtreatment characteristics. Comorbidities and location of tumorwere associated with increased risk (p<0.05). There was atrend of risk increase with size (p=0.08).

SUMMARY POINTS: • Risk following RT of STSH was higher than that in other

regions of the body. • Adjuvant RT of STSH was associated with increased

complications. • Risk was greatest when brachytherapy was used adjacent

to joints. • Comorbidities and location were associated with increased

complications. • Most complications were major and occurred late (months

to years following treatment). A better understanding of predictors of complications will be beneficial in determining timing and type of RT used to treat STSH.

108


Muscle Sliding Operation for the Treatment of Established Volkmann's Contracture

u Toru Sunagawa, MD, Hiroshima, JapanOsami Suzuki, MD, Hiroshima, JapanYasumu Kijima, MD, Hiroshima, JapanMitsuo Ochi, MD, Hiroshima, Japan

HYPOTHESIS: The treatment of established Volkmann's contracture, and todecide the indication of this procedure.

METHODS: Eleven of 22 operated cases could be followed up directly, andtheir outcome was evaluated. The age at operation rangedfrom 2 to 46, and 10 of them were under 10 years old. Threecases were graded in mild type and 8 cases were in moderatetype according to Tsugefs preoperative criteria. Thecontracture was occurred after fracture around elbow joint in9 cases, and after compressive trauma in 2 cases. The durationbetween the trauma and the operation ranged from 4 to 34months. All of the patients underwent this procedure for thetreatment of flexion contracture of the hand and wrist andpronation contracure of the forearm. At the surgery, it wasnecessary to release the entire proximal portion from the ulna,occasionally extending this into the middle and distal thirds.Total active motion (TAM) of the fingers and grip strengthwere assessed. The average follow up was 5.8 years.

RESULTS/STATISTICS:Three cases required free muscle grafting after the procedurefor the reconstruction of finger flexion. TAM of the fingerswas 60% of contralateral side in the mild cases and 15% inthe moderate cases preoperatively, and was postoperatively78% and 35% respectively. Pronation contracture of theforearm still remained. Grip strength was 56% of contralateralside in mild cases and 29% in moderate cases preoperatively,and was postoperatively 74% and 43% respectively. Pronationcontracture of the forearm had a considerable influence onADL.

SUMMARY POINTS:Preoperative findings suggesting good indication of thisprocedure are:• less flexion contracture of the wrist joint• less pronation contracture of the forearm• better grip strength

109


Total and Subtotal Amputations with Destruction of the Proximal Interphalangealand Metacarpal Phalangeal Joint: A Paradigm Shift Towards Salvage

u Darrell Brooks, MD, San Francisco, CARudolf Buntic, MD, San Francisco,CA

HYPOTHESIS: Beneficial function can be obtained utilizing a stagedapproach for salvage of digital amputations through theproximal interphalangeal (PIP) and metacarpal phalangeal(MCP) joints. Completion amputation is currentlyrecommended for these injuries.1,2

METHODS:Between 2002 and 2006 we treated 14 patients for total andsubtotal amputations characterized by destruction of their PIP(12) and MCP (4) joints in a staged approach. In the initialstage, patients underwent restoration of joint height,reconstruction of supporting joint structures, as well as repairof tendons, vessels and nerves. Tissue was transferred ortransplanted, as needed, for soft tissue coverage. In asubsequent stage, pyrolytic carbon two-piece arthroplasty(Ascension Austin, Texas) was performed through a dorsalapproach. Outcome evaluation included range of motion(ROM), grip strength, pain, and analysis of the jointcharacteristics such as lateral stability, stem loosening, andsubsidence.

RESULTS/STATISTICS:All patients completed 18 months follow-up evaluation.Mechanisms included crush, ring avulsion, and saw injury. An average of 2.8 (PIP group) and 2.0 digits (MCP group)were injured per hand. All digits undergoing stagedreconstruction survived. Outcome analysis is illustrated in table 1. Video documentation of function will be provided atpresentation.

SUMMARY POINT:Cases of traumatic joint loss in total and subtotal amputationswhich would have required fusion, at best, and completionamputation, at worst, obtained rewarding function after twostage reconstruction. These data support implementation ofour two-stage approach in selected cases.

REFERENCES:1. Soucacous PN. Indications and selection for digital

amputation and replantation. J Hand Surg [Br]. 2001 Dec;26(6):572-81

2. Allen DM, Levin LS. Tech Hand Up Exterm Surg. 2002 Dec;6(4):171-7

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Table 1Patients Joint ROM (degrees) ROM (% of nl) Avg. % Grip (% of nl) Avg. injured digits/hand11 PIP (12) 60-95 60-95 79 39-70 2.83 MCP (4 65-90 70-100 86.2 12-66 2.0


Medical Students Interested in Non-Orthopedic Residencies to Receive Inadequate Training in Musculoskeletal Medicine

l Charles S. Day, MD, Boston, MAAlbert Yeh, BA, Cambridge, MA

HYPOTHESIS: According to the AAMC, musculoskeletal (MSK) education in the medical school curricula is often fragmented (AAMCMSOP VII). Because MSK education is not well-defined,residency interest plays a significant role in the amount ofexposure that medical students have in this field and maydetermine whether or not entering residents demonstratecognitive mastery of and clinical confidence in managingcommon MSK conditions.

METHODS:A cross-sectional survey study of all Harvard Medical Students(HMS) was conducted during the 2005-2006 academic year.Two-hundred and forty nine students were surveyed yieldingan overall response rate of 74% (249/337). All participantswere asked to complete a nationally validated objectiveexamination in MSK medicine and a 30 question surveysoliciting top residency choices and all MSK electives taken,among other queries.

RESULTS:Residency interest significantly affects third-year students’performance on the cognitive mastery exam (p=.018) and also significantly affects both third- and fourth-year students’clinical confidence in examining the musculoskeletal system(p=.023, p=.015 respectively). Students’ perceived importanceof musculoskeletal medicine, regardless of residency interest,correlated with their decision to take musculoskeletal clinicalelectives (p=.009, p<.001 for third and fourth-year studentsrespectively). Perceived importance also correlated with higherclinical confidence for third year students (p=.043) andincreased exam score for fourth year students (p<.001).However, only students who listed orthopedic surgery as their top residency choice demonstrated cognitive mastery inmusculoskeletal medicine and reported above average clinicalconfidence in examining the musculoskeletal system.

SUMMARY:Students’ residency interest and their perception of theimportance of musculoskeletal medicine towards their futurecareer influence the education that they receive in this field.In particular, students interested in non-orthopedic residenciesfailed to demonstrate cognitive mastery and lack clinicalconfidence. Possible approaches for medical schools to tacklethis important issue, which merits further exploration, includerequiring additional time or providing a more structuredmusculoskeletal curriculum.

REFERENCES:1. Association of American medical Colleges. Contemporary

Issues in Medicine: Musculoskeletal Medicine Education. Washington, DC: Association of American Medical Colleges. 2005

2. Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. JBJS(Am). 2002;84:604-8

3. DiCaprio MR, Covey A, Bernstein J. Curricular requirements for musculoskeletal medicine in American medical schools. JBJS(Am). 2003;85:565-7

4. Pinney SJ, Regan WD. Educating medical students about musculoskeletal problems: are community needs reflected in the curricula of Canadian medical schools? JBJS(Am). 2001;83:1317-20

l Received support from Small Bone Innovations, AMSurgical, and Wright Medical

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An Assessment of Medical Students’ Knowledgeof and Clinical Confidence in the Upper-Extremity

Albert Yeh, BA, Cambridge, MAl Charles S. Day, MD, Boston, MA

PURPOSE: The growing concern that American and Canadian medicalschools are not effectively addressing musculoskeletal (MSK)medicine in their curricula suggests that entering residentsmay lack the knowledge and clinical skills necessary torecognize and treat common musculoskeletal disorders (AAMCMSOP report VII). We aim to investigate if there are specificweaknesses by analyzing students’ knowledge of and skillsinvolved in examining specific areas of the body.

METHOD:A cross-sectional survey study of all Harvard Medical Students(HMS) was conducted during the 2005-2006 academic year.Two-hundred and forty nine students were surveyed yieldingan overall response rate of 74% (249/337). All participantswere asked to complete a 30 question survey, which assessedthe students’ clinical confidence in conducting an MSKexamination, and a nationally validated objective examinationin MSK medicine. We specifically analyzed exam questions and survey responses dealing with the upper- and lower-extremities.

RESULTS:Fourth year students demonstrated a “low” to “adequate”level of confidence in examining the MSK system (2.66 of 5).Their overall confidence in examining the upper-extremity was also below adequate (2.55), with similar confidence in the hand/wrist (2.53), elbow (2.49), and shoulder (2.61).Compared to examining the upper-extremity, these studentsdemonstrated a significantly higher level of confidence inexamining the lower extremity (2.79, p=.02), with similarconfidence in the hip (2.64) and foot/ankle (2.51) andsignificantly higher confidence in the knee (3.23) (p<.001).Fourth year students scored 55% on the upper-extremityportion of the basic MSK competency exam which is similar to their performance on the lower-extremity (56%) butsignificantly less than their performance on the entirecompetency exam (62%, p=.01).

SUMMARY POINT:Although there is strong evidence that musculoskeletalmedicine as a whole is not being adequately taught in medicalschool curricula, there may be certain learning gaps that aremore pronounced. Our study provides some evidence thatclinical skills involving the physical examination and differentialdiagnosis of the upper-extremity may fall into one of these gaps.

REFERENCES:Reference 1: Association of American medical Colleges.Contemporary Issues in Medicine: Musculoskeletal medicineEducation. Washington, DC: Association of American MedicalColleges. 2005

l Received support from Small Bone Innovations, AM Surgical, and Wright Medical

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