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Papers by Vigneswaran Varadharajan
The Journal of Hand Surgery, Oct 1, 2022
The Journal of Hand Surgery (Asian-Pacific Volume)
The advent of nerve transfers has revolutionised the treatment of brachial plexus and peripheral ... more The advent of nerve transfers has revolutionised the treatment of brachial plexus and peripheral nerve injuries of the upper extremity. Nerve transfers offer faster reinnervation of a denervated muscle by taking advantage of a donor nerve, branch or fascicle close to the recipient muscle. A number of considerations in respect of donor selection for nerve transfers underlie their success. In this review article, we discuss the principles of donor selection for nerve transfers, the different options available and our considerations in choosing a suitable transfer in reanimating the elbow and the shoulder. We feel this will help nerve surgeons navigate the controversies in the selection of donor nerves and make appropriate treatment decisions for their patients. Level of Evidence: V (Therapeutic)
The Journal of Hand Surgery (Asian-Pacific Volume)
Background: A deficit of external rotation of the shoulder is a common sequelae of brachial plexu... more Background: A deficit of external rotation of the shoulder is a common sequelae of brachial plexus injury (BPI). This internally rotated posture of the limb becomes more apparent and functionally limiting once the patient recovers elbow flexion resulting in the hand striking the abdomen on attempted flexion (‘tummy flexion’). This precludes hand-to-mouth reach, resulting in an inability to eat with the involved hand. The aim of this study is to present the outcomes of an external rotation osteotomy of the humerus in adult BPI. Methods: All BPI patients who underwent an external rotation osteotomy of the humerus at our institution over a 5-year period from January 2015 to December 2020 were included in this study. Data with regard to the age, gender, type of BPI, time from injury to nerve surgery and from nerve surgery till external rotation osteotomy, degree of pre- and postoperative external rotation, time to union, patient satisfaction and complications were recorded. Results: The...
The Journal of Hand Surgery (Asian-Pacific Volume)
Background: The presence of a separate compartment for the extensor pollicis brevis tendon (EPB) ... more Background: The presence of a separate compartment for the extensor pollicis brevis tendon (EPB) has an implication in the treatment outcome for de Quervain disease. The EPB entrapment test, proposed by Alexander and colleagues, claims to correlate with the presence of a separate compartment for EPB. The purpose of our study is to evaluate the reliability of the EPB entrapment test in predicting a separate compartment for EPB in patients with de Quervain disease. Methods: This was a prospective observational study involving 50 consecutive patients who underwent de Quervain release by a single surgeon. Preoperatively, EPB entrapment test was performed by the operating surgeon. The outcome of the test was recorded and the presence of a separate compartment for the EPB was determined during surgery. Sensitivity, specificity, positive predictive value and negative predictive value of the EPB entrapment test was determined. Results: EPB entrapment test was positive in 28 of 50 patients. ...
The Journal of Hand Surgery (Asian-Pacific Volume)
The usual recommendation in posterior interosseous nerve (PIN) palsy is to use the flexor carpi r... more The usual recommendation in posterior interosseous nerve (PIN) palsy is to use the flexor carpi radialis instead of the flexor carpi ulnaris (FCU) for restoration of digital extension. The use of FCU takes away the only remaining ulnar deviator of the wrist. Although preserving the FCU prevents severe radial deviation deformity, we found that some patients still develop a radial deviation deformity, especially during wrist extension. We have used a brachioradialis (BR) to extensor carpi ulnaris (ECU) transfer to prevent the development of a radial deviation deformity and find that it restores the normal radio-ulnar balance of the wrist by providing a dynamic ulnar stabiliser. It is a simple addition to the standard two tendon transfers for PIN palsy with minimal donor morbidity. We have used this triple transfer for PIN palsy in seven patients with satisfactory results and no complications. Level of Evidence: Level V (Therapeutic)
The Journal of Hand Surgery (Asian-Pacific Volume)
Background: Isolated lower (C8T1) brachial plexus injury (BPI) is uncommon and the aim of treatme... more Background: Isolated lower (C8T1) brachial plexus injury (BPI) is uncommon and the aim of treatment is to achieve a satisfactory grasp enabling the use of the hand for daily activities. The aim of this study is to report the outcomes of the transfer of brachioradialis (BR) to flexor pollicis longus (FPL) and biceps to the flexor digitorum profundus (FDP) for an isolated lower BPI. Methods: This is a retrospective study of all patients with an isolated lower BPI who underwent a BR to FPL and biceps to FDP transfer for restoration of digital flexion over a 1-year period from May 2019 to June 2020. Patient demographic and injury data were collected at the presentation. Outcomes data included the ability to grasp and perform activities of daily living and DASH score. Results: The study included three patients (all men) with an average age of 30.3 years. All sustained an isolated lower BPI following a road traffic accident and tendon transfers were performed at a mean of 9.3 months after...
The Journal of Hand Surgery (Asian-Pacific Volume)
Motor deficit in patients with extended upper brachial plexus palsy is variable. A patient with o... more Motor deficit in patients with extended upper brachial plexus palsy is variable. A patient with only thumb and finger extensors may seem to have active wrist extension because of them secondarily acting at wrist and causing wrist extension. To determine the presence of wrist extensors, it is important to block the wrist extension caused by the finger and thumb extensors. Conventional muscle testing is often ineffective in these patients as they learn a variety of trick movements over the time. We describe a simple clinical test to reveal the strength of the wrist extensors only by negating the effect of digital extensors on the wrist. If wrist extensors are absent, a nerve or tendon transfer can be done to address this deficit and improve the functional outcome. Level of Evidence: Level V (Diagnostic)
The Journal of Hand Surgery (Asian-Pacific Volume), 2021
Kienbock’s disease remains a condition of uncertain etiology and our understanding about the path... more Kienbock’s disease remains a condition of uncertain etiology and our understanding about the pathogenesis is still evolving. However, a lack of consensus on the treatment is the most striking as there are wide array of treatment options described ranging from ‘doing nothing’ to a free vascularized bone graft reconstruction of the lunate. Furthermore, most treatment modalities report equivalent success rate but cumulative evidence is lacking. This ‘black hole’ in the literature presents difficulties to surgeons treating the condition and even patient’s confidence with the treatment. All the treatment options described reliably relieve pain, thus improving function and patient satisfaction. However, the disease process is not reliably altered by any of the treatment options described till date. The operative treatment chosen depends on the stage of the disease, ulnar variance, age of the patient and surgeon preference. The treatment options in early stage (before lunate collapse) aim ...
Indian Journal of Plastic Surgery : Official Publication of the Association of Plastic Surgeons of India, 2021
Replantation of digital amputations is now the accepted standard of care. However, rarely will a ... more Replantation of digital amputations is now the accepted standard of care. However, rarely will a replantation surgeon be presented with amputated fingers which have been previously replanted. In our literature search, we could find only one publication where a replanted thumb suffered amputation and was successfully replanted again. We report the technical challenges and the outcome of replanting two fingers which suffered amputation 40 months after the initial replantation and were successfully replanted again. Replantation was critical since the amputated fingers were the only two complete fingers in that hand which had initially suffered a four-finger amputation. The second-time replantation of previously replanted fingers is reported to allay the concern of the reconstructive surgeon when faced with this unique situation of “repeat amputation of the replanted finger.” Second-time replantation is feasible and is associated with high-patient satisfaction. Replantation must be atte...
The Journal of Hand Surgery, 2018
Mean postoperative length of stay (LOS) was significantly longer for the control group (20.2 AE 1... more Mean postoperative length of stay (LOS) was significantly longer for the control group (20.2 AE 11.2 hours) than the ketorolac group (13.5 AE 8.8 hours, P < .001). There was no difference in the 90-day complication rate between patients in the ketorolac group and the control group (P ¼ .905). Summary Points: There is a need for improved narcotic stewardship in orthopedic surgery. The complementary administration of ketorolac reduces postoperative pain and opioid use in children with displaced supracondylar humerus fractures. Ketorolac use reduces length of stay following CRPP for supracondylar humerus fractures and offers an opportunity for cost savings.
Indian Journal of Plastic Surgery, 2020
Extensor indicis proprius (EIP) tendon transfer is a standard operation for restoration of the th... more Extensor indicis proprius (EIP) tendon transfer is a standard operation for restoration of the thumb extension following rupture of extensor pollicis longus (EPL). In its standard form often the EIP is transferred to the EPL without inspection of the extensor tendons in the fourth compartment and it is retained in its anatomical fourth compartment. However, in a setting of EPL rupture in relation to the distal radius fracture (with or without fixation), concomitant injury to the extensor tendons to the index finger may result in failure of the transfer and even a loss of index finger extension (index finger drop) further complicating the reconstruction and resulting in immense patient dissatisfaction. We herein present two such rare cases to highlight this clinical scenario and how an awareness of this possibility and inspection of the extensor tendons to the index finger before EIP transfer allowed us to prevent this complication. In essence, if we know it, we can prevent it.
Hand Clinics, 2020
Adipofascial turnover flap is an excellent option for coverage for dorsal defects of the digits. ... more Adipofascial turnover flap is an excellent option for coverage for dorsal defects of the digits. The flap is based on the constant branches arising from the proper digital artery along the proximal and middle phalanges. It is a robust and pliable flap that can be folded on itself to fill dead spaces with minimal donor site morbidity. Transposition flaps are raised adjacent to the defect and moved sideways into the defect to cover it. They may be based distally, proximally, or laterally and typically require skin grafting of the donor site. The finger only allows narrow flaps to be raised. Rotation flaps are raised along the side of the defect. The flap uses laxity of the adjoining tissues for tension-free linear closure of the primary as well as the secondary defect. The flap rotates as a semicircle with a point of rotation being adjacent to the defect. Typically this flap is useful for small localized defects, such as those overlying the joint.
Journal of Clinical Orthopaedics and Trauma, 2019
Flexor tendon injuries have constituted a large portion of the literature in hand surgery over ma... more Flexor tendon injuries have constituted a large portion of the literature in hand surgery over many years. Yet many controversies remain and the techniques of surgery and therapy are still evolving. The anatomical and finer technical considerations involved in treating these injuries have been put forth and discussed in detail including the rehabilitation following the flexor tendon repair. The authors consider, recognition and mastery of these facts form the foundation for a successful flexor tendon repair. The trend is now towards multiple strand core sutures followed by early active mobilization. However, the rehabilitation process appears to be one of the major determinant of the success following a flexor tendon repair. Early mobilization is essential for all the flexor tendon repairs as it is proved to improve the quality of the repaired tendon. The art of achieving the harmony between a stronger repair and unhindered gliding of the repair site through the narrow flexor tendon sheath simultaneously can be mastered with practice added to the knowledge of the basic principles. © 2019 2.2. Pulley system There is a fibrous flexor sheath surrounding the tendon extending from the neck of the metacarpal to the base of the distal phalanx. At certain places, the sheath is thickened, called the pulleys.
Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India
The Journal of Hand Surgery, Oct 1, 2022
The Journal of Hand Surgery (Asian-Pacific Volume)
The advent of nerve transfers has revolutionised the treatment of brachial plexus and peripheral ... more The advent of nerve transfers has revolutionised the treatment of brachial plexus and peripheral nerve injuries of the upper extremity. Nerve transfers offer faster reinnervation of a denervated muscle by taking advantage of a donor nerve, branch or fascicle close to the recipient muscle. A number of considerations in respect of donor selection for nerve transfers underlie their success. In this review article, we discuss the principles of donor selection for nerve transfers, the different options available and our considerations in choosing a suitable transfer in reanimating the elbow and the shoulder. We feel this will help nerve surgeons navigate the controversies in the selection of donor nerves and make appropriate treatment decisions for their patients. Level of Evidence: V (Therapeutic)
The Journal of Hand Surgery (Asian-Pacific Volume)
Background: A deficit of external rotation of the shoulder is a common sequelae of brachial plexu... more Background: A deficit of external rotation of the shoulder is a common sequelae of brachial plexus injury (BPI). This internally rotated posture of the limb becomes more apparent and functionally limiting once the patient recovers elbow flexion resulting in the hand striking the abdomen on attempted flexion (‘tummy flexion’). This precludes hand-to-mouth reach, resulting in an inability to eat with the involved hand. The aim of this study is to present the outcomes of an external rotation osteotomy of the humerus in adult BPI. Methods: All BPI patients who underwent an external rotation osteotomy of the humerus at our institution over a 5-year period from January 2015 to December 2020 were included in this study. Data with regard to the age, gender, type of BPI, time from injury to nerve surgery and from nerve surgery till external rotation osteotomy, degree of pre- and postoperative external rotation, time to union, patient satisfaction and complications were recorded. Results: The...
The Journal of Hand Surgery (Asian-Pacific Volume)
Background: The presence of a separate compartment for the extensor pollicis brevis tendon (EPB) ... more Background: The presence of a separate compartment for the extensor pollicis brevis tendon (EPB) has an implication in the treatment outcome for de Quervain disease. The EPB entrapment test, proposed by Alexander and colleagues, claims to correlate with the presence of a separate compartment for EPB. The purpose of our study is to evaluate the reliability of the EPB entrapment test in predicting a separate compartment for EPB in patients with de Quervain disease. Methods: This was a prospective observational study involving 50 consecutive patients who underwent de Quervain release by a single surgeon. Preoperatively, EPB entrapment test was performed by the operating surgeon. The outcome of the test was recorded and the presence of a separate compartment for the EPB was determined during surgery. Sensitivity, specificity, positive predictive value and negative predictive value of the EPB entrapment test was determined. Results: EPB entrapment test was positive in 28 of 50 patients. ...
The Journal of Hand Surgery (Asian-Pacific Volume)
The usual recommendation in posterior interosseous nerve (PIN) palsy is to use the flexor carpi r... more The usual recommendation in posterior interosseous nerve (PIN) palsy is to use the flexor carpi radialis instead of the flexor carpi ulnaris (FCU) for restoration of digital extension. The use of FCU takes away the only remaining ulnar deviator of the wrist. Although preserving the FCU prevents severe radial deviation deformity, we found that some patients still develop a radial deviation deformity, especially during wrist extension. We have used a brachioradialis (BR) to extensor carpi ulnaris (ECU) transfer to prevent the development of a radial deviation deformity and find that it restores the normal radio-ulnar balance of the wrist by providing a dynamic ulnar stabiliser. It is a simple addition to the standard two tendon transfers for PIN palsy with minimal donor morbidity. We have used this triple transfer for PIN palsy in seven patients with satisfactory results and no complications. Level of Evidence: Level V (Therapeutic)
The Journal of Hand Surgery (Asian-Pacific Volume)
Background: Isolated lower (C8T1) brachial plexus injury (BPI) is uncommon and the aim of treatme... more Background: Isolated lower (C8T1) brachial plexus injury (BPI) is uncommon and the aim of treatment is to achieve a satisfactory grasp enabling the use of the hand for daily activities. The aim of this study is to report the outcomes of the transfer of brachioradialis (BR) to flexor pollicis longus (FPL) and biceps to the flexor digitorum profundus (FDP) for an isolated lower BPI. Methods: This is a retrospective study of all patients with an isolated lower BPI who underwent a BR to FPL and biceps to FDP transfer for restoration of digital flexion over a 1-year period from May 2019 to June 2020. Patient demographic and injury data were collected at the presentation. Outcomes data included the ability to grasp and perform activities of daily living and DASH score. Results: The study included three patients (all men) with an average age of 30.3 years. All sustained an isolated lower BPI following a road traffic accident and tendon transfers were performed at a mean of 9.3 months after...
The Journal of Hand Surgery (Asian-Pacific Volume)
Motor deficit in patients with extended upper brachial plexus palsy is variable. A patient with o... more Motor deficit in patients with extended upper brachial plexus palsy is variable. A patient with only thumb and finger extensors may seem to have active wrist extension because of them secondarily acting at wrist and causing wrist extension. To determine the presence of wrist extensors, it is important to block the wrist extension caused by the finger and thumb extensors. Conventional muscle testing is often ineffective in these patients as they learn a variety of trick movements over the time. We describe a simple clinical test to reveal the strength of the wrist extensors only by negating the effect of digital extensors on the wrist. If wrist extensors are absent, a nerve or tendon transfer can be done to address this deficit and improve the functional outcome. Level of Evidence: Level V (Diagnostic)
The Journal of Hand Surgery (Asian-Pacific Volume), 2021
Kienbock’s disease remains a condition of uncertain etiology and our understanding about the path... more Kienbock’s disease remains a condition of uncertain etiology and our understanding about the pathogenesis is still evolving. However, a lack of consensus on the treatment is the most striking as there are wide array of treatment options described ranging from ‘doing nothing’ to a free vascularized bone graft reconstruction of the lunate. Furthermore, most treatment modalities report equivalent success rate but cumulative evidence is lacking. This ‘black hole’ in the literature presents difficulties to surgeons treating the condition and even patient’s confidence with the treatment. All the treatment options described reliably relieve pain, thus improving function and patient satisfaction. However, the disease process is not reliably altered by any of the treatment options described till date. The operative treatment chosen depends on the stage of the disease, ulnar variance, age of the patient and surgeon preference. The treatment options in early stage (before lunate collapse) aim ...
Indian Journal of Plastic Surgery : Official Publication of the Association of Plastic Surgeons of India, 2021
Replantation of digital amputations is now the accepted standard of care. However, rarely will a ... more Replantation of digital amputations is now the accepted standard of care. However, rarely will a replantation surgeon be presented with amputated fingers which have been previously replanted. In our literature search, we could find only one publication where a replanted thumb suffered amputation and was successfully replanted again. We report the technical challenges and the outcome of replanting two fingers which suffered amputation 40 months after the initial replantation and were successfully replanted again. Replantation was critical since the amputated fingers were the only two complete fingers in that hand which had initially suffered a four-finger amputation. The second-time replantation of previously replanted fingers is reported to allay the concern of the reconstructive surgeon when faced with this unique situation of “repeat amputation of the replanted finger.” Second-time replantation is feasible and is associated with high-patient satisfaction. Replantation must be atte...
The Journal of Hand Surgery, 2018
Mean postoperative length of stay (LOS) was significantly longer for the control group (20.2 AE 1... more Mean postoperative length of stay (LOS) was significantly longer for the control group (20.2 AE 11.2 hours) than the ketorolac group (13.5 AE 8.8 hours, P < .001). There was no difference in the 90-day complication rate between patients in the ketorolac group and the control group (P ¼ .905). Summary Points: There is a need for improved narcotic stewardship in orthopedic surgery. The complementary administration of ketorolac reduces postoperative pain and opioid use in children with displaced supracondylar humerus fractures. Ketorolac use reduces length of stay following CRPP for supracondylar humerus fractures and offers an opportunity for cost savings.
Indian Journal of Plastic Surgery, 2020
Extensor indicis proprius (EIP) tendon transfer is a standard operation for restoration of the th... more Extensor indicis proprius (EIP) tendon transfer is a standard operation for restoration of the thumb extension following rupture of extensor pollicis longus (EPL). In its standard form often the EIP is transferred to the EPL without inspection of the extensor tendons in the fourth compartment and it is retained in its anatomical fourth compartment. However, in a setting of EPL rupture in relation to the distal radius fracture (with or without fixation), concomitant injury to the extensor tendons to the index finger may result in failure of the transfer and even a loss of index finger extension (index finger drop) further complicating the reconstruction and resulting in immense patient dissatisfaction. We herein present two such rare cases to highlight this clinical scenario and how an awareness of this possibility and inspection of the extensor tendons to the index finger before EIP transfer allowed us to prevent this complication. In essence, if we know it, we can prevent it.
Hand Clinics, 2020
Adipofascial turnover flap is an excellent option for coverage for dorsal defects of the digits. ... more Adipofascial turnover flap is an excellent option for coverage for dorsal defects of the digits. The flap is based on the constant branches arising from the proper digital artery along the proximal and middle phalanges. It is a robust and pliable flap that can be folded on itself to fill dead spaces with minimal donor site morbidity. Transposition flaps are raised adjacent to the defect and moved sideways into the defect to cover it. They may be based distally, proximally, or laterally and typically require skin grafting of the donor site. The finger only allows narrow flaps to be raised. Rotation flaps are raised along the side of the defect. The flap uses laxity of the adjoining tissues for tension-free linear closure of the primary as well as the secondary defect. The flap rotates as a semicircle with a point of rotation being adjacent to the defect. Typically this flap is useful for small localized defects, such as those overlying the joint.
Journal of Clinical Orthopaedics and Trauma, 2019
Flexor tendon injuries have constituted a large portion of the literature in hand surgery over ma... more Flexor tendon injuries have constituted a large portion of the literature in hand surgery over many years. Yet many controversies remain and the techniques of surgery and therapy are still evolving. The anatomical and finer technical considerations involved in treating these injuries have been put forth and discussed in detail including the rehabilitation following the flexor tendon repair. The authors consider, recognition and mastery of these facts form the foundation for a successful flexor tendon repair. The trend is now towards multiple strand core sutures followed by early active mobilization. However, the rehabilitation process appears to be one of the major determinant of the success following a flexor tendon repair. Early mobilization is essential for all the flexor tendon repairs as it is proved to improve the quality of the repaired tendon. The art of achieving the harmony between a stronger repair and unhindered gliding of the repair site through the narrow flexor tendon sheath simultaneously can be mastered with practice added to the knowledge of the basic principles. © 2019 2.2. Pulley system There is a fibrous flexor sheath surrounding the tendon extending from the neck of the metacarpal to the base of the distal phalanx. At certain places, the sheath is thickened, called the pulleys.
Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India