Dean G. Sotereanos

Trapezium Resection With Suspension and Interposition Arthroplasty Using Acellular Dermal Allograft for Thumb Carpometacarpal Arthritis

PURPOSEnTrapezium excision with ligament reconstruction and tendon interposition has proved to be highly effective in the treatment of thumb carpometacarpal joint arthritis. Donor-site morbidity from autograft harvest can be avoided by using an allograft. We report the outcomes after suspension and interposition arthroplasty using an acellular dermal allograft (GraftJacket; Wright Medical Technology, Inc., Arlington, TN) for thumb carpometacarpal arthritis.nnnMETHODSnEighty-nine patients (100 thumbs) had surgery for thumb carpometacarpal arthritis using acellular dermal allograft instead of flexor carpi radialis tendon autograft. Evaluation of the results was performed for 82 thumbs with adequate data. Each patient was followed up for a minimum of 12 months (average, 30 months). Pain levels, grip strength, key pinch strength, range of motion, and radiographic measurements were performed.nnnRESULTSnBetween the preoperative and final follow-up measurements, patient pain levels (on a visual analog scale) were significantly reduced, from 6.2 to 0.7. Comparisons between preoperative and postoperative strength measurements showed an average 16% increase in grip strength and 19% increase in key pinch strength. No differences were found for radial abduction and palmar abduction data, respectively. Comparison with the preoperative x-rays showed the thumb metacarpal had subsided 31% of the arthroplasty space. No patient experienced a foreign body reaction or suffered an infection in our series.nnnCONCLUSIONSnTrapeziectomy with suspension and interposition arthroplasty using an acellular dermal allograft is highly effective for the treatment of thumb carpometacarpal arthritis. This procedure provides a safe and effective alternative to autograft for both ligament reconstruction and tendon interposition and eliminates the potential morbidity of autograft harvest.nnnTYPE OF STUDY/LEVEL OF EVIDENCEnTherapeutic IV.

Vein wrapping at cubital tunnel for ulnar nerve problems

BACKGROUNDnRecurrent compression of the ulnar nerve in the cubital tunnel is a difficult problem and many solutions have been tried with variable success. Autologous vein graft wrapping is an alternative technique and it is recommended for the treatment of recalcitrant ulnar nerve compression in which 2 or more previous surgical procedures have failed to resolve the problem.nnnMETHODSnSeventeen patients with recurrent cubital tunnel syndrome were treated with autologous saphenous vein wrapping. These patients had previously undergone simple decompression, decompression combined with medial epicondylectomy, anterior submuscular, or intramuscular transposition with internal neurolysis and had persistence of symptoms. Each patient underwent both subjective and objective evaluation.nnnRESULTSnOur clinical results on 17 patients have been encouraging. All patients reported significant pain relief, while improvements in grip strength and 2-point discrimination were also observed. There were no complications, other than transient leg swelling secondary to harvesting the saphenous vein graft from the leg.nnnCONCLUSIONnThis technique is not technically demanding, has low donor site morbidity, and leads to pain relief and high patient satisfaction.

The contracted elbow: is ulnar nerve release necessary?

BACKGROUNDnProphylactic release of the ulnar nerve in patients undergoing capsular release for severe elbow contractures has been recommended, although there are limited data to support this recommendation. Our hypothesis was that more severely limited preoperative flexion and extension would be associated with a higher incidence of postoperative ulnar nerve symptoms in patients undergoing capsular release.nnnMATERIALS AND METHODSnWe conducted a retrospective review of 164 consecutive patients who underwent open or arthroscopic elbow capsular release for stiffness between 2003 and 2010. The ulnar nerve was decompressed if the patient had preoperative ulnar nerve symptoms or a positive Tinel test. Preoperative and postoperative range of motion and incidence of ulnar nerve symptoms were recorded.nnnRESULTSnThe mean improvement in the arc of motion of was 36.7°. New-onset postoperative ulnar nerve symptoms developed in 7 of 87 patients (8.1%) who did not undergo ulnar nerve decompression; eventually, 5 of these patients with persistent symptoms underwent ulnar nerve decompression. The rate of developing postoperative symptoms was higher if patients had preoperative flexion ≤ 100° (15.2%) compared with those with preoperative flexion >100° (3.7%). There was no association between preoperative extension or gain in motion arc and postoperative symptoms.nnnCONCLUSIONSnThe overall rate of ulnar nerve symptoms after elbow contracture release was low if ulnar nerve decompression was performed in patients with preoperative symptoms or a positive Tinel test. There was a higher rate of ulnar nerve symptoms in patients with more severe contractures (≤ 100° of preoperative flexion), which did not reach statistical significance.

Biceps Tendon Injuries in Athletes

Although rare, athletes involved in competitive strength training and contact sports may sustain distal tendon biceps injuries. Treatment of complete distal biceps tendon ruptures in athletes is primarily surgical. Early repair, through either one-incision or two-incision techniques with anatomic reinsertion of the ruptured tendon to the bicipital tuberosity, is highly recommended. In this article the etiology and pathophysiology of distal biceps tendon ruptures, current diagnostic modalities, and surgical indications are discussed. Also, treatment options, surgical techniques, outcomes, and potential complications are reviewed.

Supplemental Graft Fixation for Distal Radius Vascularized Bone Graft

Vascularized bone grafts from the distal radius have been used successfully for the treatment of scaphoid nonunions. Typically, the harvested graft is secured into the scaphoid with a press-fit technique. This type of fixation may lead to graft extrusion in the early postoperative period, and thus to treatment failure. In this technical note, we describe the use of micro bone suture anchors for supplemental fixation of the vascularized bone graft into the scaphoid. It is a simple and quick technique and provides an enhanced fixation of the vascularized bone graft, which is beneficial during the early critical period of bone healing.

Fibrous dysplasia around the elbow

First named by Lichtenstein in 1938, fibrous dysplasia is a noninherited, skeletal developmental abnormality that commonly presents in adolescents and young adults. Normal marrow and cancellous bone are replaced and weakened by immature woven bone and a dense fibrotic stroma containing a disorganized matrix of bony trabecular spicules. Fibrous dysplasia accounts approximately for 5% to 7% of benign bone tumors. It may be monostotic, accounting for 70% to 80% of cases, or polyostotic. Fibrous dysplasia frequently occurs in the ribs, femur, tibia, skull, pelvis, spine and shoulder. Within the long bones, the lesions are predominately diaphyseal, with an epiphyseal lesion rarely occurring. Radiographically, they are classically described by their ‘‘ground glass’’ appearance because they are well circumscribed, radiolucent lesions with a hazy quality to them. These lesions compromise the structural integrity of the involved bone and may lead to a bowing deformity in weight-bearing bones, hence the ‘‘shepherds crook’’ deformity describing coxa vara in the femur. Surgical treatment of fibrous dysplasia is palliative, the main goals being to limit pain and deformity and prevent pathologic fracture. Fractures through a lesion often heal without difficulty but are susceptible to repeat fracture because of the dysplastic nature of the bony callus that forms. Indications for surgery include nonunion, progressive deformity, or persistent pain. Surgical options include curettage and bone grafting (either cortical or cancellous), open reduction and internal fixation (ORIF), and vascularized bone grafts.