E. Hagert - Academia.edu (original) (raw)

Papers by E. Hagert

Hand (N Y), 2013

Background Proximal median nerve entrapment (PMNE, or pronator syndrome) at the elbow has traditi... more Background Proximal median nerve entrapment (PMNE, or pronator syndrome) at the elbow has traditionally been considered an elusive and rare diagnosis, as it is seldom detectable using electrophysiological techniques. In this paper, the clinical manifestations, physical diagnosis, surgical technique, and results of surgical treatment of PMNE are presented, with accompanying instructional video. Patients/Methods During 2011, 44 patients with PMNE were surgically released and followed prospectively, 22 women/22 men, mean age 48.8 (range 25-66). The patients were equally distributed between right/left hands (23/21) and the dominant hand was treated in 56 % of cases. The diagnosis was based on: (1) weakness in median innervated muscles distal to the lacertus fibrosus; (2) pain upon pressure over the median nerve at the level of the lacertus fibrosus; and (3) positive scratch collapse test. A minimally invasive surgical treatment using only local anesthesia with lidocaine-epinephrine and no tourniquet was used, and direct perioperative return of strength in median innervated muscles was seen in all subjects. Results The average preoperative quick DASH was 35.4 (range 6.8-77.2); work DASH, 44.3 (6.25-100); and activity DASH, 61.6 (12.5-100). There were 71.1 % patients who completed the 6-month follow-up, and the average postoperative quick DASH was 12.7 (range 0-43.1), which is a statistically significant reduction (p<0.0001; Student's paired t test). Similarly, the work and activity DASH was significantly reduced (p<0.001) to 12.5 (0-75) and 6.25 (0-50), respectively. Conclusions PMNE at the level of the lacertus fibrosus should be called lacertus tunnel syndrome to distinguish it from other levels of median nerve entrapment. It is a clinical diagnosis based on three distinct clinical findings: weakness, pain over point of compression, and positive scratch collapse test. Surgical release in local anesthesia allows for a safe, ambulatory, and cost-efficient procedure with low morbidity.

Clin. Orthop. Relat. Res., 2014

Journal of Hand Therapy, 2010

Study Design: Narrative review. Recent years have brought new research findings on the subject of... more Study Design: Narrative review. Recent years have brought new research findings on the subject of wrist joint proprioception, which entails an understanding of the wrist as part of a sensorimotor system where afferent information from nerve endings in the wrist joint affects the neuromuscular control of the joint. An understanding of proprioception is also essential to adequately rehabilitate patients after wrist injuries. The aim of this narrative review was to give the reader a background of proprioception as it relates to neuromuscular control and joint stability, what is presently known in relation to the wrist joint and how these findings may be applied to the field of wrist rehabilitation.

The Journal of Hand Surgery, 2010

Purpose The posterior interosseous sensory nerve innervates the dorsal capsule of the wrist, whic... more Purpose The posterior interosseous sensory nerve innervates the dorsal capsule of the wrist, which may provide nociceptive and proprioceptive sensation. Posterior interosseous sensory neurectomy (PISN) is commonly used as a primary or adjunctive procedure to provide wrist analgesia for a variety of wrist conditions. Currently, there is little information in the literature regarding the proprioceptive role of the posterior interosseous sensory nerve and the resultant effects of PISN on wrist proprioception. The purpose of our investigation was to examine the effect of PISN on wrist proprioception.

Journal of Wrist Surgery, 2015

Congress Abstract Introduction Palmar midcarpal instability (PMCI) is a painful condition charact... more Congress Abstract Introduction Palmar midcarpal instability (PMCI) is a painful condition characterized by a kinematic dysfunction of the proximal carpal row (PCR). Although its etiology is still poorly understood, it is believed to be due to congenital (or traumatic) laxity of the ligaments that stabilize the PCR, primarily, the dorsal radiotriquetral (DRT) ligament and the ulnar arm of the palmar arcuate ligament. This laxity causes an unphysiologic coupling of the midcarpal joint, which is clinically evident as a painful clunk with ulnar wrist deviation. Most symptomatic PMCI patients benefit from nonoperative management, which is based on splinting and proprioceptive neuromuscular rehabilitation. However, patients that do not respond to nonoperative management are candidates for surgical treatment. Cases with mild to moderate symptoms may be treated with soft tissue procedures, such as dorsal capsular reefing (Lichtman, 2006) or arthroscopic shrinkage (Mason, 2007; Lichtman, 2003). The purpose of this study was to present our results with a personal technique of arthroscopic ligament plication (ALP) for PMCI.

Plastic and Reconstructive Surgery, 2014

Background: Non-traumatic pain in the shoulder, arm and hand (brachialgia) is a common complaint ... more Background: Non-traumatic pain in the shoulder, arm and hand (brachialgia) is a common complaint in the field of musculoskeletal disorders, where nerve entrapment constitutes a possible cause. The effect of nerve compression is dosedependent; hence a low-level compression will only result in decreased endoneurial circulation, neural edema and a Seddon's grade-IV weakness, but won't be revealed in nerve conduction or magnetic resonance imaging studies. Due to technical limitations, several clinical options to diagnose compression neuropathies in the upper extremity have been proposed. These include blinded-controlled studies on manual muscle testing to delineate level of nerve compression, and scratch-collapse test (SCT) to verify the level of compression. In this manuscript, we describe the clinical examination and surgical techniques to diagnose and treat entrapments of the axillary and radial nerves. Methods: A previously published clinical triad for diagnosis of nerve compressions has been employed: 1) manual muscle testing to reveal weakness in specific muscles distal to the level of nerve compression; 2) pain upon compression and/or positive Tinel's sign; and 3) positive SCT at the level of nerve compression. Results: Detailed videos illustrate the examination techniques to diagnose axillary entrapment in the shoulder and radial nerve entrapments in the upper-and forearm (four levels), as well as the surgical techniques of each nerve release. Conclusions: The clinical triad of muscle testing, SCT and pain at level of nerve compression provide the clinician with a clinical foundation to analyze patients with brachialgia in a structured fashion.

Journal of Orthopaedic Research, 2005

The purpose of this study was to analyze human wrist ligaments with regard to presence of general... more The purpose of this study was to analyze human wrist ligaments with regard to presence of general innervation and mechanoreceptors. The ligaments studied were: dorsal radiocarpal (DRC), dorsal intercarpal (DIC), long radiolunate (LRL), radioscaphocapitate (RSC), ulnocarpal (UC), scapholunate interosseous (SLI) and lunotriquetral interosseous (LTI) ligaments. Specific immunohistochemical markers were used to target neuraYperineuria1 structures. Both Ruffini and Pacini-like mechanoreceptors (sensory corpuscles) as well as nerve fascicleslfree nerve fibers were identified. Ruffini corpuscles were primarily identified via their dendritic intracapsular nerve endings, whereas the Pacini-like corpuscles were identified through their thick perineurial capsules with marked p75 immunoreaction. The wrist ligaments were found to vary in innervation, the DIC, DRC and SLI being richly innervated, whereas the LRL being almost without innervation. The difference in innervation between the ligaments might reflect differential function. Ligaments without innervation might act as structures of passive restraint, whereas ligaments with rich innervation are proposed to also provide proprioceptive information. Wrist ligament injuries should, therefore, be regarded as a disturbance not only of the intrinsic carpal kinematics, but also of the coordination and proprioception of the entire wrist joint. (S. Forsgren), bjorn-ove.ljung@sos.ki.se (B.-0. Lj ung) . 0736-02666see front matter 0

Hand Clinics, 2010

The authors describe the anatomy of the distal radioulnar joint (DRUJ) and delineate the importan... more The authors describe the anatomy of the distal radioulnar joint (DRUJ) and delineate the importance of viewing this joint as part of the whole forearm. The osseous congruity and ligamentous integrity is of essence for the stability of the DRUJ, according to the principles of tensegrity. The neuromuscular control and possible proprioceptive function of the DRUJ are also outlined.

Cells Tissues Organs, 2004

The scapholunate interosseous ligament (SLIL) is biomechanically important in maintaining wrist m... more The scapholunate interosseous ligament (SLIL) is biomechanically important in maintaining wrist motion and grip strength in the hand, but its possible sensory role in the dynamic muscular stability of the wrist joint has not been examined. The aim of this study was to use immunohistochemical methods to analyze the general innervation and the possible existence of sensory corpuscles in the SLIL. The ligament was excised in its entirety from 9 patients. Antibodies against the low-affinity p75 neurotrophic receptor (p75) were used to reveal sensory corpuscles as well as general innervation. Furthermore, antibodies against the general nerve marker protein gene product 9.5 (PGP 9.5) and the glial marker S-100 were used to additionally depict innervation and corpuscular structures. Blood vessels occurred in areas interspersed throughout the homogeneous collagenous structure. In these vascularized areas, the SLIL was found to be supplied with nerve fascicles and sensory corpuscles of both the Ruffini and lamellated type. p75 immunoreactivity (IR) was detected in association with the nerve fascicles and the corpuscles, particularly in their capsule. S-100 IR was found in the Schwann cells in the central regions of the corpuscle, and PGP 9.5 IR marked the axonal structures in the corpuscles. New information on neurotrophin receptor distribution in ligaments has been obtained here. The presence of nerve fascicles and particularly sensory corpuscles in the SLIL suggests that the ligament has a proprioceptive role in the stability of the wrist. The marked p75 IR further indicates that neurotrophins play a part in a proprioceptive system in the ligament, given the importance of neurotrophins in maintaining sensory function.

Foot and Ankle Surgery, 2016

Journal of Hand Surgery (European Volume), 2015

Stability of the thumb carpometacarpal joint relies upon equilibrium between its ligaments, muscu... more Stability of the thumb carpometacarpal joint relies upon equilibrium between its ligaments, muscular support and joint congruity. We wanted to identify the muscles important in preventing or increasing dorsoradial subluxation of this joint. In ten cadaveric hands, a Fastrak ® motion tracking device was used to assess the effects of individual isometric muscle loading on the base of the thumb metacarpal relative to the radius and to the base of the middle finger metacarpal. We found that the first dorsal interosseous muscle caused the least dorsoradial translation and highest distal migration of the base of the first metacarpal, whereas abductor pollicis longus was the primary destabilizer, increasing dorsoradial misalignment. The findings show different impacts of these muscles on joint alignment and stability, which suggests that treatment should be targeted to enhance the action of the primary stabilizing muscle, the first dorsal interosseous muscle.

Journal of Hand Surgery (European Volume), 2015

Revista Iberoamericana de Cirugía de la Mano, 2015

Recibido el 15 de abril de 2015. Aceptado el 16 de abril de 2015.

Journal of Hand Surgery (European Volume), 2015

ABSTRACT

Foot & Ankle International, 2015

Various ankle ligaments have different structural composition. The aim of this study was to analy... more Various ankle ligaments have different structural composition. The aim of this study was to analyze the morphological structure of ankle ligaments to further understand their function in ankle stability. One hundred forty ligaments from 10 fresh-frozen cadaver ankle joints were dissected: the calcaneofibular, anterior, and posterior talofibular ligaments; the inferior extensor retinaculum, the talocalcaneal oblique ligament, the canalis tarsi ligament; the deltoid ligament; and the anterior tibiofibular ligament. Hematoxylin-eosin and Elastica van Gieson stains were used for determination of tissue morphology. Three different morphological compositions were identified: dense, mixed, and interlaced compositions. Densely packed ligaments, characterized by parallel bundles of collagen, were primarily seen in the lateral region, the canalis tarsi, and the anterior tibiofibular ligaments. Ligaments with mixed tight and loose parallel bundles of collagenous connective tissue were mainly found in the inferior extensor retinaculum and talocalcaneal oblique ligament. Densely packed and fiber-rich interlacing collagen was primarily seen in the areas of ligament insertion into bone of the deltoid ligament. Ligaments of the lateral region, the canalis tarsi, and the anterior tibiofibular ligaments have tightly packed, parallel collagen bundles and thus can resist high tensile forces. The mixed tight and loose, parallel oriented collagenous connective tissue of the inferior extensor retinaculum and the talocalcaneal oblique ligament support the dynamic positioning of the foot on the ground. The interlacing collagen bundles seen at the insertion of the deltoid ligament suggest that these insertion areas are susceptible to tension in a multitude of directions. The morphology and mechanical properties of ankle ligaments may provide an understanding of their response to the loads to which they are subjected.

Congress Abstract Introduction Palmar midcarpal instability (PMCI) is a painful condition charact... more Congress Abstract Introduction Palmar midcarpal instability (PMCI) is a painful condition characterized by a kinematic dysfunction of the proximal carpal row (PCR). Although its etiology is still poorly understood, it is believed to be due to congenital (or traumatic) laxity of the ligaments that stabilize the PCR, primarily, the dorsal radiotriquetral (DRT) ligament and the ulnar arm of the palmar arcuate ligament. This laxity causes an unphysiologic coupling of the midcarpal joint, which is clinically evident as a painful clunk with ulnar wrist deviation. Most symptomatic PMCI patients benefit from nonoperative management, which is based on splinting and proprioceptive neuromuscular rehabilitation. However, patients that do not respond to nonoperative management are candidates for surgical treatment. Cases with mild to moderate symptoms may be treated with soft tissue procedures, such as dorsal capsular reefing (Lichtman, 2006) or arthroscopic shrinkage (Mason, 2007; Lichtman, 2003). The purpose of this study was to present our results with a personal technique of arthroscopic ligament plication (ALP) for PMCI.

J Wrist Surg, 2012

The wide-awake approach to hand surgery involves the subcutaneous and intra-articular injection o... more The wide-awake approach to hand surgery involves the subcutaneous and intra-articular injection of large volumes of diluted lidocaine and epinephrine in the forearm, wrist, hand, and fingers. Benefits include the deletion of the risks and inconveniences of general anesthesia and the ability to watch the patient take reconstructed hand tissues through an active range of motion for adjustment of the reconstruction before the skin is closed. Watching comfortable patient's active movement during the surgery has shown major benefit in allowing reduced rupture rates in flexor tendon repair, 2-5 as well as improved tension setting in tendon transfers. 6 Wide-awake surgery has Keywords ► arthroscopy ► local anesthesia ► proprioception ► TFCC ► wide-awake surgery ► wrist

Hand (N Y), 2013

Background Proximal median nerve entrapment (PMNE, or pronator syndrome) at the elbow has traditi... more Background Proximal median nerve entrapment (PMNE, or pronator syndrome) at the elbow has traditionally been considered an elusive and rare diagnosis, as it is seldom detectable using electrophysiological techniques. In this paper, the clinical manifestations, physical diagnosis, surgical technique, and results of surgical treatment of PMNE are presented, with accompanying instructional video. Patients/Methods During 2011, 44 patients with PMNE were surgically released and followed prospectively, 22 women/22 men, mean age 48.8 (range 25-66). The patients were equally distributed between right/left hands (23/21) and the dominant hand was treated in 56 % of cases. The diagnosis was based on: (1) weakness in median innervated muscles distal to the lacertus fibrosus; (2) pain upon pressure over the median nerve at the level of the lacertus fibrosus; and (3) positive scratch collapse test. A minimally invasive surgical treatment using only local anesthesia with lidocaine-epinephrine and no tourniquet was used, and direct perioperative return of strength in median innervated muscles was seen in all subjects. Results The average preoperative quick DASH was 35.4 (range 6.8-77.2); work DASH, 44.3 (6.25-100); and activity DASH, 61.6 (12.5-100). There were 71.1 % patients who completed the 6-month follow-up, and the average postoperative quick DASH was 12.7 (range 0-43.1), which is a statistically significant reduction (p<0.0001; Student's paired t test). Similarly, the work and activity DASH was significantly reduced (p<0.001) to 12.5 (0-75) and 6.25 (0-50), respectively. Conclusions PMNE at the level of the lacertus fibrosus should be called lacertus tunnel syndrome to distinguish it from other levels of median nerve entrapment. It is a clinical diagnosis based on three distinct clinical findings: weakness, pain over point of compression, and positive scratch collapse test. Surgical release in local anesthesia allows for a safe, ambulatory, and cost-efficient procedure with low morbidity.

Clin. Orthop. Relat. Res., 2014

Journal of Hand Therapy, 2010

Study Design: Narrative review. Recent years have brought new research findings on the subject of... more Study Design: Narrative review. Recent years have brought new research findings on the subject of wrist joint proprioception, which entails an understanding of the wrist as part of a sensorimotor system where afferent information from nerve endings in the wrist joint affects the neuromuscular control of the joint. An understanding of proprioception is also essential to adequately rehabilitate patients after wrist injuries. The aim of this narrative review was to give the reader a background of proprioception as it relates to neuromuscular control and joint stability, what is presently known in relation to the wrist joint and how these findings may be applied to the field of wrist rehabilitation.

The Journal of Hand Surgery, 2010

Purpose The posterior interosseous sensory nerve innervates the dorsal capsule of the wrist, whic... more Purpose The posterior interosseous sensory nerve innervates the dorsal capsule of the wrist, which may provide nociceptive and proprioceptive sensation. Posterior interosseous sensory neurectomy (PISN) is commonly used as a primary or adjunctive procedure to provide wrist analgesia for a variety of wrist conditions. Currently, there is little information in the literature regarding the proprioceptive role of the posterior interosseous sensory nerve and the resultant effects of PISN on wrist proprioception. The purpose of our investigation was to examine the effect of PISN on wrist proprioception.

Journal of Wrist Surgery, 2015

Congress Abstract Introduction Palmar midcarpal instability (PMCI) is a painful condition charact... more Congress Abstract Introduction Palmar midcarpal instability (PMCI) is a painful condition characterized by a kinematic dysfunction of the proximal carpal row (PCR). Although its etiology is still poorly understood, it is believed to be due to congenital (or traumatic) laxity of the ligaments that stabilize the PCR, primarily, the dorsal radiotriquetral (DRT) ligament and the ulnar arm of the palmar arcuate ligament. This laxity causes an unphysiologic coupling of the midcarpal joint, which is clinically evident as a painful clunk with ulnar wrist deviation. Most symptomatic PMCI patients benefit from nonoperative management, which is based on splinting and proprioceptive neuromuscular rehabilitation. However, patients that do not respond to nonoperative management are candidates for surgical treatment. Cases with mild to moderate symptoms may be treated with soft tissue procedures, such as dorsal capsular reefing (Lichtman, 2006) or arthroscopic shrinkage (Mason, 2007; Lichtman, 2003). The purpose of this study was to present our results with a personal technique of arthroscopic ligament plication (ALP) for PMCI.

Plastic and Reconstructive Surgery, 2014

Background: Non-traumatic pain in the shoulder, arm and hand (brachialgia) is a common complaint ... more Background: Non-traumatic pain in the shoulder, arm and hand (brachialgia) is a common complaint in the field of musculoskeletal disorders, where nerve entrapment constitutes a possible cause. The effect of nerve compression is dosedependent; hence a low-level compression will only result in decreased endoneurial circulation, neural edema and a Seddon's grade-IV weakness, but won't be revealed in nerve conduction or magnetic resonance imaging studies. Due to technical limitations, several clinical options to diagnose compression neuropathies in the upper extremity have been proposed. These include blinded-controlled studies on manual muscle testing to delineate level of nerve compression, and scratch-collapse test (SCT) to verify the level of compression. In this manuscript, we describe the clinical examination and surgical techniques to diagnose and treat entrapments of the axillary and radial nerves. Methods: A previously published clinical triad for diagnosis of nerve compressions has been employed: 1) manual muscle testing to reveal weakness in specific muscles distal to the level of nerve compression; 2) pain upon compression and/or positive Tinel's sign; and 3) positive SCT at the level of nerve compression. Results: Detailed videos illustrate the examination techniques to diagnose axillary entrapment in the shoulder and radial nerve entrapments in the upper-and forearm (four levels), as well as the surgical techniques of each nerve release. Conclusions: The clinical triad of muscle testing, SCT and pain at level of nerve compression provide the clinician with a clinical foundation to analyze patients with brachialgia in a structured fashion.

Journal of Orthopaedic Research, 2005

The purpose of this study was to analyze human wrist ligaments with regard to presence of general... more The purpose of this study was to analyze human wrist ligaments with regard to presence of general innervation and mechanoreceptors. The ligaments studied were: dorsal radiocarpal (DRC), dorsal intercarpal (DIC), long radiolunate (LRL), radioscaphocapitate (RSC), ulnocarpal (UC), scapholunate interosseous (SLI) and lunotriquetral interosseous (LTI) ligaments. Specific immunohistochemical markers were used to target neuraYperineuria1 structures. Both Ruffini and Pacini-like mechanoreceptors (sensory corpuscles) as well as nerve fascicleslfree nerve fibers were identified. Ruffini corpuscles were primarily identified via their dendritic intracapsular nerve endings, whereas the Pacini-like corpuscles were identified through their thick perineurial capsules with marked p75 immunoreaction. The wrist ligaments were found to vary in innervation, the DIC, DRC and SLI being richly innervated, whereas the LRL being almost without innervation. The difference in innervation between the ligaments might reflect differential function. Ligaments without innervation might act as structures of passive restraint, whereas ligaments with rich innervation are proposed to also provide proprioceptive information. Wrist ligament injuries should, therefore, be regarded as a disturbance not only of the intrinsic carpal kinematics, but also of the coordination and proprioception of the entire wrist joint. (S. Forsgren), bjorn-ove.ljung@sos.ki.se (B.-0. Lj ung) . 0736-02666see front matter 0

Hand Clinics, 2010

The authors describe the anatomy of the distal radioulnar joint (DRUJ) and delineate the importan... more The authors describe the anatomy of the distal radioulnar joint (DRUJ) and delineate the importance of viewing this joint as part of the whole forearm. The osseous congruity and ligamentous integrity is of essence for the stability of the DRUJ, according to the principles of tensegrity. The neuromuscular control and possible proprioceptive function of the DRUJ are also outlined.

Cells Tissues Organs, 2004

The scapholunate interosseous ligament (SLIL) is biomechanically important in maintaining wrist m... more The scapholunate interosseous ligament (SLIL) is biomechanically important in maintaining wrist motion and grip strength in the hand, but its possible sensory role in the dynamic muscular stability of the wrist joint has not been examined. The aim of this study was to use immunohistochemical methods to analyze the general innervation and the possible existence of sensory corpuscles in the SLIL. The ligament was excised in its entirety from 9 patients. Antibodies against the low-affinity p75 neurotrophic receptor (p75) were used to reveal sensory corpuscles as well as general innervation. Furthermore, antibodies against the general nerve marker protein gene product 9.5 (PGP 9.5) and the glial marker S-100 were used to additionally depict innervation and corpuscular structures. Blood vessels occurred in areas interspersed throughout the homogeneous collagenous structure. In these vascularized areas, the SLIL was found to be supplied with nerve fascicles and sensory corpuscles of both the Ruffini and lamellated type. p75 immunoreactivity (IR) was detected in association with the nerve fascicles and the corpuscles, particularly in their capsule. S-100 IR was found in the Schwann cells in the central regions of the corpuscle, and PGP 9.5 IR marked the axonal structures in the corpuscles. New information on neurotrophin receptor distribution in ligaments has been obtained here. The presence of nerve fascicles and particularly sensory corpuscles in the SLIL suggests that the ligament has a proprioceptive role in the stability of the wrist. The marked p75 IR further indicates that neurotrophins play a part in a proprioceptive system in the ligament, given the importance of neurotrophins in maintaining sensory function.

Foot and Ankle Surgery, 2016

Journal of Hand Surgery (European Volume), 2015

Stability of the thumb carpometacarpal joint relies upon equilibrium between its ligaments, muscu... more Stability of the thumb carpometacarpal joint relies upon equilibrium between its ligaments, muscular support and joint congruity. We wanted to identify the muscles important in preventing or increasing dorsoradial subluxation of this joint. In ten cadaveric hands, a Fastrak ® motion tracking device was used to assess the effects of individual isometric muscle loading on the base of the thumb metacarpal relative to the radius and to the base of the middle finger metacarpal. We found that the first dorsal interosseous muscle caused the least dorsoradial translation and highest distal migration of the base of the first metacarpal, whereas abductor pollicis longus was the primary destabilizer, increasing dorsoradial misalignment. The findings show different impacts of these muscles on joint alignment and stability, which suggests that treatment should be targeted to enhance the action of the primary stabilizing muscle, the first dorsal interosseous muscle.

Journal of Hand Surgery (European Volume), 2015

Revista Iberoamericana de Cirugía de la Mano, 2015

Recibido el 15 de abril de 2015. Aceptado el 16 de abril de 2015.

Journal of Hand Surgery (European Volume), 2015

ABSTRACT

Foot & Ankle International, 2015

Various ankle ligaments have different structural composition. The aim of this study was to analy... more Various ankle ligaments have different structural composition. The aim of this study was to analyze the morphological structure of ankle ligaments to further understand their function in ankle stability. One hundred forty ligaments from 10 fresh-frozen cadaver ankle joints were dissected: the calcaneofibular, anterior, and posterior talofibular ligaments; the inferior extensor retinaculum, the talocalcaneal oblique ligament, the canalis tarsi ligament; the deltoid ligament; and the anterior tibiofibular ligament. Hematoxylin-eosin and Elastica van Gieson stains were used for determination of tissue morphology. Three different morphological compositions were identified: dense, mixed, and interlaced compositions. Densely packed ligaments, characterized by parallel bundles of collagen, were primarily seen in the lateral region, the canalis tarsi, and the anterior tibiofibular ligaments. Ligaments with mixed tight and loose parallel bundles of collagenous connective tissue were mainly found in the inferior extensor retinaculum and talocalcaneal oblique ligament. Densely packed and fiber-rich interlacing collagen was primarily seen in the areas of ligament insertion into bone of the deltoid ligament. Ligaments of the lateral region, the canalis tarsi, and the anterior tibiofibular ligaments have tightly packed, parallel collagen bundles and thus can resist high tensile forces. The mixed tight and loose, parallel oriented collagenous connective tissue of the inferior extensor retinaculum and the talocalcaneal oblique ligament support the dynamic positioning of the foot on the ground. The interlacing collagen bundles seen at the insertion of the deltoid ligament suggest that these insertion areas are susceptible to tension in a multitude of directions. The morphology and mechanical properties of ankle ligaments may provide an understanding of their response to the loads to which they are subjected.

Congress Abstract Introduction Palmar midcarpal instability (PMCI) is a painful condition charact... more Congress Abstract Introduction Palmar midcarpal instability (PMCI) is a painful condition characterized by a kinematic dysfunction of the proximal carpal row (PCR). Although its etiology is still poorly understood, it is believed to be due to congenital (or traumatic) laxity of the ligaments that stabilize the PCR, primarily, the dorsal radiotriquetral (DRT) ligament and the ulnar arm of the palmar arcuate ligament. This laxity causes an unphysiologic coupling of the midcarpal joint, which is clinically evident as a painful clunk with ulnar wrist deviation. Most symptomatic PMCI patients benefit from nonoperative management, which is based on splinting and proprioceptive neuromuscular rehabilitation. However, patients that do not respond to nonoperative management are candidates for surgical treatment. Cases with mild to moderate symptoms may be treated with soft tissue procedures, such as dorsal capsular reefing (Lichtman, 2006) or arthroscopic shrinkage (Mason, 2007; Lichtman, 2003). The purpose of this study was to present our results with a personal technique of arthroscopic ligament plication (ALP) for PMCI.

J Wrist Surg, 2012

The wide-awake approach to hand surgery involves the subcutaneous and intra-articular injection o... more The wide-awake approach to hand surgery involves the subcutaneous and intra-articular injection of large volumes of diluted lidocaine and epinephrine in the forearm, wrist, hand, and fingers. Benefits include the deletion of the risks and inconveniences of general anesthesia and the ability to watch the patient take reconstructed hand tissues through an active range of motion for adjustment of the reconstruction before the skin is closed. Watching comfortable patient's active movement during the surgery has shown major benefit in allowing reduced rupture rates in flexor tendon repair, 2-5 as well as improved tension setting in tendon transfers. 6 Wide-awake surgery has Keywords ► arthroscopy ► local anesthesia ► proprioception ► TFCC ► wide-awake surgery ► wrist