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A persistent challenge that has limited access and delivery of digit replantation surgery is timing, as ischemia time has traditionally been considered an important determinant of success. However, reports that the viability of amputated digits decreases after 6 hours of warm ischemia and 12 hours of cold ischemia are largely anecdotal. This review evaluates the quality and generalizability of available evidence regarding ischemia times after digit amputation and reported outcomes of “delayed” replantation. We identify substantial limitations in the literature supporting ischemia time cutoffs and recent evidence supporting the feasibility of delayed digit replantation. The current treatment approach for amputation injuries often necessitates transfers or overnight emergency procedures that increase costs and limit availability of digit replantation nationwide. Evidence-based changes to digit replantation protocols could lead to broader availability of this service, as well as improved care quality.

Purpose To retrospectively evaluate patients with 6-year minimum follow-up after submuscular transposition of the ulnar nerve for primary entrapment. Methods From 1992 to 2005, 142 patients were treated surgically for ulnar neuropathy at the elbow by 2 senior surgeons using a technique that preserved nerve vascularity. A total of 99 cases were eligible, and 82 elbows in 76 patients, average age 48 years, were followed for at least 6 years (average, 8.3 y). Thirty-two (42%) were male, and the dominant limb was involved in 49 (64%). The average duration of symptoms before surgery was 25 months. Clinical records were reviewed, and sensory (S0–2) and motor (M0–5) testing was performed. Dellon scores were determined, and visual analog scale and modified questionnaires from Novak et al and Kleinman and Bishop were completed. Preoperatively, 48 elbows were Dellon grade III, 33 were grade II, and one was grade I. Results There were clinically and statistically significant improvements in patient and surgeon-reported data regardless of the preoperative disease severity. Visual analog scale questionnaires, sensory scale, and motor strength all improved, with at least antigravity strength in all subjects. Dellon scores also improved, and 38 elbows had normalized to Dellon 0. Of the 33 preoperative elbows that were grade III, 15 improved to grade II, 13 to grade I, and 5 normalized. Of the 48 preoperative elbows that were grade II, 16 improved to grade I and 32 normalized. Preoperative Dellon III elbows had more residual symptoms than grade II elbows. A total of 73 elbows (89%) had a good or excellent outcome. There were no reoperations or infections. Conclusions Submuscular transposition is a safe and durable option for primary ulnar neuropathy at the elbow. Overall, good or excellent results were achieved in 89% of patients with a low complication rate. Type of study/level of evidence Therapeutic IV.

Background This study attempts to confirm that the Disabilities of Arm, Shoulder and Hand (DASH) Outcome Measure self-administered questionnaire is valid specifically for ulnar neuropathy at the elbow. Validity of the Levine-Katz questionnaire for ulnar neuropathology compared with DASH was also studied. Materials and methods Forty-eight patients with isolated ulnar nerve surgery completed a 6-month evaluation. Patients were assigned a clinical stage. The DASH and Levine-Katz questionnaires were administered, and pinch and grip strength were measured preoperatively and postoperatively. Levine-Katz questionnaires were correlated with DASH to establish criterion validity. Construct validity was tested by determining a relationship between scores and clinical stages and by comparing scores preoperatively and postoperatively. Results There was a high correlation between DASH scores and symptom severity and functional status. Although correlations were significant between DASH and biomechanical measures, correlation coefficients were lower. Postoperatively, all measures improved significantly. Conclusion This study confirms that scores on the DASH questionnaire reflect the clinical staging of ulnar neuropathy at the elbow. Level of evidence Level 1.

Purpose Timely identification of tissue ischemia is critical, both in the traumatized limb and following free tissue transfer. The purpose of this study was to determine if skin pigmentation affects the ability to detect limb ischemia. Methods We conducted a study of healthy controls exposed to limb ischemia. The subjects were classified based on skin pigmentation using a defined skin type assessment tool, a visual color scale, and self-description of race. Participants were randomized by limb and tourniquet status; surgeons were blinded to both. Ischemia was induced by tourniquet insufflations, and board-certified orthopedic and plastic surgeons who had completed an accredited hand surgery fellowship conducted physical examinations. The surgeons monitored the forearms at 2, 6, and 10 minutes based on appearance of ischemia, capillary refill, and color in 3 locations on the limbs (posterior interosseous artery flap skin territory, radial forearm flap skin territory, and the digits). Results We found a significant decrease in the ability to detect ischemia in participants with increased skin pigmentation, as documented by all metrics, when evaluating the posterior interosseous artery and radial forearm flap skin territories at all time points. For example, when monitoring the posterior interosseous artery flap with the tourniquet insufflated at time 10 minutes, 92.9% of Caucasians were correctly identified as being ischemic whereas only 23.3% of African Americans were correctly identified. Conclusions Skin pigmentation significantly affects the identification of an ischemic limb/skin flaps on physical examination. Whereas the standard treatment for monitoring of free tissue transfer is clinical examination, that may not be sufficient for patients with increased skin pigmentation. Surgeons should exercise particular vigilance during physical examination of a potentially ischemic limb/skin flaps with greater skin pigmentation. Type of study/level of evidence Diagnostic II.

20 40 60 80 100 Citation n 0 10 20 30 40 50 60 70 80 90 100 The Quality of Randomized Controlled Trials in Hand, Wrist and Elbow Surgery: A Critical Analysis of Current Literature James P. Higgins, Jaehon M. Kim, Ryan M. Zimmerman, Christopher M. Jones, Norman H. Dubin, Frank M. McCormick and Kenneth R. Means ** No funding was received in support of this project. The authors have no relevant financial disclosures. ** BACKGROUND