Techniques in Hand and Upper Extremity Surgery

Volume 10(3)
September 2006
(C) 2006 Lippincott Williams & Wilkins, Inc.
ISSN:
1089-3393
Viewing 1-14 of 14 Results

pg. 123
01 Who Should Do What?

Jupiter, Jesse B. MD
[EDITORIAL]
pg. 124-129
02 A Meta-analysis of Success Rates for Digit Replantation.

Dec, Wojciech BA
[REVIEW]
pg. 130-138
03 A New Modification of Trapeziectomy and Soft Tissue

Interposition Arthroplasty With Abductor Pollicis Longus
Advancement.
Viegas, Steven F. MD
[TECHNIQUES]
pg. 139-144
04 Arthroscopic Management of Volar Lunate Facet Fractures

of the Distal Radius.
Wiesler, Ethan R. MD; Chloros, George D. MD; Lucas, Robert M.
MD; Kuzma, Gary R. MD
[TECHNIQUES]
pg. 145-149
05 Biologic Resurfacing of the Glenoid Using a Meniscal

Allograft.
Themistocleous, George S. MD; Zalavras, Charalampos G. MD;
Zachos, Vasileios C. MD; Itamura, John M. MD
[TECHNIQUES]
pg. 150-156
06 The Hypothenar Fat Pad Transposition Flap: A Modified

Surgical Technique.
Chrysopoulo, Minas T. MD; Greenberg, Jeffrey A. MD; Kleinman,
William B. MD
[TECHNIQUES]
pg. 157-161
07 Avulsion Fractures From the Base of Phalanges of the

Fingers.
Bekler, Halil; Gokce, Alper; Beyzadeoglu, Tahsin
[TECHNIQUES]
pg. 162-165
08 Tenodesis Extension Splinting for Radial Nerve Palsy.

Szekeres, Mike BSc(OT), OT Reg(Ont.)
[TECHNIQUES]
pg. 166-172
09 A Vascularized Technique for Bone-Tissue-Bone Repair in

Scapholunate Dissociation.
Harvey, Edward J. MD, MSC 1; Sen, Milan MD 2; Martineau, Paul
MD 3
[TECHNIQUES]
pg. 173-176
10 Confirmatory Needle Placement Technique for Scalene

Muscle Block in the Diagnosis of Thoracic Outlet Syndrome.
Braun, Richard M. MD; Sahadevan, David C. BA; Feinstein, Joel MD
[TECHNIQUES]
pg. 177-180
11 A New Modification of Two-Stage FlexorTendon

Reconstruction.
Viegas, Steven F. MD
[TECHNIQUES]
pg. 181-186
12 A New Surgical Technique for the Ligament

Reconstruction of the Trapeziometacarpal Joint.
Ozer, Kagan MD
[TECHNIQUES]
pg. 187-196
13 Mini External Fixation in the Hand.

Ugwonali, Obinwanne Fidelis C. MD 1,2; Jupiter, Jesse B. MD 2,3
[TECHNIQUES]
pg. 197
14 Percutaneous Trigger Finger Treatment.

Cebesoy, Oguz MD
[LETTER TO THE EDITOR]
Techniques in Hand and Upper Extremity Surgery 10(3):123, 2006
2006 Lippincott Williams & Wilkins, Philadelphia
E D I T O R I A L
Who Should Do What?
he establishment of the journal, Techniques in Hand

and Upper Extremity Surgery, can now be viewed
as a testimony to the foresight of its original editor, Dr
Andrew Weiland, on his editorial staff as they perceived
the domain of the BHand Surgeon[ to be that of the entire
upper limb. This very edition of this journal reflects this
clearly as we present articles extending from the thoracic
outlet to the glenoid to the trigger finger!
Although there will remain a substantial discourse as to
Bwho should do what[ in the upper limb, it is becoming
evident that the boundaries for the subspecialties involved
in the upper limb surgery are truly artificial. Advances in
technology such as arthroscopic surgery are finding equal
application in the shoulder, wrist, and elbow; the training
for such procedures has become standard in most orthopaedic programs and an ever-increasing number of hand
surgery fellowships.
Yet, it is also evident that subspecialization in the
upper limb adds much to both advancing our under-
standing of problems in a specific region and improving

patient care.
These realities present some challenges to our established surgical societies in addition to those involved in
determining requirements for curricula for specialty fellowship training. In addition, regarding those entering hand
surgery programs from plastic surgical training, how best to
include and/or train these individuals will challenge all of us.
What the future may bring is the possibility of some
dedicated BUpper Limb[ fellowships extending from
18 months to 2 years and encompassing faculty from several
subspecialties to train the Bcomplete[ upper limb surgeon!
Jesse B. Jupiter, MD
Massachusetts General Hospital
Harvard Medical School
Boston, MA
Volume 10, Issue 3
Copyr ight Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
123
Techniques in Hand and Upper Extremity Surgery 10(3):124 129, 2006
R E V I E W
A Meta-analysis of Success Rates

for Digit Replantation
Wojciech Dec, BA
NYU School of Medicine
545 First Avenue, Suite 7R
New York, NY
| ABSTRACT
The decision to replant a severed part is based on the
numerous factors that influence survival of the part and
the functional and aesthetic benefits gained from
replanting. Not all amputees will benefit from or are
candidates for replantation. The decision to proceed is
therefore made by the surgeon who must consider the
mechanism and extent of injury, the age of the patient,
the presence of other medical or surgical conditions, the
likely functional outcomes, and the patients motivation
to undergo a difficult procedure, which is followed by a
lengthy recovery. This is a meta-analysis of the available
studies that tracks the outcomes, based on 9 criteria, after
the amputation of a total of 1803 digits in 1299 patients.
By combining the data from numerous sources, a statistically significant picture emerges which may be used to
educate patients and help guide the surgeon in the decision
to replant.
Keywords: microsurgery, hand, amputation, reattachment, digit, finger
| HISTORICAL PERSPECTIVE
Ever since Ronald Malt performed the first replantation
in 1962, thousands of body parts have been reattached,
and the medical community and the general population
have become educated about the possibility of reattachment. This has resulted in the severed part often
accompanying the patient to the hospital. The proper
way of transporting an amputated body part is wrapped in
gauze in a plastic bag, which, in turn, is placed into ice
water.1 This is particularly true in the case of replants
that contain muscle tissue, which is especially vulnerable
to ischemia. Direct contact with ice is to be avoided to
prevent frostbite injury.
Address correspondence and reprint requests to Wojciech Dec, BA,
NYU School of Medicine, 545 First Avenue, Suite 7R, New York,
NY. E-mail: wd271@med.nyu.edu.
124
Before surgery, radiographs of the injured hand

should be taken to assess the extent of the injury and the
feasibility of reattachment. Photographs of the amputated part and the stump should be made for documentation purposes. The patient must be informed regarding
the adverse outcomes of surgery, failure rates for
replantation, the length of recovery, and the limits of
function and aesthetic appearance that may result.1
Prophylactic antibiotics should be administered, and the
patients tetanus status should be updated, especially in
cases where contamination after the injury has occurred.
The amputated part must be prepared for replantation before the actual surgery. Usually, enough time
exists before the patient is transferred to the operating
room to accomplish this; alternatively, a second team
can prepare the severed part.2
Preparation of the severed part involves the assessment of the damage. It is especially important to consider the digital vessels. The presence of the red line
sign and the ribbon sign is an indicator of vessel damage
from longitudinally transmitted injury, which may
require vein grafting, and is a sign of a poor prognosis.2
Neurovascular structures and tendons are then identified and tagged, so that they can be quickly retrieved
during surgery.
The optimal sequence in which structures are to be
repaired is of some debate but generally follows this
sequence: bone repair, tendon repair, arterial anastomosis, nerve repair, venous anastomosis, and skin repair.
During surgery, it may be necessary to perform bone
shortening to avoid having to perform nerve and vein
grafts; 5 to 10 mm of shortening may be necessary for
tension-free neurovascular structure repair. If possible,
shortening should occur on the amputated part to
preserve the length of the stump in the case that the
replant fails. Most commonly, bone fixation is performed with wires, which span the site where the bone
has been cut. After the bone fixation has been performed, both the extensor and flexor tendons are
Techniques in Hand and Upper Extremity Surgery
Success Rates for Digit Replantation
repaired. The 2 major complications of tendon repair are

rupture and adhesion. The repair of these macrostructures is sometimes thought of as a necessary evil before
the fine microsurgical work can be performed. It is
important to remember, however, that good functional
recovery is greatly dependent on these early steps.3
It is important to perform the artery repair before
vein repair to limit ischemia time and to prevent the free
radical from being washed into the body.2 Also, this
sequence makes the intraoperative identification of
veins easier by observing back bleeding. A digital
vessel, 1 mm in diameter, can be repaired with 6 to 8
sutures of nylon.1 Patency is tested by observing capillary
refill and bleeding upon pinprick. Anticoagulants and
drugs are administered to prevent vasospasm. Usually, 1
or 2 (occasionally) veins are repaired. Finally, the skin is
closed, often with a skin graft. The hand is immobilized,
and the patient is monitored for circulatory changes after
the operation.
Special consideration must be given to the amputated
thumb because of its functional importance. Even under
less than optimal circumstances, attempts at replantation
should be made.4 Likewise, special consideration must be
made in the case of a multiple-finger amputation. The
finger with the best chance of survival and greatest importance to function should be replanted first. In the event
that all fingers are injured to the same extent and have
equal chances of survival, then the little, ring, and middle
fingers receive priority because of their use in power
gripping and functional importance. In multiple-digit
amputations, the sequence in which structures are fixed
can be improvised to limit ischemia time. Initially, the
bone is fixed, followed by the extensor tendon and one
arterial and one venous anastomosis for each finger.
Furthermore, anastomosis can be created, and the nerve
and flexor tendon can be repaired once the blood supply to
each finger has been reestablished.1
Postoperative care should include warming the
patients room to avoid the complications of vasospasm
and positioning the hand at the heart level to avoid edema,
without compromised arterial blood flow.1 Sympathetic
block can also be administered to prevent vasospasm.

Patients are encouraged to abstain from cigarette smoking
and caffeine. The replanted part is monitored for color,
capillary refill, turgor, and temperature; alternatively,
surgically placed flow monitors and surface-placed laser
Dopplers can be used.2
| FACTORS EVALUATED IN THIS

META-ANALYSIS
This study examines how 9 factors affect the outcomes
of digital replantation. To achieve a large sample size
and statistical significance, data were pooled from 8
separate studies. The factors under investigation were
the mechanism of injury, the zone of injury, the
amputated digit, smoking history, history of alcohol
use, sex, age, presence of diabetes, and ischemia time.
In all instances, amputations were complete, and the end
point marking success was survival of the digit.
| RESULTS
The mechanisms of injury (Table 1) have been divided
into 3 categories. Clean-cut amputation refers to a
guillotine injury as may occur from a knife, a laceration
which may be the result of a circular saw, or a local
crush injury involving little tissue beyond the site of
amputation as may occur from a finger placed in the
way of a closing car door. Crushing refers to an injury
that affects tissue beyond the site of the amputation and
is often seen in industrial accidents involving a press.
Finally, avulsion injury occurs when a digit is rapidly
pulled out of the hand and occurs in accidents involving
lathes and other fast-moving machines. Tissue is
damaged proximally and distally to the site of amputation in avulsion injuries.
Cleanly amputated fingers were saved at a rate of
91.4%. Amputations from crushing injury were saved at
a rate of 68.4%, and avulsed digits were saved at a rate
of 66.3%.
TABLE 1. Mechanism of injury and success of replantation

Hattori et al5
Heistein and Cook6
Janezic et al4
Kim KS et al7
Kim WK et al8
Tark et al9
Velanovich et al10
Waikakul et al11
Total digits saved (% saved)
Clean cut
16 of 16
10 of 16
91 of 129
V
42 of 48
117 of 144
172 of 204
842 of 854
1290 of 1411 (91.4)
Crushing injury (not clean)

8 of 12
7 of 19
6 of 10
10 of 12
42 of 54
V
47 of 56
8 of 24
128 of 187 (68.4)
Avulsion (not clean)

8 of 10
11 of 18
14 of 28
V
16 of 21
V
17 of 39
70 of 89
136 of 205 (66.3)
Volume 10, Issue 3
125
Dec
TABLE 2. Zone of injury and success of replantation
Hattori et al
Heistein and Cook6
Janezic et al4
Kim KS et al7
Kim WK et al8
Tark et al9
Velanovich et al10
Waikakul et al11
Total digits saved
(% saved)
Distal
phalanx
Distal IP
joint
Middle
phalanx
Proximal IP
joint
Proximal
phalanx
MP joint
37 of 44
21 of 36
V
5 of 5
48 of 64
2 of 3
V
33 of 36
146 of 188
(77.7)
18 of 20
9 of 21
V
5 of 7
62 of 71
17 of 22
V
138 of 139
249 of 280
(88.9)
V
V
V
V
V
76 of 97
V
208 of 227
284 of 324
(87.7)
V
V
V
V
V
17 of 17
V
171 of 195
188 of 212
(88.7)
V
V
55 of 84
V
V
4 of 4
V
372 of 397
431 of 485
(88.9)
V
V
20 of 32
V
V
1 of 1
V
24 of 24
45 of 57
(78.9)
MP indicates metacarpal phalangeal.
The meta-analysis suggests that crushed and avulsed

digits do not differ significantly in their survival after
reattachment (P 9 0.05). However, when success rates
for the not clean groups (crush and avulsion) are
compared with clean-cut injury, a clear difference exists
(P G 0.05). An odds ratio analysis indicates that a digit
is 5.17 times more likely to be replanted successfully
after a clean amputation than after either crushing injury
or avulsion.
The zones of injury (Table 2) have been divided into
6 categories: distal phalanx, distal interphalangeal (IP)
joint, middle phalanx, proximal IP joint, proximal
phalanx, and the metacarpal phalangeal joint. In the
case of studies that reported the zone of injury in Tamai
zone classification, best attempts were made to translate
those results into the scheme that appears here.
Digits amputated at the distal phalanx were saved at
a rate of 77.7%; those amputated at the distal IP joint
were saved at a rate of 88.9%. Digits amputated at the
level of the middle phalanx were saved at a rate of
87.7%; those amputated at the level of the proximal IP
joint were saved at a rate of 88.7%. Digits amputated at
the proximal phalanx were saved at a rate of 88.9%, and
finally, those amputated at the level of the metacarpal
phalangeal joint were saved at a rate of 78.9%.
The meta-analysis suggests that the zone of amputation makes little difference in the success of the replant
(P 9 0.05), except in the case when the amputation
occurred in the distal phalanx (P G 0.05). An odds ratio
analysis indicates that a digit severed through the distal
phalanx is 2.14 less likely to survive than one amputated
at any other level of the digit. This difference stems
from the diminished diameter of vasculature present in
the distal phalanx and the inherent difficulty of forming
successful anastomoses.
The amputated digits have been classified on the
following basis: thumb, index finger, middle finger, ring
finger, and little finger (Table 3).
Thumbs were saved at a rate of 68.1%. Index
fingers were saved at a rate of 75.0%. Middle fingers
were saved at a rate of 82.8%. Ring fingers were saved
at a rate of 82.8%, and little fingers were saved at a
rate of 88.9%.
The meta-analysis suggests that thumbs are more
difficult to salvage than the other fingers (P G 0.05). It
also seems that index fingers are less likely to survive
than all the other fingers; however, this difference is not
considered statistically significant (P 9 0.05). An odds
ratio analysis indicates that a thumb is 1.95 times less
likely to survive after replantation than any of the other
TABLE 3. Amputated digit and success of replantation

Hattori et al5
Heistein and Cook6
Janezic et al4
Kim KS et al7
Kim WK et al8
Tark et al9
Velanovich et al10
Waikakul et al11
126
Thumb
14 of 14
V
89 of 140
V
V
V
36 of 50
V
139 of 204 (68.1)
Index
12 of 15
V
V
5 of 6
V
V
28 of 39
V
45 of 60 (75.0)
Middle
10 of 13
V
V
3 of 3
V
V
15 of 18
V
28 of 34 (82.8)
Ring
12 of 13
V
V
1 of 2
V
V
11 of 14
V
24 of 29 (82.8)
Little
6 of 8
V
V
1 of 1
V
V
17 of 18
V
24 of 27 (88.9)

TABLE 4. Smoking history and success of replantation
Hattori et al5
Heistein and Cook6
Janezic et al4
Kim KS et al7
Kim WK et al8
Tark et al9
Velanovich et al10
Waikakul et al11
Total digits saved
(% saved)
TABLE 6. Sex and success of replantation
Regular
smokers
Nonsmokers
V
V
V
V
V
V
V
44 of 72
44 of 72
(61.1)
V
V
V
V
V
V
V
464 of 480
464 of 489
(96.7)
digits. This difference may be the result of different

anatomy or may be caused by a more aggressive
approach in the case of thumb replantation than would
have been made with the other less crucial digits.
Patients who had a digit amputation were classified
into 2 groups based on their smoking history before the
amputation (Table 4).
The digits of smokers were saved at a rate of 61.1%,
and those of nonsmokers were saved at a rate of 96.7%.
Only 1 study in the meta-analysis indicated a history
of smoking. Despite the small sample, a statistically significant indication exists that smokers fared worse than
nonsmokers in replanted digit survival (P G 0.05). An
odds ratio analysis indicates that the replanted digits of
nonsmokers survived at a rate 11.8 times greater than
those of smokers. This difference likely stems from the
vasoconstrictive properties of nicotine, which affects the
blood supply to the replanted digit.
into 2 groups based on their history of alcohol use
before the amputation (Table 5).
The digits of alcohol users were saved at a rate of
90.9%, and those of nonusers were saved at a rate of 92.2%.
The meta-analysis suggests that alcohol use is not a
factor that determines the survivability of a replanted
digit (P 9 0.05).
Hattori et al5
Heistein and Cook6
Janezic et al4
Kim KS et al7
Kim WK et al8
Tark et al9
Velanovich et al10
Waikakul et al11
Total digits saved
(% saved)
Male
42 of 52
19 of 34
V
6 of 8
V
V
V
327 of 366
394 of 460 (85.7)
Female
12 of 12
9 of 19
V
4 of 4
V
V
V
181 of 186
206 of 221 (93.2)

into 2 groups based on their sex (Table 6).
The digits of the male patients were saved at a rate
of 85.7%, and those of the female patients were saved at
a rate of 93.2%. Such a difference is statistically
significant (P G 0.05). An odds ratio analysis indicates
that the replanted digits of female patients survived at a
rate 2.3 times greater than those of male patients. This
suggests that being male results in less favorable outcomes after surgery. Alternatively, this difference may
be caused by the fact that male patients were more
likely to sustain amputations through more severe
mechanisms such as crushing and avulsion.11
into 2 groups based on their age (Table 7). The methods
for reporting age varied widely among the studies
included in this report. Some authors classified patients
as younger than 13 years versus older than 13; others
used 18 years as the break point. Others reported ages in
4-year intervals; others reported age by decade. Others
still reported the exact age. Consequently, the age range
for children in this meta-analysis is younger than 13 to
18 years, and that for adults is older than 13 to 18 years.
This presents a potential pitfall for interpreting outcomes according to age because there exists a 5-year
interval for which data of children and adults are mixed.
TABLE 7. Relative age and success of replantation

TABLE 5. Alcohol use history and success of replantation
Hattori et al5
Heistein and Cook6
Janezic et al4
Kim KS et al7
Kim WK et al8
Tark et al9
Velanovich et al10
Waikakul et al11
Total digits saved
(% saved)
Alcohol use
V
V
V
V
V
V
V
60 of 66
60 of 66
(90.9)
No alcohol use
V
V
V
V
V
V
V
448 of 486
448 of 486
(92.2)
Hattori et al5
Heistein and
Cook6
Janezic et al4
Kim KS et al7
Kim WK et al8
Tark et al9
Velanovich et al10
Waikakul et al11
Total digits saved
(% saved)
Child
7 of 9
13 of 34
Adult
48 of 55
15 of 19
7 of 15
V
V
V
43 of 56
34 of 36
104 of 150
(69.3)
104 of 152
10 of 12
V
V
185 of 342
474 of 516
836 of 1096
(76.3)
Volume 10, Issue 3
127
Dec
The results of the studies are still included in this report

despite the inconsistency, with the hope that some
information can be gleamed from any trend that may
be present.
The digits of children were saved at a rate of 69.3%,
and those of adults were saved at a rate of 76.3%.
Ostensibly, adults do better after replantation; however,
this difference in success rates is not considered statistically significant (P 9 0.05). If any difference does
actually exist, it may be because children with amputated
digits are treated more aggressively than adults. For
digits that would have been judged unsalvageable in
adults, replantation may have been attempted in children.
into 2 groups based on history of diabetes (Table 8).
No digits of diabetics were saved, and those of
patients without diabetes were saved at a rate of 59.6%.
Only one study in the meta-analysis indicated a
history of diabetes. Despite the small sample, a statistically significant indication exists that diabetics fared
worse than patients without diabetes in replanted digit
survival (P G 0.05). An odds ratio analysis is not
possible in this case because no digits belonging to
diabetics survived.
into 2 groups based on ischemia time of the amputated
digit (Table 9). Ischemia times of less than 12 hours are
considered short, and those of greater than 12 hours are
considered long.
The digits that had a short ischemia time survived at
a rate of 93.1%, and those that had a long ischemia time
were saved at a rate of 86.7%.
Such a difference is considered statistically significant (P G 0.05). An odds ratio analysis indicates that the
replanted digits with short ischemia times survived at a
rate 2.08 times greater than those with long ischemia
times. It would be interesting to observe survival rates at
24-hour ischemia times, but such data was not presented
in the original studies. In addition, reference is made to
the fact that digits do better after cold ischemia than
warm ischemia.5
TABLE 8. Diabetes and success of replantation

Hattori et al5
Heistein and Cook6
Janezic et al4
Kim KS et al7
Kim WK et al8
Tark et al9
Velanovich et al10
Waikakul et al11
128
Diabetic
Not diabetic
V
0 of 8
V
V
V
V
V
V
0 of 8 (0.0)
V
28 of 47
V
V
V
V
V
V
28 of 47 (59.6)
TABLE 9. Ischemia time and success of replantation
Hattori et al5
Heistein and Cook6
Janezic et al4
Kim KS et al7
Kim WK et al8
Tark et al9
Velanovich et al10
Waikakul et al11
Total digits saved
(% saved)
Short
(G12 hours)
Long
(912 hours)
V
V
V
V
V
9 of 9
V
899 of 966
908 of 975
(93.1)
V
V
V
V
V
64 of 76
V
47 of 52
111 of 128
(86.7)
| DISCUSSION
There are numerous inherent problems in creating a
meta-analysis. The various problems in each individual
study, such a subject selection bias, are passed on to
influence the meta-analysis. There are also several
problems specific to this particular report. In reporting
the zone of digit injury, some articles used the Tamai
zone classification scheme, whereas others described
the injuries in which phalanx or joint was involved. To
achieve uniformity, all reports were translated to the
latter scheme. In some cases, this may have resulted in a
sublunula zone II amputation through the extremely
proximal aspect of the distal phalanx being translated to
an amputation through the distal IP joint. Likewise,
various studies reported the age of patients in grossly
different ways. This resulted in the need to divide the
age category of the report into 2 somewhat nonspecific
subgroups of child and adult. In reporting the data for
ischemia time, no distinction was made between cold
and warm ischemia. Finally, the outcome of replantation
is, in a large part, based on the skill of the surgeon
performing the operation. The 1803 digits tracked in
this meta-analysis were reattached by numerous surgeons of variable skill at different times and in different
hospitals while following different replantation procedures. Such an arrangement eliminates the consistency
of results that could be achieved by following the results
of a single surgeon.
| SUMMARY
Numerous factors influence the survivability of digits
after replantation. Patients with a history of diabetes,
smoking, and an injury caused by either crushing or
avulsion seem to have the worst prognosis after
replantation. The amputations of the distal phalanx and
the thumb, being male, and ischemia time of greater
than 12 hours seem to have a somewhat worse
prognosis. Age and history of alcohol use do not seem
to be very influential in replanted digit survival. It must
be noted that digit replantation was successful in many

of the cases where adverse factors were present and that
the presence of such adverse factors is therefore not an
absolute contraindication for replantation. As replantation techniques are becoming more advanced and
success rates are increasing, the focus is shifting from
achieving digit survival to achieving digit function. In
some instances, a hand with a well-formed stump may
be more functional than one with a functionless digit.
The goal of replantation should not be the indiscriminate replantation of all severed fingers but the preservation of quality of life through regained function and
appearance.12 The results of the meta-analysis can be
used to help educate patients who had a digit amputation about probable outcomes of replantation and to
serve as a guide for surgeons in the decision to replant.
| REFERENCES
1. Wilhelmi BJ, Lee WP, Pagenstert GI, et al. Replantation
in the mutilated hand. Hand Clin. 2003;19:89Y 120.
2. Idler R, Steichen JB. Complications of replantation
surgery. Hand Clin. 1992;8:427 Y 451.
3. Sud V, Freeland AE. Skeletal Fixation in Digital Replantation. Microsurgery. 2002;22:165 Y 171.
4. Janezic TF, Arnez ZM, Solinc M, et al. One hundred sixtyseven thumb replantations and revascularizations: early
microvascular results. Microsurgery. 1996;17:259Y 263.
5. Hattori Y, Doi K, Ikeda K, et al. Significance of venous

anastomosis in fingertip replantation. Plast Reconstr Surg.
2003;111:1151 Y 1158.
6. Heistein JB, Cook PA. Factors affecting composite graft
survival in digital tip amputations. Ann Plast Surg. 2003;
50:299 Y 303.
7. Kim KS, Eo SR, Kim DY, et al. A new strategy of
fingertip reattachment: sequential use of microsurgical
technique and pocketing of composite graft. Plast
Reconstr Surg. 2001;107:73 Y 79.
8. Kim WK, Lim JH, Han SK. Fingertip replantations:
clinical evaluation of 135 digits. Plast Reconstr Surg.
1996;98:470 Y 475.
9. Tark KC, Kim YW, Lee YH, et al. Replantation and
revascularization of hands: clinical analysis and functional
results of 261 cases. J Hand Surg [Am]. 1989;14A:
17 Y 26.
10. Velanovich V, McHugh TP, Smith DJ Jr, et al. Digital
replantation and revascularization: factors affecting viability, prognosis, and pattern of injury. Am Surg. 1988;54:
598 Y 601.
11. Waikakul S, Sakkarnkosol S, Vanadurongwan V, et al.
Results of 1018 digital replantations in 552 patients.
Injury. 2000;31:33 Y 40.
12. Lukash FN, Greenberg BM, Gallico GG 3rd, et al. A
socioeconomic analysis of digital replantations resulting from home use of power tools. J Hand Surg [Am].
1992;17:1042 Y 1044.
Volume 10, Issue 3
129
T E C H N I Q U E
A New Modification of Trapeziectomy

and Soft Tissue Interposition Arthroplasty
With Abductor Pollicis Longus Advancement
Steven F. Viegas, MD
Department of Orthopaedics and Rehabilitation
University of Texas Medical Branch
Galveston, TX
| ABSTRACT
A new modification of trapeziectomy, soft-tissue interposition arthroplasty with a one-half slip of the flexor
carpi radialis tendon and advancement of the abductor
pollicis longus tendon for treatment of thumb carpometacarpal degenerative arthritis and instability is presented. This procedure facilitates tenodesis of the flexor
carpi radialis slip at the first metacarpal and realigns and
rebalances the thumb posture by using and advancing the
abductor pollicis longus tendon. Therefore, this new modification eliminates the need for perioperative pin fixation
of the first metacarpal, offers better soft tissue tenodesis of
the ligament reconstruction component of the procedure,
and results in improved intraoperative thumb alignment.
Keywords: trapeziectomy, interposition arthroplasty,
abductor pollicis longus advancement
nation of 3 approaches in 1986. Burton and Pellegrini

originally used one-half of the flexor carpi radialis
(FCR) tendon. However, many subsequent surgeons have
used the entire FCR tendon. Tomaino and Coleman3
reported that there was no morbidity identified that was
related to using the entire tendon of the FCR. Pin
fixation of the first metacarpal has been used in trying to
maintain position and alignment of the thumb metacarpal during early healing. A variety of different techniques have been described for the treatment of thumb
carpometacarpal arthritis with generally good results. The
technique offered in the current manuscript has several
modifications, which facilitates the procedure, improves
thumb metacarpal posture, and eliminates the need for
intraoperative pin fixation.
| INDICATIONS
The carpometacarpal joint of the thumb is certainly one
of, if not the most common location of development of
degenerative arthritis in the wrist and hand, particularly
in women. In 1949, Gervis1 studied trapeziectomy as a
treatment of osteoarthritis of the trapeziometacarpal
joint of the thumb. In fact, he, himself, underwent this
surgical procedure. The combination of ligament reconstruction and tendon interposition with trapezium
excision addresses ablation of the arthritic joint surfaces
by trapezial excision, reconstruction of the anterior
oblique ligament to prevent thumb metacarpal instability and limit or prevent axial shortening, and fascial
interposition to reduce the likelihood of impingement
between the thumb metacarpal base and the scaphoid.
Burton and Pellegrini2 originally described this combiAddress correspondence and reprint requests to Steven F. Viegas, MD,
Professor and Chief, Division of Hand Surgery, Department of
Orthopaedics and Rehabilitation, Rebecca Sealy Hospital, Rm 2.616,
301 University Boulevard, Galveston, TX 77555-0165. E-mail:
sviegas@utmb.edu.
130
The indications for surgical treatment of carpometacarpal

degenerative arthritis of the thumb and/or pantrapezial
arthritis of the thumb include deformity and/or weakness
that interfers with the patients activities of daily living
and have not responded adequately to nonoperative
treatment. Although radiographic staging has been used
to develop a treatment plan related to the stage of the
carpometacarpal joint arthritis of the thumb, more recent
studies have found that radiographs do not correlate well
with the level of the disease and/or symptom severity of
the patient.
| SURGICAL TECHNIQUE
The surgery is performed under tourniquet control. An
L-shaped incision is made over the dorsoradial aspect of
the first metacarpal base, angling volar at the level of the
trapezium and extending just to the volar radial aspect of
the palpated FCR tendon (Fig. 1). Careful subcutaneous
dissection is carried out to identify and protect the sensory branches of the radial nerve. Dissection is carried
out between the extensor pollicis brevis and abductor
Trapeziectomy and Interposition Arthroplasty
FIGURE 1. An intraoperative photograph showing the

planned L-shaped incision over the thumb metacarpal
base and trapezium and the small transverse incision at
the level of the musculotendonous juncture of the FCR.
pollicis longus (APL) tendons. Careful dissection is

carried out to identify the radial artery as it courses over
the waist of the trapezium, and deep perforators of the
radial artery are identified and cauterized with bipolar
cautery and then divided so the artery can be retracted
dorsally and proximally.
The dorsal longitudinal portion of the incision is then
utilized to expose the base of the first metacarpal, extending
through the carpometacarpal capsule over the dorsal
aspect of the trapezium and into the scaphotrapezial joint.
A cuff of tissue, including the periosteum of the first
FIGURE 3. Intraoperative photographs showing (A) the

3.2-mm drill bit used manually to make (B) the drill hole on
the dorsal aspect of the first metacarpal, approximately 1 cm
distal to the proximal base of the resected first metacarpal.
metacarpal and trapezium, is elevated on the dorsal and

volar sides of the longitudinal incision. The thumb
carpometacarpal joint and scaphotrapezial joints are
identified and examined.
FIGURE 2. Two diagrams illustrating (A) the area of

planned bone resection (shaded areas) and (B) the
essential anatomy after bone resection.

FCR tendon delivered through the thumb and forearm
incisions with tendon hooks.
Volume 10, Issue 3
131
Viegas
FIGURE 7. An intraoperative photograph showing the 0

prolene suture being used to split the FCR tendon within
its sheath.
FIGURE 5. Intraoperative photographs showing (A) a small

hemostat passed through the split FCR tendon, and (B) a 0
prolene suture passed through the split in the FCR tendon.
Using a narrow, straight rongeur, the central portion

of the trapezium is rongeured longitudinally until the trapezium is divided in 2. Once this is completed, the 2
halves of the trapezium can be displaced into the

curved tendon grasper passed retrograde from the distal
incision within the FCR tendon sheath and volar to the
FCR tendon to the proximal incision to capture the ends of
the 0 prolene suture.
132
FIGURE 8. A series of intraoperative photographs showing

(A) the radial half of the split FCR tendon delivered through
the distal incision at the level of the wrist, (B) the curved
tendon grasper passed antigrade through the FCR tendon
sheath into the defect formed by excising the trapezium to
grasp a looped wire, (C) using the looped wire as a tendon
passer to deliver the radial slip of the FCR tendon into the
space where the trapezium was located, and (D) showing
the radial slip of the FCR tendon delivered through the
wound after it has been split distally to the level of its attachment on the volar base of the second metacarpal base.
FIGURE 8. (continued).
defect, which will facilitate soft tissue dissection off of

the remaining halves of the trapezium, which can then
be easily excised. A wafer of bone is removed, using a
sagittal saw, off the base of the first metacarpal, removing
the remaining articular surface and subchondral bone at
the base of the thumb metacarpal (Figs. 2A, B). Care is
taken to identify and protect the FCR tendon that is
identified in the defect resulting from excision of the
trapezium. A 3.2-mm drill bit is then used to make a drill

hole, starting at the dorsal base of the first metacarpal
approximately 1 cm distal to the proximal base of the
first metacarpal and exiting through the volar base of the
first metacarpal (Figs. 3A, B).
Next, the FCR tendon is identified in the volar radial
aspect of the wrist through the original incision. A small
2-cm transverse incision is then made in the volar aspect
FIGURE 9. A series of intraoperative

photographs and diagrams showing
(A) a photograph of the looped wire
passed retrograde through the drill
hole in the thumb metacarpal to pass
the radial half of the FCR tendon slip,
(B) another photograph of the FCR
tendon slip passed through the drill
hole in the base of the thumb metacarpal, (C) and a diagram showing
the same.
Volume 10, Issue 3
133
Viegas
of the forearm at the musculotendinous junction of the

FCR tendon (Fig. 4). The tendon is split into radial and
ulnar halves and a zero prolene suture is passed between
the tendon halves (Figs. 5A, B). Next, a curved tendon
grasper is introduced into the flexor tendon sheath of the

FCR tendon at the volar aspect of the wrist where the
tendon was identified (Fig. 6). It is passed retrograde and
the 2 ends of the suture are grasped and delivered through
FIGURE 10. A series of intraoperative photographs and diagrams showing (A) a photograph of a hemostat splitting the APL
tendon and another hemostat passing through the split APL to grasp and deliver the FCR slip through the split APL, (B) the FCR
passing through the split APL, (C) a diagram showing the path of the FCR slip, (D) the FCR slip passed through the split APL
tendon (note the adducted posture of the thumb metacarpal), (E) distal axial traction placed on the FCR tendon slip to advance
the APL (note the abducted posture of the thumb metacarpal), and diagrams showing the path of the FCR tendon slip and
thumb posture (F) before and (G) after traction and tenodesis of the FCR tendon slip to the APL tendon.
134
the wrist incision. Using the suture, the tendon is split in 2

by means of traction on the looped suture (Fig. 7). Once
this is accomplished to the level of the incision at the
volar aspect of the wrist, the volar half of the FCR
tendon is transected at its musculotendinous juncture
and the loop suture is used to deliver that half through
the volar wrist incision. The curved tendon grasper is
then passed distally through the FCR tendon sheath into
the defect made by the excision of the trapezium. A
tendon passer, or looped 26 gauge wire, is passed
retrograde from the defect through the FCR tendon
sheath into the volar wrist incision (Figs. 8A YD). The
volar half of the FCR tendon is then passed distally and
the tendon is carefully split in 2 with traction up to the
level of its attachment onto the volar base of the second
metacarpal. The importance of splitting the FCR distally
to the level of its insertion on the second metacarpal base
is to maximize the ability for the FCR slip to act as a
suspensionplasty and maintain the reduction of the first
metacarpal to its anatomical level and prevent subsidence
of the thumb.
Using a tendon passer or looped 26 gauge wire, the
volar half of the FCR is passed through the drill hole from
the base of the first metacarpal out the dorsal aspect of the
thumb metacarpal (Figs. 9A Y C). Next, the APL tendon
FIGURE 11. A diagram illustrating the path of the FCR

slip around the intact half of the FCR tendon.
Volume 10, Issue 3
135
Viegas
is split approximately 2 cm proximal to its attachment at

the base of the thumb metacarpal and the FCR tendon slip
is passed through this split, and axial traction distally is
placed on the FCR slip (Figs. 10A YG). This will be
noted to posture the thumb metacarpal in abduction and

the MP joint in slight flexion. By advancing the APL
tendon, it also affords the opportunity to use the APL
tendon to anchor the half of the FCR tendon slip at the
FIGURE 12. A series of diagrams and intraoperative photographs showing the FCR tendon slip (A) clamped in a straight
hemostat and (B, C) rolled over the hemostat, (D) sutured to itself, then (E Y H) using the same suture advancing and rolling
the tendon slip once more.
136
point that it exits the drill hole in the thumb metacarpal

at the dorsal base of the thumb metacarpal.
Now that the FCR tendon slip has been sutured to the
advanced APL tendon, typically with 4 Y0 Ethibond
sutures, the tendon slip is passed deep into the defect
and around the remaining intact half of the FCR (Fig. 11).
The remaining length of the tendon slip is clamped and
rolled up over straight hemostats, using 4 Y0 Ethibond,
the rolled FCR tendon slip is sutured and tied. Using the
same suture, another segment of the tendon is further
rolled to increase the size of the anchovie and deliver it
further into the wound (Figs. 12A Y G). Once the suture is
tied, it is not cut, but also used to suture anchor it to the
intact segment of the FCR tendon in the base of the
wound (Fig. 13).
The volar and dorsal cuffs of tissue composed of the
thumb carpometacarpal capsule, scaphotrapezial capsule,
and trapezium and metacarpal periostium are sutured to
close the tissue around the half of the FCR tendon passing
into the void resulting from the trapezium excision. The
tourniquet, which was inflated before skin incision, is
deflated. Bleeding is controlled by bipolar cautery and
the wounds are closed. Dressings are incorporated with a
radial thumb gutter plaster splint and Ace wrapping.
| COMPLICATIONS
Complications can include numbness or hypersensitivity
in the distribution of the sensory branch of the radial
nerve. Infection is always a possible complication with
any surgical intervention as well. Generally, however,
| REHABILITATION
Skin sutures are removed at 2 weeks and a new plaster
splint and Ace wrapping are applied. At 6 weeks after the
surgery, the patient is converted to a removable radial
thumb gutter splint, which also has the interphalangeal
joint free, and the patient is to wean from the splint
working on range of motion and increasing grip and
pinch strength. This routine is continued for a 6-week
period. Then, at 3 months after the surgery, splinting is
discontinued and the patient is encouraged to use the
thumb and hand increasingly and without restrictions.
FIGURE 13. A diagram illustrating the final, complete

path of the FCR tendon slips, the APL tendon and the
position of the thumb metacarpal.
Volume 10, Issue 3
137
Viegas
success has been uniformly good and complications are

rare with this operative treatment.
| SUMMARY
This technique, which uses the 3 fundamental principles
described by Burton and Pellegrini of removing the
arthritic joint, reconstructing the anterior oblique ligament, and reducing or eliminating impingement between
the thumb metacarpal base and the scaphoid, has worked
well. The additional modifications of using a single
transverse incision at the musculotendinous junction of
the FCR and a suture loop to split the FCR tendon
minimizes the size of the incision and postoperative
morbidity of the procedure; whereas, additionally, the
advancement of the APL tendon improves the intraoperative and postoperative position of the thumb
metacarpal and eliminates the need for pin fixation of
the thumb metacarpal.
138
| ACKNOWLEDGMENTS
The author thanks Randal Morris for his assistance and
collaboration in the illustrations used in this manuscript
and Kristi Overgaard for her editorial assistance.
| REFERENCES
1. Gervis W. Excision of the trapezium for osteoarthritis of
the trapeziometacarpal joint. J Bone Joint Surg. 1949;31B:
537 Y 539.
2. Burton RI, Pellegrini VD Jr. Surgical management of basal
joint arthritis of the thumb: II Ligament reconstruction with
tendon interposition arthroplasty. J Hand Surg. 1986;11A:
324 Y 332.
3. Tomaino NM, Coleman K. Use of the entire width of the
flexor carpi radialis tendon for the LRTI arthroplasty does
not impair wrist function. Am J Orthop. 2000;29:283 Y 284.
T E C H N I Q U E
Arthroscopic Management of Volar Lunate Facet

Fractures of the Distal Radius
Ethan R. Wiesler, MD, George D. Chloros, MD, Robert M. Lucas, MD,
and Gary R. Kuzma, MD
Department of Orthopaedic Surgery
Wake Forest University School of Medicine
Winston-Salem, NC
| ABSTRACT
The clinical outcome of an intraarticular distal radius
fracture is generally thought to be associated with the
following factors: amount of radial deformity, joint
congruity, and associated soft-tissue injuries.
The proposed technique to manage this fracture
pattern that involves a displaced volar lunate facet
fragment uses wrist arthroscopy and pinning. Distraction of the fracture before arthroscopy is accomplished
either by external fixation or by the arthroscopy tower.
A freer elevator is introduced dorsally to disimpact the
fragments, and next, a nerve hook is used to reduce the
volar lunate facet, which is subsequently pinned to the
radial styloid. The remaining fragments are reduced
with interfragmentary pin fixation, and this anatomical
articular construct is fixed to the radial metaphysis.
The advantages of this technique are: (a) accurate
assessment of articular congruency by direct visualization, (b) identification and repair of associated
lesions, and (c) minimal soft tissue disruption. Potential
disadvantages of external fixation supplemented by
interfragmentary pins may be that it does not provide
for rigid stable fixation, and therefore, does not allow
for early motion compared to open reduction and
internal fixation. Furthermore, it is technically challenging, and is therefore suggested as an alternative for the
aforementioned fracture pattern.
Keywords: distal radius, fractures, arthroscopy, pins,
volar lunate facets
The clinical outcome of an intraarticular distal radius
fracture will be affected by the amount of radial
shortening, angulation, joint congruity (radio-carpal
This work has not received financial support, and the authors declare
no conflict of interest.
Address correspondence and reprint requests to Ethan R. Wiesler, MD,
Department of Orthopaedic Surgery, Wake Forest University School
of Medicine Medical Center Boulevard, Winston-Salem, NC 27157.
E-mail: ewiesler@wfubmc.edu.
and ulno-carpal joints), and associated soft-tissue

injuries.1Y4 The recommended treatment of intraarticular
fractures of the distal radius with involvement of the
volar facet of the lunate (in the past) has been open
reduction and internal fixation using a volar buttress
plate.5Y7 Multiple studies demonstrate that an articular
step-off of 1 to 2 mm is correlated with the development
of degenerative changes,1,2,4,8Y11 and that treatment
should aim at restoring an articular congruity of less
than 1 mm.12
The potential advantages of arthroscopic reduction
over more traditional techniques include: (1) accurate
assessment of the status of the articular surface by direct
visual inspection, which is superior to fluoroscopy,13Y16
(2) identification and repair of chondral and ligamentous lesions, which have been shown to occur with
distal radius fractures,16Y21 (3) washing out of fracture
hematoma and debris may allow for improved range of
motion,22 and (4) minimally invasive technique causing
less tissue damage (skin, tendons, capsule, and fewer
fracture fragments will be devitalized).
Illustrated herein is a technique for the management
of fractures of the distal end of the radius involving the
volar lunate facet using arthroscopic reduction and
interfragmentary pin fixation.
| INDICATIONS
Plain radiographs are generally sufficient to diagnose
comminuted, intraarticular fractures of the distal radius.
However, in certain situations, accurate preoperative
diagnosis is essential to determine the fracture configuration, and this may be augmented by computerized
tomography, or better by the newly developed 3dimensional computerized tomography technique. Relative indications include: (1) age between 18 and 65
years without evidence of metabolic bone disease; (2) a
3- or 4-part compression type fracture of the distal
radius (Fig. 1) involving the volar lunate facet (either
impacted or rotated) with an articular step-off of equal
or greater than 2 mm that remains irreducible after
Volume 10, Issue 3
139
Wiesler et al
FIGURE 1. Typical 3-part lunate impaction fracture of the

distal radius with depression of the volar lunate facet.
(Reproduced with permission from: Koman LA, ed. Wake
Forest University School of Medicine Orthopaedic Manual
2006. Winston-Salem, NC: Orthopaedic Press).
adequate attempts at closed reduction; and (3) the

optimum time interval after injury should be within 4
to 7 days. If reduction is attempted earlier than 4 days,
bleeding from the fresh fracture may potentially
complicate the procedure; and furthermore, the fresh
fracture and ligament tears may precipitate extravasation of arthroscopic fluid into soft tissues.14,23,24 At 7 to
10 days postinjury, the fracture fragments have started
to heal and may become too difficult to manipulate for
reduction.12,23
FIGURE 2. Operating room arrangement. The intraarticular reduction is directly assessed with the arthroscope,
while simultaneously, the C-arm will evaluate the restoration of the anatomical parameters of the distal radius, and
guide the K-wire insertion. (Reproduced with permission
from: Koman LA, ed. Wake Forest University School of
Medicine Orthopaedic Manual 2006. Winston-Salem, NC:
Orthopaedic Press).
140
FIGURE 3. The freer elevator is introduced into the

fracture line, and the dorsal fragment of the lunate facet
is moved out of the way. D indicates dorsal; P, palmar.
(Reproduced with permission from: Koman LA, ed. Wake
Forest University School of Medicine Orthopaedic Manual
2006. Winston-Salem, NC: Orthopaedic Press).
| CONTRAINDICATIONS
Contraindications include: (1) significant metaphyseal
or radial styloid comminution, (2) infection, (3) open
injuries, (4) extensive soft-tissue damage, (5) unreduced
FIGURE 4. The freer elevator serves to disimpact the

fragments before reduction to the radial column. D
indicates dorsal; P, palmar. (Reproduced with permission
from: Koman LA, ed. Wake Forest University School of
Medicine Orthopaedic Manual 2006. Winston-Salem, NC:
Orthopaedic Press).
Arthroscopy in Volar Lunate Facet Fractures of the Distal Radius
FIGURE 5. A stout nerve hook is introduced obliquely

through the fracture line and hooks the volar lunate facet
under its volar cortex. (Reproduced with permission from:
Koman LA, ed. Wake Forest University School of
Medicine Orthopaedic Manual 2006. Winston-Salem,
NC: Orthopaedic Press).
carpal dislocations, (6) median nerve involvement, and

(7) compartment syndrome in the forearm or hand.
| TECHNIQUE
The selection of general or regional anesthesia is based
on the patients and anesthesiologists preference. The
technique uses standard small joint arthroscopic equipment. The patient is positioned supine on the operating
table with the arm draped free on a radiolucent handtable. A pneumatic tourniquet is applied on the upper
arm and inflated at 250 mm Hg. After prepping and
draping, assessment of the fracture is carried-out using a
C-arm. In the case of metaphyseal comminution, the
surgeon may choose to apply external fixation and

preliminary fracture reduction using fluoroscopy to
maintain provisional realignment and length, and eliminate axial loading forces. If an external fixator is not
used, the arthroscopy tower or longitudinal traction
device will generate the reduction via ligamentotaxis to
permit the simultaneous use of arthroscopy and fluoroscopy (Fig. 2). Vertical or horizontal25 orientation may
be chosen, depending on the surgeons preference; and
several precautions are applied to minimize arthroscopic
fluid extravasation into the soft tissues: (1) the forearm
is wrapped in a compressive dressing, (2) lactate Ringer
solution is used for irrigation, because it is rapidly
absorbed from the soft tissues, and (3) irrigation is via
gravity-driven inflow, thus avoiding the use of pressurized pump inflow.
The fracture is approached from the dorsal side, and
the following portals are used: the 3-4 portal is preferred
for initial visualization (2.7 mm/30 degrees small joint
arthroscope) along with the 5-6, and 6-R portals for
instrumentation (2.7 mm arthroscopic shaver/probe for
removal of fracture hematoma and fragment manipulation). Once the arthroscope is inserted, clot and
fracture debris that are apparent are cleared to allow
an unobstructed survey of the distal radius fracture
configuration and associated soft tissue injury (eg,
triangular fibrocatilage complex tear, or ligamentous
pathology). The surgeon has to bear in mind that since
the fragments were irreducible by means of closed
reduction, this may be an indication that the fracture
fragments have lost capsular integrity and attachments,
and may thus require individual manipulation.
A freer elevator is inserted dorsally through the 3-4
portal, and is introduced into the fracture line; it will
firstly serve to disengage the dorsal fragment of the
lunate facet (Fig. 3), and is then used to disimpact the
fragments before reduction to the radial column (Fig. 4).
FIGURE 6. Manipulation under arthroscopic visualization improves articular congruency. RS indicates radial styloid; LF,
lunate facet. (Reproduced with permission from: Koman LA, ed. Wake Forest University School of Medicine Orthopaedic
Manual 2006. Winston-Salem, NC: Orthopaedic Press).
Volume 10, Issue 3
141
Wiesler et al
FIGURE 7. The lowercase letters refer to K-wires. A, K-wires are drilled and used to maintain reduction, firstly of the
dorsal (a) and volar (b) lunate facet fragments to the radial styloid. B, Additional K-wires are further used to stabilize the
dorsal and volar lunate facets (c) and (d). C, The construct is fixed to the metaphysis (e) and (f). (Reproduced with
permission from: Koman LA, ed. Wake Forest University School of Medicine Orthopaedic Manual 2006. Winston-Salem,
NC: Orthopaedic Press).
The dorsal lunate facet fragment is initially left in its

displaced position to allow access to the volar fragment.
The next step consists of introducing a stout nerve
hook obliquely through the fracture line of the lunate
facet and hooking it under the volar cortex of the volar
lunate facet fragment (Fig. 5). The hook serves to tilt,
disimpact, and then reduce the fragment (Fig. 6), which
is then fixed to the radial styloid fragment with pins
142
under image intensifier combined with direct visualization. Next, the dorsal lunate facet fragment is reduced
to the styloid volar fragment construct and fixed with
interfragmentary pins (Fig. 7A). Additional K-wires
may be inserted to fix the volar and dorsal lunate
fragments (Fig. 7B). The construct may then be
stabilized to the radial shaft using 0.62-inch K-wires
(Fig. 7C). It is worthwhile noting that in previous
Arthroscopy in Volar Lunate Facet Fractures of the Distal Radius
subsequently, final reduction of the construct to the

radial metaphysis. If the radial styloid is firstly reduced
to the metaphysis, this will not further allow subsequent
reduction of the volar lunate facet.
Concomitant soft tissue injuries can subsequently be
addressed by debridement or repair (triangular fibrocartilage complex, scapholunate interosseous, and lunotriquetral interosseous ligaments). If additional support is
required to avoid late fracture subsidence, bone graft
may be used and placed through a small dorsal incision
between the fourth and fifth dorsal compartments to
buttress the dorsal comminution.
Finally, an external fixator is needed to maintain
unloading of the joint and is applied, while wrist
distraction is still maintained by the tower.
| COMPLICATIONS
Complications secondary to the arthroscopy itself are
minimal if the aforementioned indications are respected;
however, potential complications include: (1) loss of
reduction due to comminution of the volar cortex, (2) pin
track infections, (3) potential for injury to the dorsal
sensory nerves of the radial or ulnar nerves may lead to
painful neuroma formation and sometimes to complex
regional chronic pain syndrome,26 (4) rupture of extensor
tendons caused by the dorsal subcutaneous K-wires, (5)
acute postoperative compression of the median nerve,
and (6) acute postoperative compartment syndrome.
A disadvantage of external fixation supplemented by
inter-fragmentary pins is that it does not provide for
rigid stable fixation and early motion, especially in
comminuted fractures, as does open reduction and
internal fixation. However, this drawback may be offset
by the decreased swelling and scar, an unavoidable
consequence of open reduction. In addition, no hardware related problems or removal are necessary, which
can occur with internal fixation.
FIGURE 8. A, Anteroposterior and lateral preoperative
radiographs. B, Intraoperative view showing a nerve hook
that has been introduced obliquely through the fracture
line and serving to hook the lunate facet under the volar
cortex of the volar lunate facet fragment. The volar lunate
facet fragment will be tilted, disimpacted, and then
reduced. C, Postoperative radiographs showing the final
fixation.
descriptions of techniques of arthroscopically assisted

reduction and fixation of distal radius fractures, the
radial styloid fragment is commonly the first chosen to
reduce, and will subsequently serve as landmark for the
reduction of the remaining fragments.1,6,10,23 In this
particular technique, however, careful reduction of the
remaining fragments should be performed first, and
| REHABILITATION
A volar splint is applied, and the patient is instructed to
begin range of motion of the fingers, forearm rotation,
elbow flexion, and shoulder motion immediately to
prevent stiffness. Close postoperative follow-up is
mandatory, to inspect for any loss of reduction, which
would require revision. K-wires are removed at 6 weeks
postoperatively, whereas the external fixator and the
splint are removed at 8 weeks. Muscle strengthening is
initiated at 10 weeks postoperatively.
Illustrative Case
Radiographs illustrating the case of a 19-year-old
woman with a comminuted fracture of her left distal
Volume 10, Issue 3
143
Wiesler et al
radius involving the volar lunate facet after a motor

vehicle accident are shown in Figure 8.
12. Abboudi J, Culp RW. Treating fractures of the distal

radius with arthroscopic assistance. Orthop Clin North Am.
2001;32:307Y315. ix.
| CONCLUSIONS
13. Auge WK, Velazquez PA. The application of indirect

reduction techniques in the distal radius: the role of
adjuvant arthroscopy. Arthroscopy. 2000;16:830Y835.
The technique for arthroscopically assisted reduction of

displaced intraarticular fractures of the distal radius involving the volar lunate facet described herein may offer an
invaluable alternative method with few complications
should the operating surgeon desire to proceed with closed
rather than open treatment of these difficult fractures.
| ACKNOWLEDGMENT
The authors would like to thank Anne-Marie Johnson,
CMI, for providing the illustrations contained in this
manuscript.
| REFERENCES
1. Fernandez DL, Geissler WB. Treatment of displaced
articular fractures of the radius. J Hand Surg [Am].
1991;16:375Y384.
2. Knirk JL, Jupiter JB. Intra-articular fractures of the distal
end of the radius in young adults. J Bone Joint Surg Am.
1986;68:647Y659.
3. Melone CP Jr. Articular fractures of the distal radius.
Orthop Clin North Am. 1984;15:217Y236.
4. Trumble TE, Schmitt SR, Vedder NB. Factors affecting
functional outcome of displaced intra-articular distal
radius fractures. J Hand Surg [Am]. 1994;19:325Y340.
5. Fernandez DL, Jupiter JB. Fractures of the Distal Radius:
A Practical Approach to Management, 2nd ed. New York:
Springer-Verlag, 2002.
6. Geissler WB. Arthroscopically assisted reduction of intraarticular fractures of the distal radius. Hand Clin.
1995;11:19Y29.
7. Sanders RA, Keppel FL, Waldrop JI. External fixation of
distal radial fractures: results and complications. J Hand
Surg [Am]. 1991;16:385Y391.
8. Cooney WP III, Dobyns JH, Linscheid RL. Complications
of Colles fractures. J Bone Joint Surg Am. 1980;62:
613Y619.
14. Culp RW, Osterman AL. Arthroscopic reduction and

internal fixation of distal radius fractures. Orthop Clin
North Am. 1995;26:739Y748.
15. Edwards CC, Haraszti CJ, McGillivary GR, et al. Intraarticular distal radius fractures: arthroscopic assessment of
radiographically assisted reduction. J Hand Surg [Am].
2001;26:1036Y1041.
16. Mehta JA, Bain GI, Heptinstall RJ. Anatomical reduction
of intra-articular fractures of the distal radius. An
arthroscopically-assisted approach. J Bone Joint Surg Br.
2000;82:79Y86.
17. Fontes D, Lenoble E, de Somer B, et al. Lesions of the
ligaments associated with distal fractures of the radius. 58
intraoperative arthrographies. Ann Chir Main Memb Super.
1992;11:119Y125.
18. Geissler WB, Freeland AE, Savoie FH, et al. Intracarpal
soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am.
1996;78:357Y365.
19. Mohanti RC, Kar N. Study of triangular fibrocartilage
of the wrist joint in Colles fracture. Injury. 1980;11:
321Y324.
20. Mudgal CS, Jones WA. Scapho-lunate diastasis: a
component of fractures of the distal radius. J Hand Surg
[Br]. 1990;15:503Y505.
21. Richards RS, Bennett JD, Roth JH, et al. Arthroscopic
diagnosis of intra-articular soft tissue injuries associated
with distal radial fractures. J Hand Surg [Am]. 1997;22:
772Y776.
22. Doi K, Hattori Y, Otsuka K, et al. Intra-articular fractures
of the distal aspect of the radius: arthroscopically assisted
reduction compared with open reduction and internal
fixation. J Bone Joint Surg Am. 1999;81:1093Y1110.
23. Geissler WB. Intra-articular distal radius fractures: the
role of arthroscopy? Hand Clin. 2005;21:407Y416.
9. Geissler WB. Arthroscopic treatment of intra-articular

distal radius fractures. Atlas of Hand Clinics. 1992;2:97Y124.
24. Wolfe SW, Easterling KJ, Yoo HH. Arthroscopic-assisted

reduction of distal radius fractures. Arthroscopy. 1995;11:
706Y714.
10. Geissler WB, Fernandes D. Percutaneous and limited open

reduction of intra-articular distal radial fractures. Hand
Surg. 2000;5:85Y92.
25. Lindau T. Wrist arthroscopy in distal radial fractures

using a modified horizontal technique. Arthroscopy. 2001;
17:E5.
11. Levy HJ, Glickel SZ. Arthroscopic assisted internal

fixation of volar intraarticular wrist fractures. Arthroscopy.
1993;9:122Y124.
26. Freeland AE, Geissler WB. The arthroscopic management

of intra-articular distal radius fractures. Hand Surg. 2000;
5:93Y102.
144
T E C H N I Q U E
Biologic Resurfacing of the Glenoid Using a

Meniscal Allograft
George S. Themistocleous, MD, Charalampos G. Zalavras, MD, Vasileios C. Zachos, MD,
and John M. Itamura, MD
Department of Orthopaedic Surgery
Keck School of Medicine
University of Southern California
LAC+ USC Medical Center
Los Angeles, CA
| ABSTRACT
Biologic resurfacing of the glenoid is a treatment
alternative for young patients who develop rapid and
aggressive destruction of glenoid. In 2001, a technique
was developed to allow secure fixation of a meniscal
allograft to the glenoid in combination with hemiarthroplasty replacement of the humeral head. The
authors have modified this technique by addressing
posterior wear factors, as well as circumferential covering of the glenoid perimeter. The meniscal horns are
sutured together to fashion the allograft in an ovoid
shape. The meniscus closely matches the circumference
of the glenoid and therefore 180- coverage of the
glenoid rim is achieved. In addition, the wedge shape of
the meniscus may enhance comfort and stability.
Keywords: biologic resurfacing, glenoid, meniscal
allograft, shoulder, hemiarthroplasty
Total shoulder arthroplasty has historically offered the
most predictable functional results and successful pain
relief amongst patients with advanced arthritis of the
glenohumeral joint.1Y5 Young active patients with
higher loads and joint reactive forces on their glenoid
component6 are at higher risk for glenoid failure and
revision surgery. Therefore, in this group of patients,
joint sparing alternatives should be considered that
avoid placing a prosthetic glenoid component.
Biologic resurfacing was first described by Baer7 in
1918, and is indicated in the management of young or
active patients who might develop rapid and excessive
Address correspondence and reprint requests to George S. Themistocleous,

MD, LAC+USC Medical Center, 1200 N. State Street, GNH 3900
Los Angeles, CA 90033. E-mail: themistocleousgeorge@hotmail.com.
wear of the glenoid component. The technique has been

performed to treat both osteoarthritis and rheumatoid
arthritis,8 utilizing tissues ranging from pigs bladder to
lyophilized dura mater.7,9Y11 Biologic resurfacing avoids
complications associated with prosthetic glenoid resurfacing, such as polyethylene wear, cement fragmentation, loosening and dissociation of the glenoid
component, and bone loss.6
Hybrid techniques of glenoid biologic resurfacing
combined with hemiarthroplasty have evolved. These
glenoid resurfacing techniques include autogenous
grafts including the anterior shoulder capsule, and also
allografts such as achilles tendon, fascia lata and more
recently, the lateral meniscus.12
In 1995 Burkhead and Hutton13 treated 14 patients
with biologic resurfacing of the glenoid using autogenous fascia lata or anterior shoulder capsule combined
with hemiarthroplasty. At 2 years follow-up all patients
had full pain relief and improved range of motion
(average increase in elevation, external rotation, and
internal rotation was 57-, 45-, and 6 spinal segments,
respectively). No glenoid erosion was observed on
postoperative radiographs.
Meniscal allografts have been widely used at the
knee14Y17 following complete meniscectomy. The primary goal was the articular cartilage protection from
additional damage. In 2001, Ball et al18 made the
hypothesis that by resurfacing the glenoid with a lateral
meniscal allograft, the progression of glenoid erosion
would be slowed or stopped and that the remaining bone
stock would be preserved. At an average follow-up of
24 months, 4 out of 6 patients in the study were satisfied
with the procedure, and reported minimal or no pain.
All patients had significant improvement in range of
motion; there was no radiographic sign of glenoid
erosion and the joint space was maintained. Preliminary
results have shown that the meniscal allograft has
improved mechanical properties in comparison to the
Volume 10, Issue 3
145
Themistocleous et al
Surgical Technique
FIGURE 1. The horns of the meniscus are sutured

together and 8 hash marks are circumferentially drawn.
capsular graft due to straightforward and complete

coverage of the glenoid surface. In addition, meniscal
allograft does not preclude future procedures such as
total shoulder arthroplasty or fusion.6
The purpose of this manuscript is to describe a meniscal allograft glenoid resurfacing modification of Balls
technique that may improve coverage of the glenoid.
| INDICATIONS/
CONTRAINDICATIONS
The best candidate is a young adult with severe shoulder
pain, with restriction of motion, compromised activities
of daily living, and failed arthroscopic treatment or nonoperative measures. Radiographic documentation of
asymmetric wear or structural damage of the glenoid
should be present.18 This technique is contraindicated in
skeletally immature patients, active shoulder septic
arthritis, or adjacent osteomyelitis.18
After induction of the general anesthesia the patient is

placed on the operating table in a modified beach chair
position. The shoulder should be well off of the side of
the table to allow adduction and extension of the limb
during humeral preparation.
A standard long deltopectoral approach is used for
exposure. The subscapularis tendon is divided 1 cm
medial to its attachment to the lesser tuberosity and
detached from the anterior capsule. The rotator interval
is split to the base of the coracoid process, and the
biceps tendon is cut for later tenodesis. The axillary
nerve is then protected with a Darrach retractor and the
anterior capsular release is continued inferiorly past the
6 oclock position. This is facilitated by progressive
external rotation and flexion of the adducted arm. By
extension and external rotation of the arm, the humeral
head is delivered into the wound and resected, followed
by the preparation of the proximal humerus according to
the prosthetic design selected. After humeral preparation, the glenoid is exposed and the remaining articular
cartilage is removed with a curette or burr, taking care
to preserve any remaining labrum. The superior and
middle glenohumeral ligaments and the anterior capsule
are then released just outside of the labrum and the superior border of the subscapularis is mobilized to the base
of the coracoid process. The plane between the anteroinferior capsule and the subscapularis is developed by
blunt dissection to preserve the axillary nerve.
After that the fully exposed glenoid can be assessed
in terms of bone stock, bone quality and retro or ante
version. Slight corrections can be made by light reaming
of the glenoid surface. The next step consists of
selection and preparation of the meniscal allograft from
a proximal tibia bone allograft graft (menisci with a
hemiplateau). The menisci have differences in shape;
| TECHNIQUE
Preoperative Evaluation
The routine preoperative evaluation for total shoulder
arthroplasty candidates is performed. This includes an
anteroposterior radiograph of the affected shoulder with
the arm in neutral rotation, an anteroposterior radiograph with the arm in external rotation, a scapular
lateral view, and an axillary view.19 The bony structures
should be evaluated for quantity, quality, and deformity.
CT scanning of the glenohumeral joint is particularly
useful in bone loss quantification, as well as in spatial
interpretation of bone deformity and bone version. 20Y22
For patients with suspected rotator cuff deficiency,
magnetic resonance imaging (MRI) is necessary to
evaluate both the rotator cuff integrity and the degree
of osteoarticular destruction.23 Final assessment of
glenoid status is achieved by intraoperative direct
inspection and palpation.
146
FIGURE 2. Intraoperative photograph showing bioabsorbable suture anchors passing through 8 matching
hash marks in the glenoid circumeference.
Biologic Resurfacing of the Glenoid Using a Meniscal Allograft
the lateral meniscus forms a C-shaped incomplete

semicircle, whereas the medial meniscus is more Ushaped with a wider separation of its anterior and
posterior horns.24 In addition, there are differences in
size with average medial and lateral meniscal lengths of
45.7 mm and 35.7 mm, respectively. 25 According to the
senior authors (J.M.I.) modification of the resurfacing
technique, both menisci are suitable for grafting. Therefore both of them are released from the bone and softtissues removed. The anterior and posterior horns of
each meniscus are sutured together in order to fashion
the graft into an oval shape that resembles the glenoid
surface. By using a glenoid sizer the meniscus that
better matches up to the glenoid size is selected.
After the correct size is selected, notches are placed
at the 12, 6, 3 and 9 oclock positions on the meniscal
graft and then bisected so that there are 8 hash marks
(Fig. 1). Eight bioabsorbable suture anchors 2.8 mm
(DePuy Mitek, Warsaw, Indiana Johnson & Johnson) are
then placed in the same positions in the glenoid (Fig. 2),
and are then passed through the meniscal predetermined
hash marks (Fig. 3). The sutures are firmly tied securing
the meniscal graft on the glenoid rim.
The authors agree with Ball et al. that the wedge
shape of the meniscus is particularly suited to cover the
more commonly encountered posterior wear pattern of
the glenoid.18 However, the proposed modification of
the technique by fashioning an oval-shaped meniscal
graft achieves not only coverage of the posterior part of
the glenoid rim but coverage of the entire articular
surface with an excellent fit (Fig. 4). This may be
particularly useful in patients with glenoid erosion that
is not limited to the posterior part of the articular
surface. Moreover, the wedge shape of the oval-shaped
meniscal graft recreates a concave surface that matches
the contour of the prosthetic humeral head.
FIGURE 4. Intraoperative photograph showing fixation of

the meniscus to the glenoid.
The humeral component is then reduced into the

glenoid and its stability and congruency with the
resurfaced glenoid is assessed. Routine closure is then
performed over a drain.
| CASE
The patient is a 28-year-old right-hand dominant woman
with combined anterior shoulder instability and glenoid
wear who had undergone previous stabilization procedures (capsulorraphy) (Figs. 5A, B). She complained of
pain, decreased range of motion and crepitus. Radiographic evaluation revealed glenoid erosion. The
patient underwent meniscal allograft interposition with
hemiarthroplasty.
At 16 months follow up the pain has completely
subsided. Arm elevation, increased from 80- preoperative to 110-, external rotation increased from 35preoperative to 45- and internal rotation improved from
sacroiliac joint to L2 spinous process.
The Disabilities of the Arm, Shoulder and Hand
(DASH) score range (0Y100) was improved from 63 to
9. The patient was able to return to her daily activities
and she rated her results as excellent. She was very
satisfied and stated that she would have undergone the
procedure again under the same hypothetical scenario.
The humeral stem was radiographically stable without
radiolucent lines at the bone cement interface. Glenoid
erosion was halted with preservation of the joint space
(Figs. 6A, B).
| COMPLICATIONS
FIGURE 3. Intraoperative photograph showing the
sutures passing through the meniscus at the previously
described predetermined points.
Patients who undergo biologic resurfacing are susceptible to the same complications associated with total
shoulder replacements. These include wound infection,
Volume 10, Issue 3
147
Themistocleous et al
| REHABILITATION
Postoperative rehabilitation is similar to that of total
shoulder arthroplasty. The first 2 weeks postoperatively,
the shoulder is kept immobilized in a sling. After that a
progressive passive range of shoulder motion exercise is
started that gradually evolves into active stretching and
strengthening. The patients arm remains in the sling
between sessions. Activities of daily living are encouraged, and active motion is begun after 3 weeks followed
by full active motion by 6 weeks. Physical therapy
FIGURE 5. Anterioposterior (A) and axillary (B) radiographs of a young female with a history of stabilization
procedure as evidenced by bone anchors. Glenohumeral
osteoarthritis is seen in association with wear of the
glenoid and joint space narrowing. The patient underwent
meniscal allograft interposition with hemiarthroplasty.
osteomyelitis, soft tissue ossification and failure of

fixation. Oversizing the joint with bulky and too large
meniscal graft in addition to improper implant selection
could lead in limitation of shoulder motion; this may
compromise the shoulder function at the immediate
postoperative period and adversely affect the desired
outcome. Nerve injury is a rare complication.26
148
FIGURE 6. Anterioposterior (A) and axillary (B) radiographs of the patient at 16 months follow up. The glenoid is
well maintained with clear alteration of the erosion process.
Biologic Resurfacing of the Glenoid Using a Meniscal Allograft
usually continues until range of motion and strength are

maximized. Heavy physical use of the shoulder is
prohibited for an additional 6 weeks.27
| REFERENCES
1. Barrett WP, Thornhill TS, Thomas WH, et al. Nonconstrained total shoulder arthroplasty in patients with
polyarticular rheumatoid arthritis. J Arthroplasty. 4:91Y96.
glenoid with hemiarthroplasty of the shoulder. J Shoulder

Elbow Surg. July 1995;4:263Y270.
14. Cameron JC, Saha S. Meniscal allograft transplantation
for unicompartmental arthritis of the knee. Clin Orthop
Relat Res. April 1997;164Y171.
15. Kuhn JE, Wojtys EM. Allograft meniscus transplantation.
Clin Sports Med. July 1996;15:537Y546.
16. van Arkel ER, de Boer HH. Human meniscal transplantation. Preliminary results at 2 to 5-year follow-up.
J Bone Joint Surg Br. July 1995;77:589Y595.
2. Boyd AD Jr, Thomas WH, Scott RD, et al. Total

shoulder arthroplasty versus hemiarthroplasty. Indications
for glenoid resurfacing. J Arthroplasty. December
1990;5:329Y336.
17. Veltri DM, Warren RF, Wickiewicz TL, et al. Current

status of allograft meniscal transplantation. Clin Orthop
Relat Res. June 1994;44Y55.
3. Cofield RH. Shoulder replacement. In: Kolbel R,

Helbig B, Blauth W eds. Total shoulder arthroplasty with
bone ingrowth fixation. Berlin: Springer-Verlag, 1987:
209Y212.
18. Ball CM, Galatz LM, Yamaguchi K. Meniscal allograft

interposition arthroplasty for the arthritic shoulder:
description of a new surgical technique. Techniques in
Shoulder & Elbow Surgery. 2001;2:247Y254.
4. Neer CS, Watson KC, Stanton FJ. Recent experience in

total shoulder replacement. J Bone Joint Surg Am. March
1982;64:319Y337.
19. Green A, Norris TR. Imaging techniques for glenohumeral

arthritis and glenohumeral arthroplasty. Clin Orthop Relat
Res. October 1994;7Y17.
5. Norris TR, Iannotti JP. Functional outcome after shoulder

arthroplasty for primary osteoarthritis: a multicenter study.
J Shoulder Elbow Surg. March 2002;11:130Y135.
20. Franklin JL, Barrett WP, Jackins SE, et al. Glenoid

loosening in total shoulder arthroplasty. Association
with rotator cuff deficiency. J Arthroplasty. 1988;3:
39Y46.
6. Baumgarten KM, Lashgari CJ, Yamaguchi K. Glenoid

resurfacing in shoulder arthroplasty: indications and
contraindications. Instr Course Lect. 2004;53:3Y11.
7. Baer WS. Arthroplasty with the help of animal membrane.
Am J Orthop Surg. 1918;16:171.
8. Milbrink J, Wigren A. Resection arthroplasty of the
shoulder. Scand J Rheumatol. 1990;19:432Y436.
9. Baghian S, Font-Rodriguez D, Williams GR. Soft-Tissue
Interposition Without Hemiarthroplasty for Treatment
of Degenerative Glenohumeral Arthritis in Young
Patients. AAOS 70th Annual Meeting, New Orleans,
LA, 2003.
10. Miehlke RK, Thabe H. Resection interposition arthroplasty of the rheumatoid shoulder. Rheumatology.
1989;12:73Y76.
11. Tillmann K, Braatz D. Resection interposition arthroplasty
of the shoulder in rheumatoid arthritis. Rheumatology.
2005;12:68Y72.
12. Cameron BT, Iannotti JP. Alternatives to total shoulder
arthroplasty in the young patient. Techniques in Shoulder
& Elbow Surgery. 2004;5:135Y145.
13. Burkhead WZ Jr, Hutton KS. Biologic resurfacing of the
21. Mallon WJ, Brown HR, Vogler JB III, et al. Radiographic

and geometric anatomy of the scapula. Clin Orthop Relat
Res. April 1992;142Y154.
22. Randelli M, Gambrioli PL. Glenohumeral osteometry
by computed tomography in normal and unstable shoulders. Clin Orthop Relat Res. July 1986;151Y156.
23. Bell RH, Noble JS. The management of significant
glenoid deficiency in total shoulder arthroplasty.
J Shoulder Elbow Surg. May 2000;9:248Y256.
24. Alford W, Cole BJ. The indications and technique for
meniscal transplant. Orthop Clin North Am. October 2005;
36:469Y484.
25. McDermott ID, Sharifi F, Bull AM, et al. An anatomical
study of meniscal allograft sizing. Knee Surg Sports
Traumatol Arthrosc. March 2004;12:130Y135.
26. Brems JJ. Complications of shoulder arthroplasty: infections, instability, and loosening. Instr Course Lect. 2002;
51:29Y39.
27. Barrett WP, Franklin JL, Jackins SE, et al. Total shoulder
arthroplasty. J Bone Joint Surg Am. July 1987;69:
865Y872.
Volume 10, Issue 3
149
T E C H N I Q U E
The Hypothenar Fat Pad Transposition Flap:

A Modified Surgical Technique
Minas T. Chrysopoulo, MD, Jeffrey A. Greenberg, MD, and William B. Kleinman, MD
2766 Richardson St.,
Fitchburg, WI
| ABSTRACT
The hypothenar fat pad flap has been shown to produce
reliable clinical results for the treatment of recurrent
carpal tunnel syndrome secondary to cicatricial tethering. The flap utilizes soft vascularized tissue that does
not compromise hand function and is of sufficient size
to provide median nerve coverage in the carpal tunnel.
We describe technical modifications that facilitate
improved, tension-free transposition of the pedicled fat
pad flap. These modifications enable transfer of vascularized tissue and decrease iatrogenic damage to the
important perforator vessels. The hypothenar fat pad
transposition flap provides a reliable source of vascularized local tissue that can be used successfully as an
adjunct to neurolysis for the treatment of recurrent
idiopathic CTS secondary to perineural scarring.
Keywords: carpal tunnel syndrome, flap, hypothenar,
fat pad, recurrent
Carpal tunnel syndrome (CTS) is the most common
entrapment neuropathy afflicting 0.1% to 10% of the
general population and up to 15% of those in high-risk
occupations. According to Palmer,1 medical costs in the
US are estimated to be more than $2 billion per year.
Greater than 400,000 surgical procedures are being
performed annually.
Kulick2 and Plancher3 found that the incidence of
persistent symptoms following carpal tunnel release (CTR)
varies from 10% to 25%. The most commonly cited causes
are inadequate distal ligament release, recurrent flexor
tenosynovitis, postoperative adhesions and neural fascicular
scarring. Reoperation is needed in up to 3% of patients.
According to Cobb,4 persistent symptoms following
reoperation are likely and failure is more frequent than
after primary carpal tunnel surgery. Langloh5 stated that
the most common pathologic finding at reexploration
was nerve compression secondary to tenosynovial
hypertrophy.
Address correspondence and reprint requests to Minas T. Chrysopoulo,
M.D., PRMA 9635 Huebner Road, San Antonio, TX 78240. E-mail:
minas@dr.com.
150
Recurrent symptoms, according to Hunter,6 are

usually the result of median nerve adherence to the
radial leaf of the transected transverse carpal ligament
(TCL). Wrist motion leads to traction on the adherent
nerve with resulting dysesthesia and recurrent symptoms. Our findings are consistent with Hunter and we
believe that the majority of cases result from epineural
fibrous fixation secondary to the formation of postoperative adhesions.
Results following repeat decompression and neurolysis are often disappointing.5 Some patients are
unfortunately subjected to multiple explorations with
the median nerve extricated from the transverse carpal
ligament during each procedure. Recurrent symptoms
develop coincident with scarring and adherence to the
previously divided leaf of the transverse carpal ligament. Several procedures, 3,7Y16 including local
flaps,10,12,13 free flaps such as omentum14 and vein
wrapping,15,16 have been described to prevent adherence
and scarring of the median nerve. All of these
procedures aim to improve median nerve gliding by
providing an improved tissue environment around the
neurolysed nerve, however, many of them are technically demanding use tissues of insufficient size and
require the sacrifice of normal, functioning muscle.
The hypothenar fat pad flap was initially described by
Cramer7 and subsequently modified by Strickland8 and
Mathoulin.9 The procedure essentially mobilizes a vascularized fat pad from the hypothenar eminence, which is
then interposed between the neurolysed median nerve
and the radial wall of the carpal canal.
The hypothenar muscles and the transverse carpal
ligament are consistently covered with a layer of adipose
tissue supplied by a minimum of 3 arterial branches
which originate from the ulnar artery in Guyons canal
(Figs. 1, 2). Previous cadaver studies by Plancher3
showed that segmental ulnar artery branches arise
approximately every centimeter, beginning at the distal
wrist flexion crease, and range between 0.7 and 1.5 mm
in diameter. Local muscle perforators provide additional
blood supply to the fat pad. The skin overlying the
hypothenar fat pad is supplied by a subdermal rete of
arterioles running through the superficial adipose tissue.
The ulnar digital nerve of the small finger runs deep to
Hypothenar Fat Pad Flap
FIGURE 1. Diagrammatic cross section demonstrating the hypothenar fat pad in relation to the scarred median nerve
nonadherent to the TCL.
the distal third of the fat pad after branching from the
ulnar nerve in Guyons canal.
Cramer,7 Strickland,8 and Plancher3 emphasized that
the deep dissection necessary to mobilize the hypothenar fat pad flap was safe, provided it terminated as
soon as the neurovascular structures in the canal of
Guyon are visualized (Fig. 3). A segment of the ulnar
leaf of the TCL was then excised. Once freed, the flap
was either advanced or turned over and secured deep to
the radial leaf of the transverse carpal ligament. Postoperatively, the hand was immobilized with a fair
amount of radial-ulnar compression for 2 weeks with
the thumb abducted to relieve tension on the repair.
Mathoulin9 advocated routine division of the deep
branch of the ulnar artery that runs alongside the deep
motor branch of the ulnar nerve. He subsequently
dissected the ulnar artery away from the ulnar nerve
completely (Fig. 4). Only with these maneuvers was he
able to free up the flap sufficiently to allow coverage of
the median nerve.
Surprisingly, all these previous descriptions of
surgical technique have been extremely vague. The
purpose of this study was to fully describe our
modification of the hypothenar fat pad flap transfer.
enar fat pad flap is not indicated for the treatment of

flexor tenosynovitis which is also often the cause of
primary and recurrent CTS.
| INDICATIONS/CONTRAINDICATIONS
The hypothenar fat pad flap is indicated as an adjunct to
neurolysis for the treatment of recurrent idiopathic CTS
secondary to cicatricial tethering of the median nerve at
the wrist. The diagnosis of recurrent CTS should be
made based on history and clinical exam and supported
by confirmatory electrodiagnostic studies. The hypoth-
FIGURE 2. Fat pad blood supply. Segmental branches

off the ulnar artery occur approximately every centimeter,
beginning at the distal wrist flexion crease. Vessels range
between 0.7 and 1.5 mm in diameter.
Volume 10, Number 3
151
Chrysopoulo et al
FIGURE 3. Representation of the traditional dissection, terminating at the neurovascular structures in Guyons canal.
| TECHNIQUE
Under regional anesthesia, previous incisions are incorporated into an incision with proximal and distal oblique
extensions (Fig. 5). A large hypothenar skin flap is
elevated.
The subdermal rete vasculature supplying the
hypothenar skin flap is preserved by leaving a thin
layer of adipose tissue on the skin flap (Fig. 6).
Maintenance of skin vasculature minimizes the risk of
postoperative wound complications. This superficial
dissection continues towards the ulnar border of the

hand.
The fat pad flap is then elevated off the hypothenar
musculature and the TCL. The ulnar NV bundle is
elevated with the flap. Unlike Cramer, Strickland and
Plancher, we do not stop our dissection once the bundle
is visualized. We therefore obtain greater flap mobility
without compromising blood supply. Unlike Mathoulin,
we do not feel it is necessary to dissect or skeletonize
the ulnar NV bundle in any way. Dissection is carried
FIGURE 4. Adaptation of Mathoulins original diagrammatic representation. Demonstrates skeletonization of the ulnar
neurovascular bundle and division of the deep branch of the ulnar artery (Mathoulin C, Bahm J, Roukoz S, Pedicled
hypothenar fat pad flap for median nerve coverage in recalcitrant carpal tunnel syndrome. Hand Surg 2000;5(1):33Y40).
152
The pedicled fat pad flap is then raised, transposed

across the uncinate process and interposed between the
median nerve and the radial wall of the carpal canal
(Figs. 9, 10). The median nerve and flexor pollicis
longus tendon are thereby totally surrounded by the flap,
which is secured tension-free deep to the radial leaf.
| REHABILITATION
A postoperative splint keeping the wrist in neutral
position is applied for 2 weeks. Postoperative radialulnar compression is not necessary.
| DISCUSSION
FIGURE 5. Previous carpal tunnel incision extended

proximally and distally.
down to the hamate and the entire ulnar leaf of the TCL
is excised off the hamate hook (Figs. 7, 8). Complete
ulnar leaf excision facilitates maximal elevation of the
flap along with the ulnar NV bundle.
An important feature of recurrent idiopathic CTS is loss

of neural gliding secondary to postoperative adhesions
and epineural fibrous fixation. Any surgical intervention
performed for recurrent idiopathic CTS must therefore
include not only neurolysis, but also the provision of a
healthy, unscarred bed through which the median nerve
can glide. This bed must also provide a physical barrier
between the median nerve and the radial leaf of the
ligament to prevent readherence.
Several surgical procedures have been described that
have attempted to fulfill these criteria. Milward10 was
the first to describe the use of an abductor digiti minimi
muscle flap for coverage of the median and ulnar nerves
at the wrist in a single patient who had undergone
multiple procedures for recurrent CTS. Extensive
perineural fibrosis was found on surgical exploration.
The use of this flap necessitates the sacrifice of the main
FIGURE 6. The superficial dissection preserves the subdermal rete vasculature supplying the hypothenar skin flap.
Volume 10, Number 3
153
Chrysopoulo et al
FIGURE 7. The flap is raised deep to the ulnar neurovascular pedicle. The ulnar leaf of the TCL is excised.
abductor of the small finger though Milward claims

little residual functional deficit secondary to the compensatory function of the flexor digiti minimi muscle.
Wilgis11 described the use of a lumbrical flap. Longterm clinical results have not been published and, once
again, the procedure requires sacrifice of a small
intrinsic muscle, with insufficient bulk and area to
cover the scarred median nerve.
Dellon12 performed cadaveric dissections on 16

upper extremities and showed that a pronator quadratus
flap based on a neurovascular pedicle consisting of the
anterior interosseous artery and nerve may provide
adequate coverage of the median nerve distal to the
wrist crease. However, this dissection is technically
demanding and, once again, reports of clinical experience with this flap are lacking.
FIGURE 8. Hypothenar fat pad flap prior to transposition demonstrates segmental fat pad blood supply.
154
FIGURE 9. Diagrammatic cross-section showing the inset fat pad.
Median nerve coverage with a palmaris brevis

muscle turnover flap was reported by Rose.13 The thin
muscle lies adjacent to the carpal tunnel and according
to Rose can be easily rotated to cushion the median
nerve. Though there is no resultant functional loss from
this procedure, the muscle is often too small to provide
sufficient coverage. Furthermore, the palmaris brevis is

absent in at least 2% of patients.8
Free tissue transfer has also been suggested for
coverage of the median nerve at the wrist. Wintsch14
reconstructed a gliding bed for the median nerve by
transferring an adventitial flap based on the thoracodorsal
FIGURE 10. Diagrammatic view of the volar wrist demonstrating the inset fat pad providing vascularized protection to the
neurolysed median nerve.
Volume 10, Number 3
155
Chrysopoulo et al
vessels to 5 wrists following neurolysis and flexor

tenolysis. A variety of other free flaps have also been
used, including omentum. These procedures involve
microsurgical techniques and are far more technically
demanding than local reconstructive options. They also
involve significant donor site morbidity and should
therefore be reserved for salvage situations only.
Sotereanos15 and Varitimidis16 reported the use of
autogenous saphenous vein wrapping of the median
nerve in patients with recurrent CTS secondary to
cicatricial tethering. Subjective criteria such as pain
and sensation, as well as objective criteria such as 2point discrimination and electrodiagnostic studies
improved postoperatively.
The hypothenar fat pad flap has been shown to produce
reliable clinical results without hypothenar muscle wasting
or weakness.3,8 The flap does not sacrifice functional
tissue and is of sufficient size to provide median nerve
coverage in the carpal tunnel. The technical modifications described are easy to perform and allow safe
transposition of the pedicled fat pad flap, with subsequent
tension-free interposition between the median nerve and
the radial leaf of the transverse carpal ligament. Furthermore, the hypothenar fat pad transposition flap
provides a reliable source of vascularized local tissue
that can be used successfully as an adjunct to neurolysis
for the treatment of recurrent idiopathic CTS.
| REFERENCES
1. Palmer DH, Hanrahan LP. Social and economic costs of
carpal tunnel surgery. Instr Course Lect. 1995;44:
167Y172.
2. Kulick ML, Gordillo G, Javidi T, et al. Long-term analysis
of patients having surgical treatment for carpal tunnel
syndrome. J Hand Surg [Am]. 1986;11:59Y66.
3. Plancher KD, Idler RS, Lourie GM, et al. Recalcitrant
carpal tunnel. The hypothenar fat pad. Hand Clinics.
1996;12:337Y349.
156
4. Cobb TK, Amadio PC. Outcome of reoperation for carpal

tunnel syndrome. Hand Clin. May 1996;12:313Y323.
5. Langloh ND, Linscheid RL. Recurrent and unrelieved
carpal-tunnel syndrome. Clin Orthop. 1972;83:41Y47.
6. Hunter JM. Recurrent carpal tunnel syndrome, epineural
fibrous fixation, and traction neuropathy. Hand Clin.
1991;7:491Y504.
7. Cramer LM. Local fat coverage for the median nerve. In:
Lanford LL, ed. Correspondence newsletter for Hand
Surgery. 1985:35.
8. Strickland JW, Idler RS, Lourie GM, Plancher KD. The
hypothenar fat pad flap for management of recalcitrant
carpal tunnel syndrome. J Hand Surg [Am]. September
1996;21:840Y848.
9. Mathoulin C, Bahm J, Roukoz S. Pedicled hypothenar fat
pad flap for median nerve coverage in recalcitrant carpal
tunnel syndrome. Hand Surg. 2000;5:33Y40.
10. Milward TM, Stott WG, Kleinert HE. The abductor digiti
minimi muscle flap. Hand. 1977;9:82Y85.
11. Wilgis EF. Local muscle flaps in the hand. Anatomy as
related to reconstructive surgery. Bull Hosp Jt Dis Orthop
Inst. 1984, Fall;44:552Y557.
12. Dellon AL, Mackinnon SE. The pronator quadratus
muscle flap. J Hand Surg [Am]. May 1984;9:423Y427.
13. Rose EH, Norris MS, Kowalski TA, et al. Palmaris brevis
turnover flap as an adjunct to internal neurolysis of the
chronically scarred median nerve in recurrent carpal tunnel
syndrome. J Hand Surg [Am]. March 1991;16:191Y201.
14. Wintsch K, Helaly P. Free flap of gliding tissue. J Recon
Micr. April 1986;2:143Y150.
15. Sotereanos DG, Giannakopoulos PN, Mitsionis GI, et al.
Vein-graft wrapping for the treatment of recurrent
compression of the median nerve. Microsurgery.
1995;16:752Y756.
16. Varitimidis SE, Vardakas DG, Goebel F, et al. Treatment
of recurrent compressive neuropathy of peripheral nerves
in the upper extremity with an autologous vein insulator.
J Hand Surg [Am]. March 2001;26A:296Y302.
T E C H N I Q U E
Avulsion Fractures From the Base of Phalanges

of the Fingers
Halil Bekler, Alper Gokce, and Tahsin Beyzadeoglu
Department of Orthopaedics and Traumatology School of Medicine
Yeditepe University
Istanbul, Turkey
| ABSTRACT
Avulsion fractures of the phalanges are among challenging problems encountered in the hand surgery. These
fractures are characterized by existence of small bone
fragments usually attached to a collateral ligament. They
mostly occur in metacarpophalangeal and proximal
interphalangeal joints. Bony gamekeepers thumb is one
of the well-known. Inadequate reduction and healing of
these fractures may lead to joint deformity, chronic
instability and posttraumatic arthritis. Existence of very
small bone fragments and involvement of joint surface
are the obvious factors predisposing to technical problems in reposition and fixation of these fractures.
Avulsion fractures are intraarticular according to their
configuration and need anatomic reduction. AO principles depending on stable fixation and compression have
difficulties to be applied to these fractures owing the
inconvenience of the osteosynthesis materials and implants available are designed for fracture fixation of
larger bones. Fixation may result in further comminution
of the fragments.
Keywords: fracture, phalanx, osteosynthesis, avulsion
fracture
with these of the thumb and other avulsion fractures of

the fingers.2 Wire suture, Kirschner wire (K-wire),
screw, and plates are widely used for fracture fixation
in the hand.3 Lister popularized wire suture technique
for treatment of fracture dislocation of the interphalangeal joints. The advantages were limited exposure
necessity and availability in most operating room, but
untwisting of the knot and possibility of the breakage
were major disadvantages. Pin fixations are the most
commonly preferred methods, but these are subject to
loosening and migration and provide poor compression.
Recently, mini screws have been widely used but if not
placed correctly, may cause distraction or fragment comminution.4 The size of the avulsed fragment is critical
for mini screw application if the fragment volume is less
than twice of the size of the screw hole; fragmentation
or avascular necrosis would occur. We prefer to use the
classification of collateral ligament avulsion fracture by
Jupiter5 that is more projective for type of treatment and
outcome. Collateral ligament avulsion fractures were
classified as nondisplaced type 1, comminuted type 2,
displaced type 3, displaced impacted type 4, vertical
shear type 5, and type 6 proximal shear.5 There is some
controversy in the treatment of nondisplaced fracture.6,7
Avulsion fractures from the base of phalanges are wellrecognized injuries especially at the metacarpophalangeal joint of the thumb. In 1963, Lee1 reported a large
series of 223 cases of fractures of the phalanges, and 34
of them were named as Bproximal phalangeal corner
fractures.^ The main treatment was conservative; only 2
were surgical; one was stabilized by catgut sutures, and
in another case, the fragment was excised. Perkins
(1958) recommended fragment removal if rotated,
whereas Flatt (1959) recommended immobilization for
3 weeks. Studies have grouped these fractures along
Address correspondence and reprint requests to Halil Bekler, MD.
Devlet yolu Ankara Cad No. 102-104, Istanbul, Turkey. E-mail:
hbekler@yahoo.com.
FIGURE 1. Preoperative radiological view of avulsion fracture.
Volume 10, Issue 3
157
Bekler et al
FIGURE 4. Kirschner wire is used like joystick to reduce

the fragment and keep in place.
FIGURE 2. Dorsal approach to the fracture; extensor hood,
and dorsal capsule are opened and gently retracted.
Avulsed fragment is underview.
One of the important discussions about these fractures is

the surgical approach. Most authors preferred and
described dorsal approach for surgical fixation.3,5,8,9
| TECHNIQUES
Operative interventions of the phalanges are accomplished with intravenous regional, general anesthesia, or
brachial plexus block according to the needs and
preferences of the patient, surgeon, and anesthesiologist.
The extremity is prepared, draped. Exsanguination is
performed with Esmarch bandage, and a tourniquet is
elevated to 250 mm HG for adults.
For avulsion fractures from the base of proximal
phalanges, gentle longitudinal curved incision is performed on the dorso-ulnar side of the mentoposterior
position joint. The incision should allow access to the
avulsed fracture site. Care must be taken not to injure the
cutaneous nerve. The adductor tendon aponeurosis,
extensor hood is divided at its insertion onto the extensor
tendon and tagged for further repair. The joint capsule, if
not ruptured, is open longitudinally. Fracture fragment,
collateral ligament, and articular cartilage are then
viewed. Volar plate may also be examined with gentle
distraction. Hematoma is irrigated and removed. We
FIGURE 3. Displaced small bony fragment.
158
nearly always observe the fragment rotated but have

never had any difficulty to reduce the displaced fragment
(Figs. 1 Y3). The most difficult step of this procedure is
to decide if the osteosynthesis material should be used.
A fine K-wire may be used like a joystick to secure
reposition during the procedure. Care should be taken to
preserve collateral ligament attachment. Insertion of
screws will need more technical expertise, but it is more
secure than a K-wire. The screw must be replaced
through the fracture line perpendicularly and bicortically. Placement in lag manner is more secure. Size of
the avulsed bone is imperative for screw fixation; drill
holes must be less than half of fragment wide. At
Jupiters5 tension wire fixation technique, a drill hole is
made 1 cm distal to the fracture line, in direction dorsal
to palmar, and a stainless steel wire is passed from this
hole and through the insertion of collateral ligament as
the Figure 8. The wire is tightened after secure
reduction. Care must be taken to avoid excessive
tightening and wire breakage, which it is not so easy
to apply, in our opinion.
FIGURE 5. Another K-wire used for creating a hole

parallel and 2 mm distal to the first.
Avulsion Fractures from the Base of Phalanges of the Fingers
FIGURE 6. A thin cerclage wire is passed through

the hole.
FIGURE 8. Good apposition of fracture line, nearly ideal
reduction of articular surface continuity.
We recommend a new modification of the wire

fixation technique. After access to the fracture side and
reposition of the fragment, a 1-mm K-wire is applied
through the fragment, perpendicular to the fracture line
(Fig. 4). This wire keeps the reduction of the fragment
secure. Then, another K-wire of the same diameter is
drilled through the fragment, 2 mm distal and parallel to
the first K-wire or just distal to fracture line when the
fragment is very small (Fig. 5). A loop of narrow-gauge
stainless steel wire is prepared and pulled through this
drill hole with the help of a 21-gauge syringe needle
(Fig. 6). The use of a syringe needle is mandatory; wire
must perforate skin and soft tissue in a unique tract
because this would be important for future removal. The
loop is placed tightly around the proximal end of the first
K-wire holding the fragment. The 2 ends of the cerclage
wire are then pulled out under traction and tied over a
button on the skin (Figs. 7Y 10). The correct reposition
and compression at fracture site is seen, capsule and
soft tissues are repaired with absorbable stitches. The
same technique may be used in avulsion of proximal
interphalangeal joint. Dorsolateral surgical approach is
used. The lateral and central bundles of the extensor
mechanism are elevated; dorsal incision of the capsule
is then made to expose the fracture site. Reduction and
stabilization may be accomplished in the same manner.
FIGURE 7. The loop is placed strongly around the

proximal end of the first K-wire and tightened.
Avulsion fracture of distal phalanges, called bony

mallet, may be treated with the same technique. This
may be easily approached by a small dorsal skin
incision; avulsion fracture was reduced using K-wire
like a joystick. A thin K-wire was inserted in an
antegrad fashion from the dorsal corner of the avulsed
fragment to distal main bone to secure fixation. A thin
cerclage wire applied from a drill hole at distal phalange
just distal to fracture line and parallel to the first K-wire
was used for compression.
The operated hand is immobilized in a palmar slab,
and the patient is then referred to a hand therapist. Joints
were mobilized under the supervision of the hand
therapists usually on the sixth day. Immobilization may
be as long as 3 weeks for an incompatible patient. At the
6-week follow-up, radiological control is performed. If
the consolidation of the fracture is seen, extradermal end
FIGURE 9. Postoperative x-ray control.
Volume 10, Issue 3
159
Bekler et al
FIGURE 10. Lateral view.
of the K-wire is pulled-out and this free loop of cerclage

wire is easily removed.
| COMPLICATION
FIGURE 12. Acceptable end result of complicated case.
technique are related to an extradermal situation of the

button and wires. Skin irritation and pin tract infection
disappear after removal of the fixation materials.
Inadequate fixation due to deficient wire tightening
is rarely observed (Fig. 11), but the end results are
acceptable (Fig. 12).
The ultimate goal is to provide the restoration of function

and anatomy of the joint, but many complications may be
experienced. Most of them are related to the fixation
materials. K-wires are subject to loosening and migration, screw fixation may cause fragmentation of small
bony avulsion, and distraction at fracture site or loosening. Avascular necrosis of fragment may be seen
after excessive surgery. The major problems of this
| DISCUSSION
FIGURE 11. Angulations and joint surface incongruence

due to inadequate wire tightening.
The main difficulty in the surgical treatment of the

phalangeal avulsion fractures lies in the fact that neither
conventional nor more developed fracture fixation
methods can consistently ensure the desired quality of
osteosynthesis and avoid related complication. The
primary goal in the fracture treatment of the hand is to
restore the functional capacity. For this goal, we need a
good fracture healing achieved by neutralization of
external deforming forces by fixation methods.10 The
dorsal surgical approach described is widely used in the
treatment of avulsion fractures, but some authors
suggest the use of volar approach for avulsion fracture
of the metacarpophalangeal joint because it is a more
direct approach to the fracture.11 However, the use of a
volar A1 pulley approach needs a more experienced hand
surgeon. Dorsal way, on the contrary, needs only gentle
surgical technique. K-wires and cerclage wiring are 2
frequently used methods in such fractures but cannot alone
provide consistent and satisfactory bone healing and joint
mobility. Combination of K-wire and cerclage with the
principle of tension band technique is frequently used for
the treatment of patella and olecranon fractures. In this
technique, rotation is blocked by 2 K-wires, whereas
160
Avulsion Fractures from the Base of Phalanges of the Fingers
cerclage wire realizes tension effect. Tension wire fixation

described by Jupiter5 is an excellent way for fixation of
small bony fragment of avulsion trauma. To combine a
thin K-wire is useful for rotational stability. Tension band
effect of our technique is also created by wire, but more
laterally to the fracture side augmenting the moment arm
and is more effective than simple tension wire fixation. A
combined fixation with thin K-wire and loop of cerclage is
a useful method to achieve acceptable reposition, fixation,
and compression in avulsion fractures of the phalanges. It
also allows safe early mobilization of the involved joint.
Use of thin K-wire and cerclage also has the advantage of
easy implant removal without any incision.
of the metacarpophalangeal joint of the finger. J Hand

Surg Br. 1997;22:667 Y 671.
4. Jones WW. Biomechanics of small bone fixation. Clin Orthop.
1987;214:11Y 18.
5. Jupiter JB, Sheppard JE. Tension wire fixation of
avulsion fractures in the hand. Clin Orthop. 1987;214:
113 Y 120.
6. Kuz JE, Husband JB, Tokar N, et al. Outcome of avulsion
fractures of the ulnar base of the proximal phalanx of the
thumb treated nonsurgically. J Hand Surg Am. 1999;24:
275 Y 282.
7. Louis DS. Avulsion fractures from the ulnar base of the
proximal phalanx of the thumb. J Hand Surg Am. 1999;
24:1119 Y 1120.
8. Dubert T. Acute PIP joint fractures. Chir Main. 2005;24:1Y16.
| REFERENCES
1. Lee MLH. Intra-articular and peri-articular fractures of
the phalanges. J Bone Joint Surg Br. 1963;45:103 Y 109.
2. Shewring DJ, Thomas RH. Avulsion fractures from the
base of the proximal phalanges of the fingers. J Hand
Surg Br. 2003;28:10 Y 14.
3. Sakuma M, Nakamura R, Inoue G, et al. Avulsion fracture
9. Husband JB, McPherson SA. Bony skiers thumb injuries.

Clin Orthop. 1996;327:79 Y 84.
10. Brennwald J. Fracture healing in the hand. Clin Orthop.
1996;327:9 Y 11.
11. Kuhn KM, Dao KD, Shin AY. Volar A1 pulley approach
for fixation of avulsion fractures of the base of the
proximal phalanx. J Hand Surg Am. 2001;26:762 Y 771.
Volume 10, Issue 3
161
T E C H N I Q U E
Tenodesis Extension Splinting for Radial

Nerve Palsy
Mike Szekeres, BSc(OT), OT Reg(Ont.)
Department of Hand Therapy, Hand and Upper Limb Centre
St. Josephs Health Care, London, Ontario, Canada
| ABSTRACT
Injuries to the radial nerve or posterior interosseous nerve
can lead to significant functional limitation. Inability to
extend the wrist and/or digits prevents the hand from being
positioned properly for functional tasks. Therapy after
radial nerve injury is geared toward maintaining passive
extension of the wrist and digits. Sensory reeducation can
also be performed but often not necessary since the distribution of the nerve distally is on the dorsoradial surface
of the hand. Since nerve regeneration is often a lengthy
process and the extent of recovery is variable, splinting the
involved extremity is used to prevent contractures and
maximize function. This article introduces a new splint
that allows patients to extend the fingers and thumb via a
tenodesis effect at the wrist. In early trials, it has produced
excellent results for enhancing functional use of the
injured extremity while nerve regeneration occurs or until
tendon transfers have been performed.
Keywords: radial nerve, splinting, functional orthotics
his article is designed to introduce a dynamic

extension assist for the fingers and the thumb and
wrist that can be used for radial nerve injuries. This splint
uses a Phoenix wrist hinge combined with digital outriggers to achieve extension while allowing active flexion
for functional use. As with the splint designs mentioned
previously in the literature, the patient actively flexes the
wrist slightly to increase tension on the digital slings and
extend the fingers and thumb for grasping objects. The
hinge at the axis of rotation of the wrist helps prevent distal
migration of the forearm component and serves as the
attachment for the outriggers of the fingers and thumb.
Patients with trauma to their radial nerve may be unable
to extend either their wrist and/or digits depending on
the level and extent of nerve injury. This often leads to
Address correspondence and reprint requests to Mike Szekeres,
Department of Hand Therapy, Hand and Upper Limb Centre, 268
Grosvenor Street, London, Ontario, Canada N6A 4L6. E-mail:
mikes@sjhc.london.on.ca.
162
severe impairment in hand function. Initial rehabilitation of these injuries depends on several factors,
including the level of nerve injury, amount of axonal
disruption, and associated injury of surrounding tissues.
Several splints have been outlined as an extension
assistance for patients with radial nerve trauma and are
used as temporary orthotics to enhance function while
nerve regeneration occurs or until tendon transfers are
performed to restore wrist and digital extension. Hannah
and Hudak1 reviewed the functional improvements that
occurred with 3 different splint designs after radial nerve
palsy. The three spints that were compared were a static
wrist splint, a tenodesis suspension splint, and a dynamic
extension splint. This single case design showed that a
static wrist splint was not beneficial for improving functional use of the hand. A tenodesis suspension splint and a
dynamic extension splint both improved functional use in
their tests.
A splint originally described by Crochetiere et al2 and
later modified by Hollis3 and Colditz4 uses static cord
instead of dynamic rubber bands to suspend the proximal
phalanges. These splints are effective in recreating the
tenodesis effect for the digits to allow flexion and extension, but do not include an outrigger to allow thumb
extension and abduction. The rationale for not including
the thumb has been that it is an awkward outrigger
placement on those splint designs.5 The use of a wrist
hinge allows for simple placement of a radial outrigger.
The functional benefits that we have seen with thumb
inclusion seem to far outweigh any Bawkwardness^ of a
radial outrigger.
| TECHNIQUE OF SPLINT
FABRICATION
1. Start by fabricating a wrist hinge with only the hinge
for hardware as outlined in Figure 1. Note that the
base of the splint is placed on the dorsal aspect of the
forearm instead of the volar side. (We make all static
progressive hinges for stiff wrists in this fashion
because it improves the angle of pull and reduces the
counterforce to prevent the base of the splint from
migrating distally.)
Tenodesis Extension Splinting
FIGURE 1. Fabrication of the wrist hinge on the dorsum

of the forearm.
2. Add elastic from the forearm base to the hinge to

provide a dynamic extension assist for the wrist (Fig. 2).
The size and resistance of the elastic should be such
that it allows the patient to comfortably flex the wrist
but brings the wrist back into extension when the
flexors are relaxed.
3. Add finger outriggers on to the hinge. Feed line from
the finger slings through the outrigger and secure to a
d-ring at the proximal end of the splint. The line
should be tight enough to pull the metacarpophalangeal (MCP) joints into extension when the
wrist is brought into slight flexion but should still
allow active flexion of the MCP joints with the wrist
relaxed in extension (Figs. 3A, B).
4. Add the thumb outrigger. The outrigger must be bent
and placed so that it will pull the thumb into both
extension and abduction. Place the sling on the
thumb and feed the line through the wrist hinge as
shown in Figure 4.
FIGURE 2. Addition of elastics for wrist extension.
FIGURE 3. Finger slings are added. Tension must be

adjusted to allow full digital flexion with the wrist relaxed,
but still fully extend the MCPs when the wrist is brought
into slight flexion.
5. The splint allows the position of the MCP joints of the

fingers to be controlled by actively flexing or relaxing
the wrist. Slight flexion of the wrist pulls the MCP
joints into extension, and relaxation of the wrist allows
FIGURE 4. The thumb outrigger is bent to place the

thumb in abduction and extension. The line is fed over
the wrist hinge so that tension is placed on the line when
the wrist is flexed.
Volume 10, Issue 3
163
Szekeres
FIGURE 5. Radial and ulnar deviation is possible within the splint.
digital flexion. The thumb is also pulled into extension

and abduction when the wrist is flexed by using the
hinge as a pulley. Radial and ulnar deviation is also
possible as shown in Figure 5.
| DISCUSSION
One biomechanical issue that arises with this splint is the
less than optimal angle of pull on the proximal phalanx.
The wrist hinge does not have enough length to allow a
90-degree angle of pull. This can be overcome by
replacing the distal wire of the hinge and replacing it

with a custom bent wire. We have not personally found
the angle of pull to be an issue with respect to patient
pain or comfort. If this splint was designed to increase
range of motion of an injured joint, the direction of pull
would need to be at or near 90 degrees. The slight compressive force on the MCP joints in this case is not a concern since this is not an area of pathology associated with
radial nerve dysfunction.
One disadvantage of this splint is that it places a
palmar bar in the hand, where the previous splint designs
FIGURE 6. A, A patient with radial nerve palsy. Note the extreme wrist flexion required to achieve a small amount of digital
extension. B, Same patient using the splint. C, Grasping larger objects is possible owing to the thumb assistance.
164
Tenodesis Extension Splinting
have not. The palmar bar is necessary to keep the wrist

hinge in place.
Adding the thumb component to the splint to allow
extension and abduction significantly improves the
ability to grasp large objects (Fig. 6). After trying several
of the splints previously described in the literature, we
have found the above splint to be the most successful
design for patient comfort and enhancement of functional
abilities. This splint has only been used on a couple of
patients thus far. Further investigation is required to
determine patient satisfaction, and to quantify the
improvement in function that this splint provides. Our
early results with this splint have been very promising.
| REFERENCES
1. Hannah SD, Hudak PL. Splinting and radial nerve palsy: A
single-subject experiment. J Hand Ther 2001;14:195Y201.
2. Crochetiere W, Granger CV, Ireland J. The BGranger^
orthosis for radial nerve palsy. Orthop Pros 1975;29:27.
3. Hollis I. Innovative splinting ideas. In: Hunter Jea, ed.
Rehabilitation of the Hand. St. Louis: Mosby, 1978.
4. Colditz J. Splinting for radial nerve palsy. J Hand Ther
1987;1.
5. Colditz J. Splinting the Hand With a Peripheral Nerve
Injury. Rehabilitation of the Hand and Upper Extremity,
5th ed. St. Louis, Missouri: Mosby, 2002:622Y 634.
Volume 10, Issue 3
165
T E C H N I Q U E
A Vascularized Technique for Bone-Tissue-Bone

Repair in Scapholunate Dissociation
Edward J. Harvey, MD, MSC
Division of Orthopedic Surgery
McGill University Health Centre
Montreal, Canada
Milan Sen, MD
Department of Orthopaedics
University of California
San Francisco General Hospital
San Francisco, CA
Paul Martineau, MD
Department of Orthopaedics and Sports Medicine
University of Washington
School of Medicine
Seattle, WA
| ABSTRACT
Several surgical options have been used for the repair of

scapholunate instability over the last 50 years. The many
options have included neglect, reduction with percutaneous pinning, primary repair, partial fusions, tendon
weaves, and others. Recent advancements in scapholunate repair and anatomy have been aimed at a more physiological repair. Composite replacement of the entire
scapholunate interval similar to other tendon repairs seen
in orthopedic surgery has become popular. Currently, more
common hand-based grafts are bone-retinaculum-bone,
third or second metacarpal-carpal bone or hamate-capitate
grafts. There still exist some failures in the outcome after
any of these procedures. This technique demonstrates the
use of a vascularized autograft replacement on a pedicled
graft. This procedure is the natural extension of the third or
second metacarpal-carpal bone autograft, previously reported in the literature. The use of this proven graft, with
a pedicle based on the intermetacarpal artery, may avoid
some of the late complications seen with other autografts.
Keywords: scapholunate dissociation, wrist, autograft,
dorsal intercalated segment instability, ligament
There were no sources of support for the material contained in this
manuscript.
Address correspondence and reprint requests to Edward Harvey, MD,
MSc, McGill University Health Center, Department of Orthopaedic
Surgery, Montreal General Hospital, Room B5.159.5, 1650 Cedar
Avenue, Montreal, Quebec, Canada H3G 1A4. E-mail: edward.harvey@
much.mcgill.ca.
166
Several surgical options have been used for the repair of

scapholunate instability over the last 50 years. Rotatory
subluxation of the scaphoid produces well-documented
degenerative changes in the wrist.1 Treatment for the
acute dislocation is aimed at regaining normal anatomy
by percutaneous pinning or anatomical reduction and
repair of the ligamentous relationships through surgery.
The many options have included neglect, reduction with
percutaneous pinning, primary repair, partial fusions, and
tendon weaves.2Y20 Recent advancements in scapholunate
repair and anatomy have been aimed at a more physiological repair. Composite replacement of the entire
scapholunate interval similar to other tendon repairs
seen in orthopedic surgery has become popular. Attention has centered on the replacement of the dorsal
portion of the scapholunate intraosseous ligament
(SLIL). Several biomechanical and anatomical studies
have identified this area to be the most functionally
important area of the SLIL. An attempt to achieve a
reconstruction that more closely reproduces the dorsal
support of the SLIL has generated research into using
bone-tissue-bone (BTB) composite grafts.6,18,21Y24
Although there are no long-term outcome data associated
with these repairs, early to medium length follow-up
reports with these techniques have been favorable.7,24
Weiss16 first described a BTB from the dorsum of
the hand that is harvested near Lister tubercle (third ex-
Vascularized Technique for Bone-Tissue-Bone Repair
FIGURE 1. AP (anteroposterior) radiograph of a wrist

9 months after surgery with a nonvascularized bone
ligament bone graft. The bone blocks are intact within
the scaphoid and lunate, but the ligament has stretched
or torn. Presumably, this has occurred due to weakening
after the revascularization process of the ligament during
the normal reparative course.
tensor compartment base) on the distal radius. Harvesting of the extensor retinaculum and bone block allowed
the fashioning of a bone-retinaculum-bone composite
graft that was used to reconstruct the dorsal portion of
the SLIL. Biomechanical testing was reported.25 The
BTB autograft was significantly weaker than the SLIL.
Other authors began to look at options based within the
hand itself that might have better biomechanical characteristics to replace the SLIL. The carpometacarpal boneligament-bone complex at the base of the second or
third metacarpal was proposed as a replacement for the
SLIL. These articulations are relatively immobile and,
therefore, were seen as expendable if needed for SLIL
reconstruction. Both of these grafts were also easily obtainable through the same dissection used for SLIL repair. These grafts also give a cartilaginous replacement
for the SLIL interval on both the scaphoid and lunate
surfaces. Harvey and Hanel6 carried out a study of cadaveric matched SLIL, second metacarpal-trapezoid
ligament, third metacarpal-capitate ligament, and dorsal
retinaculum. Stiffness and strength were obtained from
fresh-frozen specimens tested to failure with a servohydraulic apparatus, as accomplished in previous studies.
The second metacarpal-trapezoid ligament and the third
metacarpal-capitate ligament most closely approximated
the stiffness and strength of the SLIL. The dorsal periosteal retinaculum was significantly less stiff and weaker
than the SLIL. These 2 new grafts were seen as desirable
graft replacements. Another group of researchers substantiated these findings.22 A small clinical series with
short-term follow up showed that the third metacarpalcarpal BTB has been successful.7 In general, the clinical
outcome for BTB grafts is excellent and has been successful in the hands of several surgeons.
The 2 main complications with BTB procedures (nonvascularized) are graft pullout, usually from the lunate,
and graft stretching (Fig. 1), with an increased scapholunate interval but no loss of the scapholunate angle. Graft
pullout occurs from a lack of healing in a patchy vascularized lunate, typically seen in chronic dissociations or
lunate dislocations. Lack of healing eventually results in
hardware failure. Stretching of the SLIL replacement
occurs after several months with loss of the tight SLIL
interval. Presumably, this is due to the revascularization
phase of healing.
In an attempt to prevent these 2 observed complications, a vascularized BTB has been designed and is in
current usage. A typical third metacarpal-carpal graft can
be harvested based on the radial-sided intermetacarpal
artery. This artery is lifted and protected as it is traced
back to the radial artery. The dorsal intercarpal ligament
is incised and repaired during the procedure. The artery
origin from the radial artery is freed and the resultant
pedicle is sufficient to allow placement of the graft in the
trough fashioned on the scaphoid and lunate as per Weiss.
The original technique of third metacarpal-capitate BTB
(without vascular pedicle) was used for all chronic scapholunate deficient wrists. Results are no worse than the
literature results for all comers. However, the best results
observed in short-term follow-up have been in those
patients with shorter time from injury to treatment, those
with a more dynamic component than static, or in those that
did not have a fixed radio-lunate angle of greater than 30-.
The few patients treated as acute injuries have done well.
Primary repair of the scapholunate ligament has been
largely unsuccessful as an isolated procedure.4,19 The
procedure described in this manuscript is primarily indicated for wrists with scapholunate dissociation that
is acute (less than 6 months) in nature. In addition, the
scapholunate dissociations should have a correctable instability pattern by manipulation of the lunate. Wrists
that are more chronic in nature may be fixed in dorsal
intercalated segment instability, with a lunate that is not
correctable by manipulation. In this setting, the current
technique alone would not be sufficient to correct the
wrist deformity. If a patient with chronic dissociation
Volume 10, Issue 3
167
Harvey et al
the intermetacarpal artery can be easily traced back to its

origin at the radial artery. The procedure should be done
under tourniquet control. The arm should not be exsanguinated before the tourniquet is used to visualize the
vascular pedicle during the case. If vigorous manipulation
of the dorsum of the hand occurs, then the vascular
pedicle will not be easily visualized and the tourniquet
must be deflated then reinflated to optimize pedicle
continuity during dissection.
The approach to the wrist is through the 3Y4 interval,
with a slightly longer incision to include the base of the
third metacarpal, as depicted in Figure 2. The dark line
represents the incision. An alternate incision is depicted
by the dotted line. This alternate incision allows an
easier inspection of the origin of the vascular pedicle
from the radial artery. The arrow is pointing to an outline of the third metacarpal. An obvious scapholunate
gap (Fig. 3, arrowhead) is seen between the scaphoid (S)
and the lunate (L). The third metacarpal-capitate joint
can be located by inserting a needle along the ulnar
border of the joint under fluoroscopic guidance, to
ensure that misguided dissection of the ligament does not
occur while exploring the third metacarpal-capitate area
FIGURE 2. Approach to the dorsal wrist for this procedure. The straight line between Listers tubercle (large
white oval) and the base of the third metacarpal (white
arrow) is the normal incision use for third metacarpal
nonvascularized BTB. This incision can be used for a
vascularized graft but if better visualization is wanted of
the radial artery origin of the pedicle, the curved incision
along the dotted line is more optimal.
and normal articular cartilage is taken to the operating

room to have a BTB procedure, then a volar approach is
added with pie crusting of the lunate-radial articulation
and release of the lunate-triquetral area. This will allow
correction of the deformity before placing the vascularized graft. Patients without normal articular cartilage
should have another procedure for the correction of the
wrist deformity, as a BTB procedure will not address
the articulating surface defects satisfactorily.
| TECHNIQUE
The surgical procedure is accomplished through a single
extensile incision on the dorsum of the wrist.26 The interval
between the third and fourth extensor compartment is
extended by 1 to 2 cm, to include the base of the third
metacarpal. With minimal undermining of the skin flap,
168
FIGURE 3. Intraoperative AP radiograph of a reduced

scapholunate dissociation. Large k-wires can be seen
from the ulnar and radial sides, holding the gap reduced.
The black rectangle represents the graft donor site. This
block of bone is taken for the BTB graft. The small white
arrows trace the approximate location of the pedicle. The
black rectangle is delineated in the operation by the
placement of small k-wires under fluoroscopic control. In
this image, 3 k-wires have been placed at the box
corners. This allows the surgeons visualization of the
correct sire of bone cuts without removing extensively the
soft tissue from the graft.
FIGURE 4. The graft has been harvested and moved to

the trough, cut in the scaphoid and lunate. The large
black arrow is pointing to the donor site at the third
metacarpal-capitate. The pedicle can be seen (traced by
the small white arrowheads) as it comes proximally in the
wound to the scapholunate area. Ulnar and radial k-wires
have been placed through the skin to hold the reduction
(white arrows).
(Fig. 2, rectangle). This ensures a full ligament for

harvest. The entire width of the ligament, with the appropriate bone blocks, is taken at this interval (Fig. 2). A
large piece of graft is used to ensure adequate bone
fixation for the screws.
The donor graft (Fig. 3) is removed from the
metacarpal-capitate area. An osteotome is used to cut a
trough in the scaphoid and lunate, after the bones have
FIGURE 5. The pedicle is illustrated on another patient. It

is easily visualized in the wound (black arrows). The
radial and ulnar sides of the hand are labeled. The
second extensor compartment can be seen in the wound.
It must be lifted to perform the procedure.
been pinned in a reduced fashion. Often, the lunate is

first reduced with a transarticular pin removed after
scaphocapitate and scapholunate pins have been introduced. All final k-wires must be placed volar to allow
free access to the bony trough. The k-wires may have to
be inserted from the ulnar side to avoid the terminal
branches of the radial artery. Full flexion is then possible
to design the bony trough in the scaphoid and lunate, in a
position that allows adequate size of the bone plugs.
Creation of the trough in flexion also allows the distal
radius to cover the graft with the wrist resting in an
anatomical position. The graft is introduced into the
trough, cut by the osteotome, and secured in place with
two 1.5-mm screws, one each in the scaphoid and the
lunate. If there is any risk of injury to the pedicle by
placement of the screw, then a k-wire may be used
instead. Alternatively, one may rely on the interference
fit of the graft in the bony trough, in addition to the
position under the radius during the splinting phase to
provide sufficient fixation and protection during the graft
healing phase. However, 1 side must be fixed with a
screw to ensure anatomical healing. The scaphoid (S) and
lunate (L) will be partially obscured by the ligament and
fascia that cover the graft itself, however, this area is
FIGURE 6. Lateral radiograph postsurgery. The pins are

holding the scaphoid and lunate in a more normal angle
(black lines). Small clips from the pedicle dissection can
be seen at the dorsum of the wrist.
Volume 10, Issue 3
169
Harvey et al
relationship of the radius and the lunate (no dorsal intercalated segment instability deformity).
| COMPLICATIONS
FIGURE 7. AP radiograph after surgery. A single screw

was used only for the graft fixation on the scaphoid.
under the radius in the anatomical position. The pedicle

is taken down with the donor graft. The pedicle is easily
visualized, running from the third metacarpal graft site
under the second extensor compartment back to the
radial artery (Fig. 4). Figure 5 illustrates the graft and its
vascularized pedicle properly positioned in the scapholunate bony trough.
Figure 6 shows a postoperative lateral radiograph,
with reduction of the scapholunate angle and normal
This procedure is technically exacting. A sufficiently

large bone block must be obtained on either side of the
donor site articulation. In particular, it is more difficult
to ensure that a sufficient bone block is obtained in the
capitate side. The capitate often runs vertically away
from the dissection plane, and direct and radiological
visualization must be used to ensure an appropriate graft
size. Although the vascular supply to the grafts is
consistent, care must be taken in the elevation of the
graft and pedicle. It should be done under loupe
magnification for better definition. During dissection
of the pedicle, a perforating branch from the volar blood
supply that pierces near the distal scaphoid pole and
enters the volar surface of the intermetacarpal artery can
be encountered. The pedicle can be quite adherent to the
volar arch at this point. The volar arterial branch must
be clipped at this point. The dissection can be further
complicated due to the insertion of the dorsal intercarpal
ligament that must be taken down in a z-plasty fashion.
It may appear as if the pedicle has been transected, if
careful attention is not paid at this moment (Fig. 7).
| REHABILITATION
Rehabilitation is started after the removal of the cast at
8 weeks postoperatively. Pins are removed and a
FIGURE 8. One-year postoperative radiographs of the SLIL graft. Screw placement in the scaphoid and lunate is stable
with a maintained SLIL gap (A). The scapholunate angle is maintained on the lateral radiograph (B).
170
removable splint is prescribed. Gentle-active and activeassisted range of motions are initiated. Passive range of
motion is started at 12 weeks postoperatively. Finger and
elbow range of motion and strengthening are encouraged
throughout the postoperative course (Fig. 8).
3. Beredjiklian PK, Dugas J, Gerwin M. Primary repair of

the scapholunate ligament. Tech Hand Up Extrem Surg.
1998;2:269 Y273.
4. Bickert B, Sauerbier M, Germann G. Scapholunate ligament repair using the mitek bone anchor. J Hand Surg [Br].
2000;25:188Y192.
5. Cohen MS, Taleisnik J. Direct ligamentous repair of scapholunate dissociation with capsulodesis augmentation. Tech
Hand Up Extrem Surg. 1998;2:18 Y24.
| CONCLUSIONS
There exist several published options to repair a SLIL
insufficiency. The technique discussed in this manuscript
represents merely the newest approach to the problem.
Unquestionably, the early results for these BTB procedures, in general, are excellent compared with other historical options. Although this procedure is technically
demanding, it may not be beyond the scope of many hand
surgeons. The BTB repair, in whatever form the surgeon
chooses, is a good option for scapholunate repair and may
become part of the future armamentarium of all hand
surgeons. This technique is a new modification of an
established technique. The clinical experience of only
3 patients at one-year follow-up is a small number. There
have been no complications in shorter-term follow-up
patients. The procedure is no harder than the performance
of a vascularized pedicle used for other bone defects in
the hand and wrist. It is taken from the same region as the
second metacarpal graft commonly used for vascularized
scaphoid grafts. As such, surgeons that are able to harvest
a pedicled vascular graft in the wrist should have no difficulty with the procurement of his graft.
Currently, more common hand based grafts are boneretinaculum-bone, third or second metacarpal-carpal
bone, or hamate-capitate grafts. There still exist some
failures in the outcome after any of these procedures.
The current manuscript illustrates the use of an autograft
reconstruction with a vascularized pedicle to address
this pathology. This procedure is the natural extension
of the third or second metacarpal-carpal bone autograft,
previously reported in the literature. The use of this proven
graft with a pedicle, based on the intermetacarpal artery,
may avoid some of the late complications seen with
other autografts and potentially improve the outcomes
of SLIL reconstruction.
6. Harvey E, Hanel D. Autograft replacements for the scapholunate ligament: a biomechanical comparison of hand
based autografts. Journal of Hand Surgery. 1999;24A:
963 Y 967.
7. Harvey E, Hanel D. What is the ideal replacement for the
scapholunate ligament in a chronic dissociation? Can. J.
Plast. Surg. 2000;8:143 Y146.
8. Kleinman W, Carrol C. Scapho-trapezio-trapezoid
arthrodesis for treatment of static and dynamic scapholunate instability: a ten year prospective on pitfalls and
complications. J Hand Surg. 1990;15A:408 Y 414.
9. Krakauer J, Bishop A, WP C. Surgical treatment of
scapholunate advanced collapse. J Hand Surg. 1994;
19A:751Y759.
10. Lavernia CJ, Cohen MS, Taleisnik J. Treatment of scapholunate dissociation by ligamentous repair and capsulodesis. J Hand Surg [Am]. 1992;17:354 Y359.
11. Linscheid RL. Scapholunate ligamentous instabilities (dissociations, subdislocations, dislocations). Ann Chir Main.
1984;3:323 Y330.
12. Linscheid RL, Dobyns JH. Treatment of scapholunate
dissociation. Rotatory subluxation of the scaphoid. Hand
Clin. 1992;8:645 Y 652.
13. Misra A, Hales P. Blatts capsulodesis for chronic scapholunate instability. Acta Orthop Belg. 2003;69:233Y238.
14. Muermans S, De Smet L, Van Ransbeeck H. Blatt dorsal
capsulodesis for scapholunate instability. Acta Orthop
Belg. 1999;65:434 Y 439.
15. Viegas SF, Dasilva MF. Surgical repair for scapholunate
dissociation. Tech Hand Up Extrem Surg. 2000;4:
148 Y153.
16. Weiss A-P. Scapholunate ligament reconstruction using a
bone-retinaculum-bone autograft: a new technique. AAOS
Trans. 1996;213:169.
17. Weiss AP, Sachar K, Glowacki KA. Arthroscopic debridement alone for intercarpal ligament tears. J Hand Surg
[Am]. 1997;22:344 Y349.
| REFERENCES
1. Watson HK, Weinzweig J, Zeppieri J. The natural progression of scaphoid instability. Hand Clin. 1997;13:
39 Y 49.
18. Wolf JM, Weiss AP. Bone-retinaculum-bone reconstruction of scapholunate ligament injuries. Orthop Clin North
Am. 2001;32:241Y246. viii.
2. Augsberger S, Necking L, Horton J, et al. A comparison

of scaphoid-trapezium-trapezoid fusion and four bone
tendon weave for scapholunate dissociation. J Hand Surg.
1992;17A:360 Y369.
19. Wyrick JD, Youse BD, Kiefhaber TR. Scapholunate

ligament repair and capsulodesis for the treatment of
static scapholunate dissociation. J Hand Surg [Br]. 1998;
23:776 Y780.
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Harvey et al
20. Zarkadas PC, Gropper PT, White NJ, et al. A survey of
the surgical management of acute and chronic scapholunate instability. J Hand Surg [Am]. 2004;29:848Y857.
21. Berger RA, Imeada T, Berglund L, et al. Constraint and
material properties of the subregions of the scapholunate
interosseous ligament. J Hand Surg [Am]. 1999;24:
953 Y962.
22. Cuenod P, Charriere E, Papaloizos MY. A mechanical
comparison of bone-ligament-bone autografts from the
wrist for replacement of the scapholunate ligament. J Hand
Surg [Am]. 2002;27:985Y990.
23. Viegas SF, Yamaguchi S, Boyd NL, et al. The dorsal
172
ligaments of the wrist: anatomy, mechanical properties,

and function. J Hand Surg [Am]. 1999;24:456 Y 468.
24. Weiss AP. Scapholunate ligament reconstruction using a
bone-retinaculum-bone autograft. J Hand Surg [Am].
1998;23:205Y215.
25. Shin SS, Moore DC, McGovern RD, et al. Scapholunate
ligament reconstruction using a bone-retinaculum-bone
autograft: a biomechanic and histologic study. J Hand
Surg [Am]. 1998;23:216 Y221.
26. Harvey EJ, Hanel DP. Bone-ligament-bone reconstruction
for scapholunate disruption. Tech Hand Up Extrem Surg.
2002;6:2Y5.
T E C H N I Q U E
Confirmatory Needle Placement Technique

for Scalene Muscle Block in the Diagnosis
of Thoracic Outlet Syndrome
Richard M. Braun, MD, David C. Sahadevan, BA, and Joel Feinstein, MD
RMB, Inc.
San Diego, CA
| ABSTRACT
Scalene muscle block is often performed to assist with
the clinical differentiation of primary sources of pain
and weakness in the upper limb when the differential
diagnosis includes thoracic outlet syndrome. This
presentation offers a simple clinical method to assess
needle placement in the scalene muscle before an
injection of local anesthetic which, if properly placed,
weakens the scalene muscle and often leads to temporary relief of symptoms associated with neurovascular
compression. An appropriate scalene block response
provides assistance with medical decision making.
Keywords: thoracic outlet syndrome, scalene muscle
block, scalene block
In 1939, Gage1 described a patient with disabling
symptoms associated with spasticity in the scalenus
anticus muscle. A technique for accurate anatomical
needle placement is not found in this single case report;
however, injection of local anesthetic into the scalene
muscle resulted in a major reduction in the patients
symptoms. Operative scalenotomy was successful in
providing permanent relief for this patient.
In 1991, Sanders2 described the relevant anatomy of
the scalene muscle block, a specific procedure to follow
when performing the injection, and the use of this test as
a significant prognostic indicator for patients who later
required surgical treatment of thoracic outlet syndrome
(TOS).
Atasoy3 provided accurate anatomical markings on
the surface of the neck for guidance during the muscle
block procedure. He noted that major symptomatic
improvement associated with scalene muscle block
was associated with a good surgical outcome.
Address correspondence and reprint requests to David Sahadevan, BA,

770 Washington Street, Suite 301, San Diego, CA 92103. E-mail:
dsahadevan@bluelink.andover.edu.
Sanders2 and Atasoy3 noted that the onset of a

brachial plexus nerve block associated with impaired
sensation in the upper limb negates the diagnostic value
of the scalene muscle block. A brachial plexus nerve
block, which results in sensory loss in the upper limb, is
considered a false-positive test because it provides a
temporary relief of symptoms without specificity to the
effect of the scalene muscle in a causal relationship to
TOS. A false-negative test may be anticipated if there is
no change in the patients symptoms because of
inappropriate needle placement.
The issue of needle placement into the scalene
muscle was addressed by Jordan, a neurologist, who
used electrodiagnostic equipment to localize needle
placement.4 Jordan et al5 later reported on the effectiveness of Botox scalene blocks for the treatment of
patients with TOS.
| INDICATIONS/
CONTRAINDICATIONS
Thoracic outlet syndrome may be suspected in patients
who present with localized tenderness over the brachial
plexus in the affected supraclavicular area, pain and
fatigue with use of the limb, and increased disability
while working overhead. These patients often experience sensory abnormalities that may include numbness,
paresthesias, or hypersensitivity directly over the brachial plexus or along the medial arm and forearm.
Scalene muscle block is considered an adjunct to the
standard diagnostic postural provocations used to
identify this clinical condition.6Y8 The block is particularly helpful when a neurogenic type of TOS is
suspected, and there is no obvious pulse loss with arm
elevation or shoulder depression, suggesting a negative
or normal Wright or Adson response.
Contraindications to scalene muscle block may include allergies to local anesthetic drugs or unstable medical or psychological conditions. An appropriate subjective
response is important for the evaluation of the test. It is
necessary for the subject to be a reliable reporter.
Volume 10, Number 3
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Braun et al
| RATIONALE FOR CONFIRMATORY

NEEDLE PLACEMENT TEST
Assessment of needle position is based on the function
of the scalene muscle, which arises from the cervical
spine and inserts onto the first rib.9 The function of this
muscle is to assist respiration and chest elevation. This
is in contrast to the adjacent sternomastoid muscle,
which originates on the posterior skull and inserts into
the sternum and the clavicle.8 The sternomastoid moves
the head and the neck. It does not affect respiration or
chest-rib excursion.
A needle placed in the scalene muscle will move,
sometimes dramatically, with respiration. The sternomastoid is active with head elevation or neck movement; however, the scalene muscle remains still and
does not demonstrate any appreciable muscle excursion
amplitude during head or neck motion.
This specific differential respiratory function of the
scalene muscle serves as the basis for the confirmatory
FIGURE 1. A, The scalene muscle is palpable within the

triangle bordered by the sternomastoid muscle and
clavicle. B, The injection approaches from the lateral
border of the sternomastoid muscle, at a slightly cephalad, slightly medial angle.
174
needle placement test. Appropriate synchronous movement of the needle during respiration confirms scalene
localization.
| TECHNIQUE
The patient may be seated, as suggested by Sanders,2 or
placed in a supine position, as described by Atasoy.3
The patients head faces forward with the neck slightly
extended.
Although complications of this injection are rare,
reasonable caution and proximity of resuscitation equipment may be advisable.
The clavicle is palpated and/or marked as the lower
border of the posterior cervical triangle. The anterior border of the triangle is the lateral edge of the sternomastoid
muscle, which can be palpated and marked. These 2 significant structures are easily identified and provide
orientation for the location of the anterior scalene muscle,
which descends at approximately 30-degree angle away
from the lateral border of the sternomastoid, toward the
medial third of the clavicle.
The site for the injection is approximately 2 fingerbreadths above the clavicle at the lateral edge of the
sternomastoid muscle along the line of scalene descent
onto the first rib (Fig. 1A).
An alternative needle placement may be directed
through the lateral fibers of the sternomastoid muscle. In
thin individuals, the firm scalene muscle is palpable
because the superficial tissues and the soft featureless
scalene fat pad offers no resistance to the examiners
finger.
If approaching from the lateral border of the
sternomastoid muscle, the 1- to 1.5-in, 25-gauge needle
on a Luer-Lok syringe is introduced in a slightly
cephalad angle and slightly medial direction. If
approaching through the lateral fibers of the sternomastoid, the needle passes more directly posterior and
slightly cephalad (Fig. 1B).
Aspiration is advised before any injection of local
anesthetic is made. A grossly bloody aspirant probably
means that the needle has entered one of the large veins
in the area.
Specific concern is advised for medial needle
placement resulting in a venipuncture of the jugular
vein in the carotid sheath of the neck. An accessory
jugular or transverse cervical vein may be entered,
which may produce gross blood on aspiration. Should
this occur, the needle is moved to avoid an intravascular
injection.
Needle proximity or entry into brachial plexus
nerves is associated with pain and paresthesias, often
radiating into the limb. Should this occur, the needle is
moved to avoid a resultant brachial plexus nerve block,
Needle Placement
The location of the needle within the scalene muscle

may be verified at this time, before the injection of
lidocaine. The syringe is now removed from the needle.
The confirmatory needle placement test is performed after removing the syringe from the needle.
The patient is instructed to breathe deeply while the
needle is observed. Synchronous needle motion associated with patient respiration confirms needle placement in the scalene muscle (Fig. 2A and B).
The patient is asked to flex and extend the neck
slowly to evaluate needle activity during head or neck
motion. If the needle is well positioned in the scalene
muscle, head motion will not result in any significant
movement of the needle.
Aggressive deep inspiration associated with appropriate excursion of the needle will verify that the needle
is properly placed in a respiratory muscle. When the
examiner is satisfied with needle placement in the
scalene muscle, 4 to 5 mL of 1% lidocaine is injected.
Approximately 5 to 10 minutes is allowed to elapse
before obtaining the patients subjective response to the
block. Substantial subjective improvement absent sensory
loss caused by brachial plexus nerve block in the affected
limb suggests that the diagnosis of TOS is realistic, and
medical decision making is facilitated.
The effects of the block may last much longer than
the relatively short-acting duration of the lidocaine.3 A
repeat examination of the patient shortly after the block
may demonstrate significant but temporary improvement in the functional capacity and a significant change
in the patients subjective complaints.
Patients are not permitted to drive until they have
fully recovered from the injection and are fully alert.
| COMPLICATIONS
FIGURE 2. A, The needle is placed within the anterior

scalene muscle. The patient is relaxed before inhalation.
B, Needle excursion is clearly visible during active
inhalation, confirming placement in a respiratory muscle
(ie, anterior scalene) rather than postural muscle (ie,
sternomastoid).
which would result in limb numbness and would

confound the results of the scalene muscle block.
In most cases, the needle can be felt to penetrate the
solid structure of the scalene muscle, which lies
posterior and slightly medial to the lateral edge of the
sternomastoid muscle.
Scalene muscle block is not considered a procedure of

high risk for nerve or vascular injury. Sanders2 and
Jordan and Machleder4 have reported no significant
complications in performing several hundred scalene
muscle blocks.
Similarly, there have been no patient injuries or
complications after this procedure. We have experienced
no sustained neurovascular complaints in more than 100
cases where the described technique has been used.
Sanders2 and Atasoy3 have discussed concurrent
brachial plexus or sympathetic block with this injection.
Occasional onset of brachial plexus anesthesia (ie,
numbness in the upper limb) is not considered a
complication but does negate the diagnostic value of
the procedure.
In our series, several patients developed Horner sign
within a few minutes of the injection. This subsided
quickly because of the short effective duration of the
Volume 10, Number 3
175
Braun et al
1% lidocaine injection. Hoarseness may also be experienced for approximately 1 hour after the block.
4. Jordan SE, Machleder HI. Diagnosis of thoracic outlet

syndrome using electrophysiologically guided anterior
scalene blocks. Ann Vasc Surg. 1998;12:260Y264.
| SUMMARY
5. Jordan SE, Ahn SS, Freischlag JA, et al. Selective

botulinum chemodenervation of the scalene muscles for
treatment of neurogenic thoracic outlet syndrome. Ann
Vasc Surg. 2000;14:365Y369.
Scalene muscle block provides significant assistance

with the diagnosis and medical decision-making process
for managing patients with TOS. Accurate needle
placement is essential for an appropriate block that
minimizes the chances for a brachial plexus nerve block
and assures a meaningful patient response.
6. Adson AW, Coffey JR. Cervical rib: a method of anterior

approach for relief of symptoms by division of the scalenus
anticus. Ann Surg. 1927;85:839Y857.
1. Gage M. Scalenus anticus syndrome: a diagnostic and

confirmatory test. Surgery. 1939;5:599Y601.
7. Wright IS. The neurovascular syndrome produced by

hyperabduction of the arms: the immediate changes
produced in 15 normal controls, and the effects on some
persons of prolonged hyperabduction of the arms, as in
sleeping, and certain occupations. Am Heart J. 1945;29:
1Y19.
2. Sanders R. Thoracic Outlet Syndrome: A Common Sequela

of Neck Injuries. Philadelphia, PA: JB Lippincott Co, 1991.
8. Roos DB, Owens JC. Thoracic outlet syndrome. Arch Surg.

1966;93:71Y79.
3. Atasoy E. Thoracic outlet compression syndrome. Orthop

Clin North Am. 1996;27:265Y303.
9. Gray H, Pick TP, Howden R, eds. Anatomy, Descriptive

and Surgical. New York, NY: Bounty Books, 1977.
| REFERENCES
176
T E C H N I Q U E
A New Modification of Two-Stage Flexor

Tendon Reconstruction
Steven F. Viegas, MD
Professor and Chief, Division of Hand Surgery
Department of Orthopaedics and Rehabilitation
University of Texas Medical Branch
Galveston, TX
| ABSTRACT
A new modification of 2-stage flexor tendon reconstruction is described. This new modification includes
the utilization of the insertion of the flexor digitorum
profundus tendon to develop a distal tunnel for initial
placement of the silicon rod at the first stage and
subsequent placement of the tendon graft at the second
stage. This allows a more distal attachment of the
tendon graft at the second stage of the reconstruction, to
maximize tendon excursion and minimize adhesions to
the volar plate of the distal interphalangeal joint.
Therefore, this new modification offers better distal
interphalangeal joint function and ease of second stage
distal tendon graft attachment.
Keywords: flexor tendon, reconstruction, 2-stage
adhesions and/or limited motion remain a concern

whenever tendon reconstruction is undertaken.
| INDICATIONS
Indications to embark on a 2-stage tendon reconstruction procedure include severe soft tissue trauma to the
tendon sheath, pulleys, soft tissue, and/or skin. Significant delay between the initial injury and attempt at
delayed primary repair may also result in inability to
successfully reapproximate and repair the lacerated
flexor tendons because of retraction and atrophy of the
tendon and/or muscle.
Stage 1 Surgery
Hunter1 first described the use of tendon implants in the
reconstruction of flexor tendon lacerations in 1965.
Subsequently, in 1971, Hunter and Salisbury2 reported
their 10-year experience using tendon implants as part of
a staged technique to reconstruct severely damaged flexor
tendons. Hunters technique, which was based on earlier
studies by Bassett and Carroll, attached silicon rods at the
distal end, leaving the proximal aspect of the tendon
implant in the distal forearm. A passive exercise program
was used during wound healing and, subsequently, to
regain full passive range of motion of the finger, during
which time a smooth, well-organized pseudotendon
sheath would form around the tendon implant. The subsequent stage of the tendon reconstruction was performed
approximately 3 months or more after the first stage,
where the tendon implant was replaced by a tendon graft.
Despite various methods of tendon attachment, tendon
Address correspondence and reprint requests to Steven F. Viegas, MD,

Professor and Chief, Division of Hand Surgery, Department of
Orthopaedics and Rehabilitation, Rebecca Sealy Hospital, Room
2.616, 301 University Boulevard, Galveston, TX 77555-0165. E-mail:
sviegas@utmb.edu.
The finger is approached through a volar zigzag incision

from the level of the distal insertion of the flexor
digitorum profundus (FDP) to the level of lumbrical
attachment to the profundus in the palm. The neurovascular bundles are identified and protected throughout
the procedure. Surgery is performed under tourniquet
control and with loop magnification. The flexor tendons
are excised, leaving a distal stump of the FDP tendon
adequate to subsequently reach and suture to the A5
pulley. The proximal FDP tendon is transected at the
level of the lumbrical origin. If any lumbrical contracture and/or joint contractures are present, those are also
addressed at this time. A more proximal, axially oriented, curved incision is made proximal to the wrist
flexor crease in the ulnar half of the volar aspect of the
forearm. The proximal stump of the flexor digitorum
sublimus tendon is identified at its musculotendonous
junction and excised. Care is taken during the excision
of any scar or scarred adhered stumps of the flexor
tendon to maintain the integrity of the flexor tendon
sheath and pulley system. If there is a significant
compromise of the pulleys, particularly of the A2 and/
or A4 pulleys, pulley reconstruction should also be
addressed at this time.
Volume 10, Issue 3
177
Viegas
FIGURE 1. Intraoperative photograph showing the trial

implant passed beyond the A5 pulley, with the distal
attachment of the FDP released except for its most
distal attachment.
FIGURE 3. An intraoperative photograph of the

implant, which has been passed retrograde through
the tendon sheath by using the trial implant as an
implant passer by suturing the trial implant to the
tendon implant from end to end.
The distal stump of the FDP, which is attached to

the volar base of the distal phalanx, is sharply elevated
off the distal phalanx, leaving only the distalmost
portion of the FDP attached (Fig. 1). Once the implant
is passed beneath the distal stump of the FDP and
sutured to it, the proximal end of the FDP stump is
sutured to the distal edge of the A5 pulley (Figs. 2AYE).
This develops a distal tunnel into which the silicon
tendon implant is placed. The appropriate size of the
silicon tendon implant trial is tested, and through a
combination of passive flexion and extension of the
finger and proximal traction on the tendon implant,
sizing can be assessed to make certain that the tendon
freely glides without kinking or binding. The trial
implant can be used to pass the actual implant by
suturing them from end to end (Fig. 3). The proximal
aspect of the tendon implant is passed into the distal
forearm, between the level of the profundus and
sublimus tendons, making sure to adequately dissect,

through blunt dissection, an adequate space to allow
free, unrestricted proximal and distal migration of the
flexor tendon implant, with combined flexion of the
finger and wrist and combined extension of the finger
and wrist (Fig. 4). The surgeon should be certain that
simultaneous full extension of the finger and the wrist
does not result in sufficient distal migration of the
proximal end of the tendon implant, so that it moves into
the carpal tunnel. If this happens, the tendon could fold
on itself and/or kink. The length of the silicon tendon
implant may need to be adjusted by cutting a section of
the tendon implant to shorten it, thereby preventing an
excessively long tendon implant, which may extend too
proximal into the forearm. The tourniquet is released.
Hemostasis is controlled using bipolar cautery, and the
skin incisions are closed using simple interrupted sutures.
Perioperative antibiotics are used.
FIGURE 2. A series of diagrams showing

(A) the distal stump of the FDP tendon and the
A5 pulley, (B) release of all but the most distal
attachment of the FDP tendon, (C) placement
and suturing of the trial implant under the
released portion of the FDP tendon, and
(D) attachment of the proximal stump of the
FDP to the distal edge of the A5 pulley.
178
Two-Stage Flexor Tendon Reconstruction

proximal end of the silicon tendon implant lying in the
prepared space between the flexor digitorum sublimis and
the flexor digitorum profundi tendons.
Stage 2 Surgery
After adequate healing and once full passive range of
motion has been regained in the digit, which usually
takes 3 months, the proximal curvilinear incision in the
distal forearm is reopened, and the proximal stump of
the flexor tendon implant is identified. The most distal
aspect of the volar zigzag incision is also opened, again
under tourniquet control. The distalmost insertion site of
the stump of the FDP tendon is split centrally, and the
distal aspect of the tendon implant is identified. Next,
the palmaris longus tendon is identified and harvested in
its entirety, including a segment of the palmar aponeurosis to maximize the length of the tendon graft.
The proximal stump of the palmaris longus tendon
graft is used to create the proximal juncture. This is
performed first as a number of authors 3Y5 have
expressed as their preference, which is shared by the
current author. Adjustment at the fingertip level for final
modification of tendon graft length and tension is
subsequently performed. A Pulvertaft weave is used to
attach the proximal stump of the palmaris longus tendon
graft to the flexor profundus tendon, just distal to the
musculotendinous junction at the common profundus
FIGURE 5. A diagram illustrating the palmaris longus

tendon graft passed through the split in the distal attachment of the FDP tendon through the distal fingertip pulp
and out the tip of the finger.
tendons.3 The silicon tendon implant is used to pass the

palmaris longus tendon from proximal to distal by
suturing the distal end of the profundus tendon to the
proximal aspect of the silicon rod. The distal end of the
silicon tendon implant and, subsequently, the tendon
graft is drawn through an incision made at the distal tip
of the finger pulp (Fig. 5).
Tension of the graft can be tested by placing a
syringe needle transversely through the tendon graft
projecting distal to the fingertip. Using a combination
of observation of the relative cascade of the different
fingers and passive tenodesis, appropriate tension can be
obtained by adjusting tendon length. Once the appropriate
tension has been obtained, which the current author determines as a slight increased tension beyond the normal
cascade, the palmaris longus tendon graft can be sutured at
the distal portion of the FDP stump attachment, which is
split (Fig. 6). The tourniquet that is also used during this
stage of surgery is released, and meticulous hemostasis is
again gained by bipolar cautery. Skin incisions are closed
by simple interrupted sutures.
This technique places the palmaris longus tendon
graft distal insertion more distal to the volar plate of
the distal interphalangeal (DIP) joint, which should
minimize the likelihood of adhesions developing
between the tendon graft and the volar plate of the
DIP joint, thus maximizing the subsequent range of
motion of the DIP joint of that digit. The tourniquet is
then released, adequate hemostasis is obtained by
bipolar cautery, and the skin incisions are closed using
simple interrupted stitches.
| REHABILITATION
After stage 1, the wounds are dressed, and a posterior
plaster splint, maintaining the wrist in approximately
30 degrees short of full flexion, metacarpophalangeal
joints in 70 degrees of flexion, and IP joints extended, is
applied and incorporated with Ace wrapping. Two weeks
after surgery, the sutures are removed, and the patient is
fitted with a removable splint, positioning the wrist and
digits in the same way as the intraoperative plaster splint.
FIGURE 6. A diagram illustrating the palmaris longus

tendon graft trimmed to lie within the fingertip pulp and
sutured to the split FDP tendon.
Volume 10, Issue 3
179
Viegas
The patient is allowed to come out of the splint to work

on a combination of active wrist and passive finger range
of motion for the next 2 weeks. At 4 weeks, the splint is
discontinued. The patient continues working on range of
motion, and when full passive range of motion and
maturation of the surgical scar is obtained, the patient is
ready for the second stage of the procedure.
Rehabilitation after stage 2 of the procedure also
entails similar postoperative splinting. At 3 to 5 days
after the second stage of the procedure, patients are
fitted with Kleinert-type dynamic flexion assist splinting
with an extension block. Two to 3 weeks after the
surgery, short arc active extension flexion and place and
hold flexion exercises can be added to their therapy
program. Resistance is added to the exercise regimen at
6 weeks after surgery. If any proximal interphalangeal
joint or DIP joint contractures develop, dynamic splinting can be added at 6 to 8 weeks after surgery.
| COMPLICATIONS
Adhesions and/or joint contractures can develop. The
best approach to minimize or avoid this problem is the
compliance with the postoperative rehabilitation program. Infection is always a possibility after either stage 1
or 2 procedures. Impingement or breakage of the tendon
implant can result in inflammation and swelling along the
pseudosheath formed around the silicon tendon implant.
180
| SUMMARY
The modification of the distal attachment of the tendon
graft seems to better protect the integrity of the volar plate
of the DIP joint, which better avoids subsequent DIP joint
flexion contracture and maximizes DIP joint motion.
| ACKNOWLEDGMENT
The author thanks Randal Morris for his assistance and
collaboration in the illustrations used in this manuscript
and Kristi Overgaard for her editorial assistance.
| REFERENCES
1. Hunter JM. Artificial tendons: early development and
application. Am J Surg. 1965;109:325Y338.
2. Hunter JM, Salisbury RE. Flexor tendon reconstruction in
severely damaged hands: a two staged procedure using a
silicon dacron reinforced gliding prosthesis prior to tendon
grafting. J Bone Joint Surg. 1971;53A:829Y858.
3. Pulvertaft RG. Suture materials and tendon junctures. Am J
Surg. 1965;109:346Y352.
4. Snow JW, Littler JW. A non-suture distal fixation technique for tendon grafts. Plast Reconstr Surg. 1971;47:91Y92.
5. Stenstrom S. A new method for distal anastamosis in flexor
tendon grafting. Scand J Plast Reconstr Surg. 1967;
1:64Y67.
T E C H N I Q U E
A New Surgical Technique for the Ligament

Reconstruction of the Trapeziometacarpal Joint
Kagan Ozer, MD
Department of Orthopedic Surgery
Denver Health Medical Center
and University of Colorado
School of Medicine
Denver, CO
| ABSTRACT
Isolated traumatic dislocation of the trapeziometacarpal
joint is rare compared with fracture-dislocation of the
joint. The mechanism of injury is usually axial loading
on a flexed thumb metacarpal, leading to dorsal dislocation of the joint. Closed reduction with immobilization is an acceptable method of treatment if the joint is
stable after the reduction. Otherwise, early ligamentous
reconstruction is recommended to reduce the likelihood
of secondary arthritis. Various surgical techniques have
been used to reestablish the ligamentous integrity of the
joint; however, these techniques usually reconstruct
only 1 or 2 ligaments around the joint. The current
technique is aimed to reconstruct all 4 ligaments of the
trapeziometacarpal joint using a half strip of extensor
carpi radialis brevis tendon.
Keywords: extensor carpi radialis brevis, ligament reconstruction, trapeziometacarpal joint, traumatic dislocation
Trapeziometacarpal (TM) joint dislocation is a rarely
reported injury in the English literature. Almost all cases
are dorsal dislocations with axial loading injury.1 Y 5
Recommended treatment modalities show a wide variety depending on duration of the dislocation, condition
of the joint surfaces, and inherent stability of the joint
after reduction. For acute dislocations, it is generally
agreed to perform closed reduction and immobilization
for 4 to 6 weeks provided that the joint is stable after
reduction.6,7 Some authors add percutaneous pinning to
this treatment. For subacute and chronic cases, however,
this approach may result in persistent instability and
redislocation of the joint. Watt and Hooper6 treated 9
patients with closed reduction and cast immobilization
and 3 with closed reduction and percutaneous Kirschner
Address correspondence and reprint requests to Kagan Ozer, MD,
Denver Health Medical Center, 777 Bannock Street, MC:0188,
Denver, CO 80204. E-mail: Kagan.Ozer@dhha.org.
wire fixation. Three patients in the first group and 1 in the

8
second had persistent instability. Simonian and Trumble
also reported persistent instability in 4 of 8 patients after
closed reduction and percutaneous Kirschner wire fixation of acute TM joint dislocations and significantly
better results with early ligament reconstruction. These
studies suggest that early ligamentous reconstruction is
recommended for persistent and recurrent instability.
Anatomy
Four ligaments and the joint capsule are the main stabilizers of the TM joint. The ligaments include dorsoradial,
intermetacarpal, palmar (anterior oblique), and dorsal
(posterior oblique) ligaments5,9 (Fig. 1). The importance
of each one of these ligaments on the stability of the TM
joint is debated. Eaton and Littler10 believed that the
palmar (anterior oblique) ligament is the key stabilizing
structure and gave little credit to the dorsal ligaments in
joint stability. Others, however, found the dorsal (posterior oblique) and intermetacarpal ligaments to be the key
stabilizers of the joint.11,12 Pellegrini13 showed that the
degeneration of the palmar (anterior oblique) ligament
increases shear forces across the joint, leading to osteoarthritis and subluxation of the joint. Strauch et al5 studied
the importance of the TM joint ligaments in providing
stability to the joint. Serial sectioning of the ligaments
was performed on 38 cadaver thumbs. Unlike previous
studies, the stability of the joint was evaluated with the
first metacarpal in neutral, flexed, and extended positions.
The primary restraint to dorsal dislocation was found to
be the dorsoradial ligament with significant contributions
from the other 3 ligaments. In light of these studies, it is
clear that all 4 ligaments contribute to TM joint stability.
| INDICATIONS/
CONTRAINDICATIONS
The following are indications for open reduction and
ligamentous reconstruction of the TM joint:
1. irreducible dislocations (acute or chronic),
Volume 10, Issue 3
181
Ozer
2. reducible, but unstable joint (acute or chronic), and

3. chronic symptomatic laxity or recurrent dislocation.
In addition to the above, the primary indication to use
the current technique is the complete disruption of all 4
ligaments leading to dislocation of the TM joint. Contraindication for surgery is the presence of chondral erosions
suggesting development of degenerative arthritis.
Reduction and Assessment of the Joint Status
FIGURE 1. Schematic representation of the anatomy of
ligaments of the TM joint. (1) Dorsoradial ligament, (2)
intermetacarpal ligament, (3) palmar (anterior oblique)
ligament, and (4) dorsal (posterior oblique) ligament.
A 6-cm zigzag skin incision is placed at the dorsal aspect

of the TM joint (Fig. 2A). Superficial branches of the
radial nerve and the dorsal branch of the radial artery
are dissected and protected until the end of the surgery. In chronic dislocations (96 weeks), a pseudocapsule
FIGURE 2. A, The patient had an irreducible dislocation, presented 2 weeks after the injury. B, The first tunnel hole is
made at the base of the metacarpal from dorsal to palmar direction. C, A second tunnel hole connecting to the first one
perpendicularly is made from ulnar to radial direction. D, A third tunnel hole is made through the trapezium from dorsal to
palmar direction. First and second tunnels are connected at the base of the thumb; first and third tunnels are parallel to
each other.
182
Surgical Technique for TMJ Ligament Reconstruction
surrounding the metacarpal base is usually encountered.

This capsule is excised. The joint surfaces are exposed. It
is necessary to remove all the fibrotic tissue preventing
concentric reduction of the joint before the reduction
maneuver is attempted. Once the joint is reduced,
stability of the joint is assessed. If the joint is not
stable, but the articular surfaces are well preserved,
ligament reconstruction is indicated.
For the preparation of the TM joint, 3 tunnels are
made at the base of the first metacarpal and trapezium.
On the first metacarpal, 2 connecting tunnel holes perpendicular to each other are made 5 to 7 mm distal to the
articular surface. The first tunnel is drilled from dorsal to
palmar direction (Fig. 2B) and a second one from radial
to ulnar (Fig. 2C). On the trapezium, 1 tunnel is drilled
from dorsal to palmar direction (Fig. 2D). All 3 tunnels
are drilled using a 1.2-mm drill bit.
Preparation of the Extensor Carpi

Radialis Brevis Tendon and the
Trapeziometacarpal Joint
A separate 2-cm incision is placed on the dorsum of the
middle third of the forearm to identify the extensor carpi
radialis brevis (ECRB) musculotendinous junction. With
the aid of two 25-gauge loop wires, the ECRB tendon is
split into 2 equal slips, and the radial slip is detached
proximally and pulled distally, leaving its insertion to the
base of the second metacarpal intact.
Passage of the Tendon and Tying the Knot

Passage of the tendon through holes is also performed with
the aid of 25-gauge loop wires. The ECRB tendon is first
passed from ulnar hole to palmar hole at the base of the
first metacarpal (Fig. 3A). Then, the tendon is passed
from the palmar to dorsal direction through the trapezium
FIGURE 3. A, Split ECRB tendon is turned 90 degrees inside the bone, passed from ulnar to palmar hole with the aid of
stainless steel wires; this passage reconstructs the intermetacarpal ligament. B, The tendon crosses the joint on the
palmar side and pulled from palmar to dorsal through the trapezium tunnel; this passage reconstructs the palmar
(anterior oblique) ligament. C, Then the tendon crosses the joint on the dorsal side and is passed from dorsal to radial
hole at the base of the metacarpal; this reconstructs the dorsal (posterior oblique) ligament. D, The tendon is sutured to
itself on the dorsal surface of the trapezium. This final pass forms the dorsoradial ligament.
Volume 10, Issue 3
183
Ozer
TABLE 1. Collected presentation of cases that underwent trapeziometacarpal joint ligament reconstruction using the split extensor
carpi radialis brevis tendon
Duration from
time of injury to
surgery (wk)
3
Sex, age (y),

dominance
Male, 28,
RHD
Mechanism
of injury
Clenched
fist injury
Initial
treatment
None
Indication for
surgery
Persistent
dislocation
Male, 50,
RHD
Motorcycle
accident
Closed reduction,
thumb spica
cast for 8 wk
Recurrent
dislocation
11
Male, 30,
RHD
Fall during a
soccer game
Closed reduction,
thumb spica
cast for 12 wk
14
Male, 45,
RHD
MVA
Closed reduction,
thumb spica
cast for 12 wk
Recurrent
dislocation
(in 4 d after the
completion
of casting)
Persistent
instability
16
Follow-up
Full, pain-free ROM; returned
to ADL in 3 mo with no
restrictions, no arthritic changes
at 24 mo with concentric
reduction of the joint
Able to oppose against middle
phalanx of the small finger,
otherwise pain-free ROM,
minimal subchondral sclerosis
at the TM joint on both sides at
18 mo, returned to ADL and
bike riding with no restrictions
in 3 mo after the surgery
Full, pain-free ROM; returned
to ADL with no restrictions in
4 mo after the surgery, no
arthritic changes at 20 mo
Able to oppose against the tip of
the small finger, pain-free
ROM, no arthritic changes at
19 mo, returned to ADL with
no restrictions in 3 mo after
the surgery
ADL indicates activities of daily living; RHD, right hand dominant; MVA, motor vehicle accident; ROM, range of motion.
tunnel crossing the TM joint on the palmar side (Fig. 3B).

This passage of the tendon ensures the reconstruction of
the intermetacarpal ligament and the palmar ligament of
the TM joint. After that, the tendon crossing the TM joint
on the dorsum is passed from dorsal to radial hole of the
first metacarpal and is sutured to itself on the dorsal
surface of the trapezium using 2.0 Ethibond suture

material (Figs. 3C, D). Reduction is confirmed under
fluoroscan. At the end of the surgery, the joint capsule is
closed using interrupted 3.0 polydioxanone suture material, and the patients upper extremity is placed in a
thumb spica splint. The patient is immobilized for a total
FIGURE 4. A 28-year-old, right-hand Y

dominant man felt a pop and noticed
prominence at the base of his right
thumb after hitting a wall during an
altercation. He did not seek medical
attention initially. Two weeks later, he
was seen at the outpatient clinic complaining of limited motion, pain, and lack
of improvement in his status. On physical examination, a painful, fixed, bony
prominence was noted on the dorsal
aspect of the thumb base. Range of
motion was limited in all planes of TM
joint with intact sensation to light touch.
X-rays showed dorsal-radial dislocation
of the first metacarpal on the trapezium.
184
Surgical Technique for TMJ Ligament Reconstruction
FIGURE 5. Follow-up examination 18 months after the surgery shows full ROM in all planes. X-ray shows congruent
reduction with no arthritis.
of 4 weeks. Gentle range-of-motion (ROM) exercises are

continued for another 4 weeks.
| RESULTS
The technique described in this article was used on 4
patients with complete disruption of ligamentous support
around the TM joint (Table 1). Cases presented in the
study had a minimum 18 months of follow-up. One patient
(50 years old, right hand dominant) had a limited abduction
of the thumb (60 vs 85 degrees on the contralateral site)
due to tight reconstruction of intermetacarpal ligament.
During the follow-up, all cases had concentric reduction of
the joint with no signs of arthritis of the TM joint or
avascular necrosis of the trapezium (Figs. 4, 5; Video 1).
| DISCUSSION
Clinically, there have been several reports of various
techniques of ligament reconstruction for persistent and
recurrent instability after TM joint dislocation and instability.14 Y 24 Among these, the Eaton-Littler10,17,19,20,25
technique is one of the most commonly used and timetested techniques. The Eaton-Littler technique uses split
flexor carpi radialis tendon, which remains attached

distally and is woven through the first metacarpal. This
technique reconstructs the strong palmar ligament and
reinforces the dorsal capsule. In a study assessing
Eatons technique, 97% of the subjects (n = 34) reported
good to excellent results without progression to arthritis.20 However, most of these patients were at the
prearthritic stage of degenerative joint disease with
possible involvement of only the palmar ligament of
the TM joint. In the phase of a traumatic dislocation
of the joint, the retrospective evaluation of 9 patients
using the same technique, Simonian and Trumble8
reported no pain at work in 8 patients with 98% motion in flexion-extension and 90% abduction compared
with uninjured thumb. Three patients had stage 2 narrowing of the joint, whereas 6 had no changes in the joint.
Although these 9 cases reportedly had traumatic disruption
of the palmar oblique ligament, no specific reference was
given for the rest of the ligamentous injury. As a result, the
success rate of Eatons technique in the presence of
complete disruption of all 4 ligaments is not clear.
In the current report, intermetacarpal ligament was the
first ligament reconstructed, followed by palmar ligament.
Volume 10, Issue 3
185
Ozer
Both of these ligaments, however, were not enough to

stabilize the joint. It was only after reconstruction of all 4
ligaments that satisfactory stability was established. This
kind of ligamentous reconstruction provides a 4-sided box
around the joint. The tightness of ligaments can still be
changed before the final knot and should be adjusted
carefully. The laxity of ligaments determines the ROM.
Potential problems include too tight or too loose reconstruction, in which the former may narrow the joint space
leading to limited motion and early degenerative changes,
and the latter may cause persistent pain and instability.
| REFERENCES
1. Chen VT. Dislocation of the carpometacarpal joint of the
thumb. J Hand Surg. 1987;12B:246 Y 251.
2. Moore JR, Webb CA, Thompson RC. A complete dislocation of the thumb metacarpal. J Hand Surg. 1978;3:547Y 549.
3. Shah J, Patel M. Dislocation of the carpometacarpal joint
of the thumb. Clin Orthop. 1983;175:166 Y 169.
4. Hooper GJ. An unusual variety of skiers thumb. J Hand
Surg. 1987;12A:627 Y 629.
5. Strauch RJ, Behrman MJ, Rosenwasser MP. Acute dislocation of the carpometacarpal joint of the thumb: an anatomic
and cadaver study. J Hand Surg. 1994;19A:93 Y 98.
6. Watt N, Hooper G. Dislocation of the trapezio-metacarpal
joint. J Hand Surg. 1987;12B:242 Y 245.
7. Uchida S, Sakai A, Okazaki Y, et al. Closed reduction and
immobilization for traumatic isolated dislocation of the
carpometacarpal joint of the thumb in rugby football
players. Am J Sports Med. 2001;29:242 Y 244.
8. Simonian PT, Trumble TE. Traumatic dislocation of the
thumb carpometacarpal joint: early ligamentous reconstruction versus closed reduction and pinning. J Hand
Surg. 1996;21A:802 Y 806.
9. Pieron AP. The mechanism of the first carpometacarpal
joint. Acta Orthop Scand. 1973;148(Suppl):7 Y 104.
10. Eaton RG, Littler JW. Ligament reconstruction for the
painful thumb carpometacarpal joint. J Bone Joint Surg.
1973;55A:1655 Y 1666.
11. Harvey FJ, Bye WD. Bennetts fracture. Hand. 1976;8:
48 Y 53.
186
12. Pagalidis T, Kuczynski K, Lamb DW. Ligamentous

stability of the base of the thumb. Hand. 1981;13:29 Y 35.
13. Pellegrini VD Jr. Osteoarthritis of the trapeziometacarpal
joint: the pathophysiology of the articular cartilage
degeneration. I. Anatomy and pathology of the aging
joint. J Hand Surg. 1991;16A:967 Y 974.
14. Eggers GWN. Chronic dislocation of the base of the
metacarpal of the thumb. J Bone Joint Surg. 1945;27:
500 Y 501.
15. Brunelli G, Monini L, Brunelli F. Stabilization of the
trapeziometacarpal joint. J Hand Surg [Br]. 1989;14:
209 Y 212.
16. Cho KO. Translocation of the abductor pollicis longus tendon:
a treatment of chronic subluxation of the thumb carpometacarpal joint. J Bone Joint Surg. 1970;52A:1166Y 1170.
17. Eaton RG, Lane LB, Littler JW, et al. Ligament reconstruction for the painful carpometacarpal joint. A long-term
assessment. J Hand Surg. 1984;9A:692 Y 699.
18. Kestler OC. Recurrent dislocation of the first carpometacarpal joint repaired by functional tenodesis. J Bone Joint
Surg. 1946;28:858 Y 861.
19. Lane LB, Eaton RG. Ligament reconstruction for the
painful Bprearthritic^ thumb carpometacarpal joint. Clin
Orthop. 1987;220:52 Y 57.
20. Lane LB, Henley DH. Ligament reconstruction of the
painful, unstable, nonarthritic thumb carpometacarpal
joint. J Hand Surg [Am]. 2001;26:686 Y 691.
21. Slocum DB. Stabilization of the articulation of the greater
multangular and the first metacarpal. J Bone Joint Surg.
1943;25:626 Y 630.
22. Biddulph SL. The extensor sling procedure for an unstable
carpometacarpal joint. J Hand Surg. 1985;10A:641 Y 645.
23. Varitimidis SE, Sotereanos DG. Palmar oblique ligament
reconstruction for carpometacarpal joint dislocation in an
11 year old: a case report. J Hand Surg. 1999;24A:
505 Y 507.
24. Elmaraghy MW. Anterior oblique ligament reconstruction
of the thumb using the transverse carpal ligament: description of a new procedure. Ann Plast Surg. 2000;45:19Y 23.
25. Freedman DM, Glickel SZ, Eaton RG. Long-term followup of volar ligament reconstruction of the thumb. J Hand
Surg [Am]. 2000;25:297 Y 304.
T E C H N I Q U E
Mini External Fixation in the Hand

Obinwanne Fidelis C. Ugwonali, MD
Brigham and Womens Hospital
Boston, MA
Boston, MA
Jesse B. Jupiter, MD
Orthopaedic Hand Service
Massachusetts General Hospital
Boston, MA
Boston, MA
| ABSTRACT
External fixation is an effective means of addressing
several pathologies of the hand. The advantages of its use
include the ability to achieve stable fixation, minimize soft
tissue trauma at the site of injury, and allow wound care
and mobilization of adjacent joints. External fixators can
be constructed from material readily available in the
operating room or obtained from a commercial source.
Sufficient rigidity can be achieved by any of these means.
Improper placement, although achieving rigid fixation, may
compromise motion and overall function if basic principles
of external fixation are not followed or if the anatomy of the
hand is not taken into consideration. The objective of this
article is to describe the technique of application of mini
external fixation, emphasizing the basic principles of
external fixation as they relate to the specific anatomy of
the hand. In addition to fracture fixation, various other uses
are described including distraction lengthening, arthrodesis,
treatment of nonunion, and infection.
Keywords: mini external fixation, handfracture, arthrodesis,
lengthening, nonunion
of Hoffmans original fixator designed in the 1930s

remains in widespread use today. These early fixators
remained large and cumbersome and therefore were not
suited to the hand. The first external fixators for the hand
and carpus combined Kirschner wires and methylmethacrylate. Although these materials are easily obtained, once
assembled, these fixators are not modifiable.1,4Y6
Micks and Hagar designed the first mini external
fixator for compression arthrodesis of the digital
skeleton in the 1960s.7 Work by Jaquet in Switzerland
led to the first commercially available mini external
fixator for the hand and carpus in the mid 1970s.8Y10 His
design had 3 degrees of freedom and could be adjusted
during or after surgery. Since then, several types of
fixators have been described including commercially
available fixators and fixators that can be constructed
with materials readily available in the operating
room.11Y13 Most of the available devices and techniques,
for the most part, are able to provide sufficient rigidity
regardless of pin placement and withstand torsional
stresses (Figs. 1Y4).14
Early external fixators were crude, but the ability to

achieve reduction by ligamentotaxis was realized. Parkhill
of the United States and Lambotte of Belgium, at the turn
of the century, developed external fixators simultaneously
on opposite sides of the Atlantic.1Y3 Raul Hoffman, Otto
Stader, and Roger Anderson further modified external
fixators throughout the 1920s and 1930s.3 A modification
Although most injuries of the hand can be treated with

nonoperative management, certain injuries involving
significant soft tissue injury require operative fixation.
External fixation is effective for the treatment of these
injuries.15Y18 It is especially useful for osteomyelitis, open
fractures with segmental bone loss, and further surgery
after failed osteosynthesis. The major advantage of external fixation is the ability to obtain fracture stabilization
without further wound dissection and devascularization
while maintaining joint mobility and facilitating soft
tissue care.11,15
Address correspondence and reprint requests to Jesse B. Jupiter, MD,

Yawkey Center, Suite 2100, 55 Fruit St, Boston, MA 02114. E-mail:
jjupiter1@partners.org.
Volume 10, Issue 3
187
Ugwonali and Jupiter
FIGURE 1. Basic external fixation with smooth Kirschner

wires and methylmethacrylate cement.
The management of an open fracture will be an

indication for external fixation, if the fracture involves
segmental injury, extensive comminution, significant soft
tissue damage, or gross contamination. External fixation
allows rigid immobilization of the injury while allowing
early motion at adjacent joints. It obviates the need for
operative reduction at the fracture site, therefore minimizing further soft tissue trauma. Furthermore, it allows
access to the wound for soft tissue care because casting is
not necessary. Contraindications for use of external
fixators for fractures include severe osteoporosis. A
relative contraindication is poor patient compliance.19
Other situations that are amenable to external
fixation include arthrodesis, osteotomy fixation, treatment of delayed union or nonunion, tumor resection and
stabilization, and distraction lengthening.20 Extra- and
intraarticular osteotomies for malunion can be effectively stabilized by external fixation. Distraction lengthening is indicated in situations where risks of digital
FIGURE 2. The Kessler external device developed for

digital lengthening can be used for thumb ray fractures.
188
FIGURE 3. The mini Hoffman external fixation device

applied for a complex proximal phalanx fracture.
replacement or composite tissue transfer outweigh the

benefits. Some of the current situations involve congenital anomalies, traumatic amputations, and defects
caused by infection, tumor, or trauma.21 In the upper
extremity, there are no set guidelines governing the need for
lengthening if there is a digital length discrepancy. External
fixation can also be used as an adjunct for stabilization in
soft tissue reconstructions such as cross-finger flaps or webspace reconstructions.16
| TECHNIQUE
Fractures
External fixation of a fractured phalanx leads to the best
functional result if applied within the limits of the
involved phalanx or metacarpal, avoiding involvement
of the adjacent joints. This is not always possible
especially in fractures with intraarticular extension or
extraarticular fragments too small for pin placement.
FIGURE 4. The mini Arbeitsgemeinschaft fur Osteosynthesefragen (AO) external fixation for thumb injury.
FIGURE 5. The basic components of the AO mini external fixation system. A, Two sizes of pin-holding clamps. B, 3.0/3.0-mm
bar-to-bar connecting clamps. C, 1.25- and 1.6-mm threaded trocar tipped Kirschner wires. D, Carbon fiber connecting rods.
FIGURE 6. The basic steps of mini external fixation application. A, Two Kirschner wires are placed on either side of the
fracture. B, Each wire is connected to pin-holding clamps into the larger of the two holes. C, The 2 clamps are connected
with a carbon fiber rod. D, Two additional Kirschner wires are placed through the pin-holding clamps.
Volume 10, Issue 3
189
When possible, it is preferable to place pins dorsolaterally for border digits to limit contact and interference with neighboring digits.
The same principles of achieving rigidity in the
lower extremity apply to the hand. Pin diameter has
the greatest effect on rigidity. Other factors associated
with increased rigidity include number of pins, decreasing interpin spacing, and decreasing bone to fixator
distance.
Middle Phalanx. The basic components of any type of
mini external fixation system that has application in the
hand will include pin-holding clamps, threaded-tip
wires or pins, a variety of lengths of connecting bars,
and clamps to connect rods to each other and to the pinholding clamps (Fig. 5). The versatility of these devices
will permit a variety of applications both in location and
in frame construction.
The authors have the most experience with the
mini external systems manufactured by Synthes, Ltd
and Howmedica.
Using the proximal phalanx as an example, a threadedtipped 1.2- or 1.6-mm Kirschner wire initially is placed on
either side of the fracture or defect. A pin-holding clamp is
attached to each pin, and the clamps can be provisionally

connected with a carbon fiber rod. A second threadedtipped Kirschner wire is then placed through the remaining
holes in the pin-holding clamps (Fig. 6).
Angled connecting bars can also be placed into the
pin-holding clamps, which will then permit the connecting
rod to be more dorsal to the pins and avoid interfering with
adjacent digit (Fig. 7).
It is important to emphasize that the alignment of
the phalanx can be gained after both sets of pins and pin
clamps have been applied, which will facilitate initial
pin placement.
The postoperative care of the fixation pins consists of a
small gauze wrapped around the pins to remain in place
for the initial 7 to 10 days postsurgery, followed by daily
cleansing with hydrogen peroxide or saline. On occasion,
the skin around the pins will need to be released under
local anesthesia in the office.
Proximal Phalanx. The specific anatomy of the
proximal phalanx is such that the extensor hood is
thickened down the midline. Placement of the fixation
pin down the midline would therefore interfere with
the extensor mechanism. Drendth and Klasen22 pointed
FIGURE 7. Additional components of the AO mini external fixation system. A, Angled connecting bar to permit the
connecting rod to rest above the digit. B, The frame construct with the angled bar. C, 3.0/3.0-mm bar-to-bar clamps. D,
The use of this connecting clamp holding 2 small carbon fiber rods.
190
out that in cadaver specimens, placement of fixator

pins just lateral to dorsal midline was biomechanically
superior to lateral placement of the pins just dorsal to
midlateral line, the so-called 10-oclock position given
the oblique orientation of the extensor hood fibers
laterally (Figs. 8AYD). Pin placement and application
of external fixator device follow the same principles
described above for the middle phalanges. Results of
management of phalangeal fractures have historically
not been as good as that of the middle phalanges, likely
owing to the anatomy of the extensor mechanism and
dynamic deforming forces at the fracture site. Attention
to detail is especially important to these fractures.
The proximal phalanx of the thumb can be stabilized
with dorsal midline pins as long as the extensor pollicis
longus, which is just ulnar to midline, is avoided. Placement of the pins just dorsal to lateral midline is also
acceptable (Figs. 9AYD).
Metacarpal. Metacarpal fracture comprised 20% of
the fractures treated with external fixation reported by
Drendth and Klasen,22 whereas phalangeal fractures
comprised the remaining 80%. Given the greater soft
tissue coverage of the metacarpals, these fractures are
often more amenable to internal fixation. External
fixation is still a viable option in severe soft tissue and
open injuries, especially injuries involving segmental
bone loss not amenable to internal fixation.
The technique of external fixation of the middle

digits involves a longitudinal midline incision to identify the extensor tendons. One incision is made proximal
and one distal to the fracture site. Incise fascia down to
the bone just lateral to the tendon. Pins are placed similar to the techniques applied to the phalanges. Incisions
for the small finger are placed ulnar to midline, and
those for the index finger are placed radial to midline.
Fractures involving the thumb metacarpal generally
occur at the base and sometimes have intra-articular
extension such as in the Rolando or Bennett fracture.
Similar principles of external fixation apply if the
fracture does not involve an intraarticular extension.
External fixation bridging the carpometacarpal joint can
be used to effectively treat these fractures (Fig. 7).
Kontakis et al23 had 7 excellent results and 1 poor result
out of 11 patients with Rolando fractures treated with 2
pins distally on the metacarpal and 1 proximally through
the trapezium (Figs. 10AYB, 11).
In a previously published series, 20 (91%) of 22
acute fractures healed primarily. There was also 100%
solid bony union in 6 primary arthrodeses and interpositional grafts.15
Arthrodesis
The most commonly fused joints in the hand are the interphalangeal joints. Fusion success rates are comparable
FIGURE 8. A and B, A complex proximal phalanx fracture in a 16-year-old male patient seen 3 weeks after injury with
early callous. C, A closed reduction was accomplished and held in place with a mini Hoffman external fixation frame.
D, Excellent healing with good digital function.
Volume 10, Issue 3
191
with other techniques.15 Similar principles involved in

fracture fixation apply to arthrodesis. Rigid fixation is
paramount. In these situations, more than 2 pins maybe
necessary and neighboring metacarpals may be used to
achieve this goal (Figs. 12AYD).
Union has been shown to be accelerated with
compression as compared with immobilization alone.24Y28
Braun and Rhoades24 demonstrated that loads of 650
to 800 g can be generated with external fixation constructed with PMMA and K-wires. They had union in all
interphalangeal and metacarpophalangeal joints treated
by their technique.15 Similarly, compression can be
achieved with the mini external fixator. Supplemental
compression screw can be used if adequate rigidity is
not achieved intraoperatively.
Infection
Although external fixation is a well-established method for
the treatment of infected nonunion of long bones in the
lower extremities, its use in the upper extremity is less
frequent.29 External fixation represents a major advance in
the management of septic conditions of the hand.15,25,30,31
The advantages also include the ability to achieve rigid
fixation, avoid fixation at the site of infection, and

continue soft tissue care without the additional need of
casting or splinting. Some of the indications for external
fixation in hand infections include potentially infected,
complex hand injuries; established infected fractures and
nonunion; chronic osteomyelitis; septic arthritis; and
infections after arthropathy in the hand.30
Treatment of hand infections with external fixation
follows similar principles described above for fractures
and arthrodesis. In addition, certain strategies are
critical in eliminating the infection. First, aggressive
debridement of nonviable infected tissue is the most
important factor in eradicating the infection. Antibiotics
will not penetrate nonviable necrotic avascular tissue.
Tendons, nerves, and vessels should be preserved
whenever possible. If debridement leads to significant
bone loss, distraction with the fixator is paramount
to maintain length and soft tissue tension. If vital
structures are exposed as a result of adequate debridement, a local rotation or pedicled flap is the first choice
for soft tissue coverage. If no vital structures are
exposed, delayed or secondary wound closure is an
option.
FIGURE 9. A complex fracture of the thumb proximal phalanx with vascular injury. A, The x-ray of the injury. B, After
revascularization and 2 long screws, the fracture is bridged with a mini external fixator. C, The frame construct for the
complex thumb injury. D, 2 weeks after frame removal, early thumb function.
192
FIGURE 10. A, A complex impacted articular fracture at the base of the thumb metacarpal (case courtesy of Dr Lady
Nagy). B, After open reduction and cancellous grafting, the reduction is protected with a small external fixation construct with
pins in both thumb and index metacarpal.
Repeated debridement, especially in acute infections, may be necessary for excision of necrotic tissue.
This type of staging minimizes recurrence of infection.
Once adequate debridement is achieved, definitive
management can be implemented. If bone loss is not
severe, cancellous bone grafting may be all that is
needed. If there is segmental bone loss, corticocancellous bone grafting should be considered for bone
replacement. External fixation can be used throughout
the stages of treatment or used just during the debridement stage. It is recommended that bone grafting be
performed within 10 days of these severe injuries.
Distraction Lengthening
Distraction lengthening can be performed with or
without neo-osteogenesis or callotasis. Distraction
lengthening with neo-osteogenesis has several advantages over lengthening without neo-osteogenesis. Some
of the advantages include less risk of needing bone
grafting; pain is less likely and when encountered is less
severe; stretch adaptation of soft tissue is more easily
accommodated; and catastrophic problems such as
excessive fibrosis, severe or chronic pain reactions, or
gangrene are much less likely.32
The technique of distraction osteogenesis involves
an osteotomy, a brief delay period to allow callus
formation, followed by slow lengthening through a
healing fracture callus. For digital lengthening, we
usually make a midline dorsal incision over the
bone to be lengthened. The extensor apparatus is
reflected to expose the periosteum. Two pins are placed
distal and 2 proximal to the intended osteotomy site.
FIGURE 11. An alternative method of mini external fixation for a complex base of thumb fracture is with a mini lengthener
with one pin in the trapezium and one in the thumb metacarpal.
Volume 10, Issue 3
193
FIGURE 12. A, A severe infection after replantation of the index and long fingers. The long finger required an amputation;
the index finger survived, but with an infected proximal interphalangeal joint. B, A mini external fixator was used to
stabilize the joint and allow rehabilitation of the injured ring and little digits. C, Radiographs at 6 months show fused joint.
D, Functional results.
The pins can be placed within the incision or through

separate stab incisions away from the site of distraction. A longitudinal incision in line with the skin
incision is made through the periosteum, and the
periosteum is gently elevated just at the planned
osteotomy site and carefully retracted. The osteotomy
is performed with sharp osteotomies to completely
divide the bone. The periosteum is then sutured closed
with 5Y0 or 6Y0 absorbable suture. The clamp and rod
are applied to assemble the external fixator. A fluoroscopic image is needed to confirm that the osteotomy
is complete and that the fixator is able to in fact
distract through the osteotomy site. If the osteotomy
proves unstable, a buried smooth Kirschner wire can be
passed through the osteotomy and will not hinder
distraction (Fig. 13).
A sterile dressing is applied and left in place until
distraction is started. This period is generally 5 days
in children and 7 days in adults to allow the initial
194
fracture callus to form. Pin site care is started on the

day lengthening begins, using peroxide or isopropyl
alcohol twice daily. Four separate lengthenings of
0.25 mm for a total of 1.0 mm per day are fast enough
to avoid premature consolidation and slow enough to
allow callotasis with each distraction. Distraction
is performed until the desired length is achieved. A
2-month period of immobilization with the external
fixator is required to allow the new bone to organize
into a trabecular network. Bridge plating obviates the
need for lengthy immobilization and allows rehabilitation to begin sooner.
| POSTOPERATIVE CARE
To control postoperative swelling, the hand should be
kept elevated. A sling can be worn to help keep the hand
elevated while walking. Digital range of motion should
be started after a few days.
FIGURE 13. A thumb lengthening using a mini distracter with later plate fixation.
The pin sites are cleaned thrice in the first week,

twice in the second week, and once in the third week.
Hydrogen peroxide can be used for the first 2 to
3 weeks, then alcohol. After the third week, pin care
may no longer be necessary.
The fixator can be removed after the fracture has healed
radiographically, usually after 5 to 6 weeks. This can be
performed as an outpatient procedure. After removal, the
wound is covered by dry dressing and heals in 3 to 4 days.
2. Jupiter J. External fixation in the upper extremity. Instr

Course Lect. 1990;39:209Y218.
3. Putnam M, Walsh T. External fixation for open fractures of
the upper extremity. Hand Clin. 1993;9:613Y623.
4. Nagy L. Static external fixation of finger fractures. Hand
Clin. 1993;9:651Y657.
5. Rosenberg L, Kon M. A Bdo-it-yourself^ distraction
fixator for phalangeal bone loss. Ann Plast Surg. 1986;
16:359Y360.
6. Shehadi S. External fixation of metacarpal and phalangeal
fractures. J Hand Surg [Am]. 1991;16:544Y550.
| COMPLICATIONS
External fixation can cause significant morbidity if attention is not given to pin placement. Misdirected pins can
injure musculotendinous structure, nerves, or vessels. The
overall incidence of neurovascular injury is less than 1%.33
Pin-tract infection can occur. Overall incidence is
estimated at 8%, with actual sequestrum and osteomyelitis developing in less than 1%.33 In our series, there
was only one pin tract infection, which required pin
removal but did not alter the clinical course.15 Predrilling may help reduce this incidence by reducing the
heating of bone and associated necrosis.
Malunion and nonunion were more common with
older external fixators because of the limited ability
to modify their position or apply compression once placed.
7. Micks JE, Hagar DL. Exhibit. A method of accelerating

fusion of small joints. J Bone Joint Surg Am. 1968;50:1269.
8. Buchler U. The small AO external fixator in hand surgery.
Injury. 1994;25:55Y63.
9. Freeland A. External fixation for skeletal stabilization of
severe open fractures of the hand. Clin Orthop. 1987;
214:93Y100.
10. Hochberg J, Ardenghy M. Stabilization of hand phalangeal fractures by external fixator. W V Med J. 1994;
90:54Y57.
11. Parsons SW, Fitzgerald JA, Shearer JR. External fixation
of unstable metacarpal and phalangeal fractures. J Hand
Surg [Br]. 1992;17:151Y155.
12. Watson JA. A simple external fixator for metacarpal and
phalangeal fractures. Injury. 1993;24:635Y636.
13. Shehadi SI. External fixation of metacarpal and phalangeal
fractures. J Hand Surg [Am]. 1991;16:544Y550.
| REFERENCES
1. Freeland A, Jabaley M. Stabilization of fractures in the
hand and wrist with traumatic soft-tissue and bone loss.
Hand Clin. 1988;4:425Y36.
14. Fitoussi F, Ip WY, Chow SP. External fixation for

comminuted phalangeal fractures: a biomechanical cadaver study. J Hand Surg [Br]. 1996;21:760Y764.
Volume 10, Issue 3
195

15. Ashmead D 4th, Rothkopf DM, Walton RL, et al.
Treatment of hand injuries by external fixation. J Hand
Surg [Am]. 1992;17:954Y964.
16. Cziffer E. Static fixation of finger fractures. Hand Clin.
1993;9:639Y650.
17. Schuind F, Burny Brussels F. Surgical anatomy of the
hand. In: Schuind F, Burny Brussels F, eds. New
Techniques in Osteosynthesis at the Hand: Principles,
Clinical Applications and Biomechanics. New York:
Karger, 1990:2Y11.
18. Fahmy NR. The Stockport Serpentine Spring System
for the treatment of displaced comminuted intra-articular
phalangeal fractures. J Hand Surg [Br]. 1990;15:303Y311.
19. Pennig D, Gausepohl T, Mader K, et al. The use of
minimally invasive fixation in fractures of the handVthe
minifixator concept. Injury. 2000;31:102Y112.
20. Bishop AT. Small joint arthrodesis. Hand Clin. 1993;
9:683Y689.
21. Seitz WH Jr, Froimson AI, Wenner SM. Distraction
osteogenesis lengthening in the hand and upper extremity.
Instructional Course Symposium at the 47th Annual
Meeting of the American Society for Surgery of the
Hand; November 11Y14, 1992; Phoenix, AZ.
22. Drendth DJ, Klasen HJ. External fixation for phalangeal
and metacarpal fractures. J Bone Joint Surg Br. 1998;
80:227Y230.
23. Kontakis GM, Katonis PG, Steriopoulos KA. Rolandos
196
fracture treated by closed reduction and external fixation.

Arch Orthop Trauma Surg. 1998;117:84Y85.
24. Braun RM, Rhoades CE. Dynamic compression for
small bone arthrodesis. J Hand Surg [Am]. 1985;10:
340Y343.
25. Cziffer E, Farkas J, Turchanyi B. Management of
potentially infected complex hand injuries. J Hand Surg
[Am]. 1991;16:832Y834.
26. Ferlic DC, Turner BD, Clayton ML. Compression arthrodesis of the thumb. J Hand Surg. 1983;8:207Y210.
27. Leonard MH, Capen DA. Compression arthrodesis of
finger joints. Clin Orthop. 1979;145:193Y198.
28. Micks JE, Hagar DL. Exhibit. A method of accelerating fusion
of small joints. J Bone Joint Surg Am. 1968;50:1269.
29. Jupiter JB, First K, Gallico III GG, et al. The role of
external fixation in the treatment of posttraumatic osteomyelitis. J Orthop Trauma. 1988;2:79Y93.
30. Allieu Y, Chammas M, Hixson ML. External fixation for
treatment of hand infections. Hand Clin. 1993;9:675Y682.
31. Freeland AE, Senter BS. Septic arthritis and osteomyelitis.
Hand Clin. 1989;5:533Y552.
32. Seitz WH Jr, Dobyns JH. Digital lengthening with
emphasis on distraction osteogenesis in the upper limb.
Hand Clin. 1993;9:699Y706.
33. Green S. Complications of pin and wire external fixation.
Instr Course Lect. 1990;39:219Y28.
L E T T E R T O T H E E D I T O R
Percutaneous Trigger Finger Treatment

Oguz Cebesoy, MD
Gaziantep University Faculty of Medicine
Orthopedic and Traumatology
Gaziantep, Sahinbey, Turkey
Dear Editor:
I would like to comment on the article by
Slesarenko et al,1 BPercutaneous release of A1 pulley.^
I would like to congratulate the authors for their
valuable contribution to the relevant literature.
Stenosing tenosynovitis, or trigger finger, is an
entity seen commonly by hand surgeons.
The authors found in their cadaver study that a
percutaneous trigger digit release resulted in a high
percentage of incomplete releases of the A1 pulley,
especially in the thumb, index, and little fingers.1 In the
authors study, some of the most current literature, noting
that percutaneous release of trigger finger was a safe and
effective outpatient procedure, was not cited.2Y4
I assume that in the authors study, there was no
clinical evidence of a trigger digit.1
In a clinical patient setting using the percutaneous
technique, the sudden release of resistance can be noted
by the hand surgeon and the patient at the needle tip.
This observation aids in an adequate release. The oftenobserved fibrous nodule in the A1 pulley is also a useful
guide for the insertion of needle tip.
In my opinion, another important factor for a high
clinical success rate in percutaneous release of trigger
digits is the communication with the patient during the
procedure. The hand surgeon can directly see and feel

his success by noting normal serial motion of the
released trigger finger.
In my experience, as well as that of other authors,
percutaneous trigger finger release is a simple, safe,
effective, and cost-effective method of treatment in the
management of the trigger finger.
| REFERENCES
1. Slesarenko YA, Mallo G, Hurst LC, et al. Percutaneous
release of A1 pulley. Tech Hand Up Extrem Surg. 2006;
10:54Y56.
2. Ragoowansi R, Acornley A, Khoo CT. Percutaneous trigger
finger release: the lift-cut` technique. Br J Plast Surg.
2005;58:817Y821.
3. Park MJ, Oh I, Ha KI. A1 pulley release of locked trigger
digit by percutaneous technique. J Hand Surg [Br]. 2004;
29:502Y505.
4. Maneerit J, Sriworakun C, Budhraja N, et al. Trigger
thumb: results of a prospective randomised study of
percutaneous release with steroid injection versus steroid
injection alone. J Hand Surg [Br]. 2003;28:586Y589.
Volume 10, Issue 3
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Volume 10(3)

(C) 2006 Lippincott Williams & Wilkins, Inc.

Viewing 1-14 of 14 Results

01 Who Should Do What?

02 A Meta-analysis of Success Rates for Digit Replantation.

03 A New Modification of Trapeziectomy and Soft Tissue

04 Arthroscopic Management of Volar Lunate Facet Fractures

05 Biologic Resurfacing of the Glenoid Using a Meniscal

06 The Hypothenar Fat Pad Transposition Flap: A Modified

07 Avulsion Fractures From the Base of Phalanges of the

08 Tenodesis Extension Splinting for Radial Nerve Palsy.

09 A Vascularized Technique for Bone-Tissue-Bone Repair in

10 Confirmatory Needle Placement Technique for Scalene

11 A New Modification of Two-Stage FlexorTendon

12 A New Surgical Technique for the Ligament

13 Mini External Fixation in the Hand.

14 Percutaneous Trigger Finger Treatment.