Jeffrey A. Greenberg

Salvage of the failed Darrach procedure

Six patients (5 post-traumatic, 1 rheumatoid) underwent a three-component reconstruction for correction of dorsal instability and radioulnar impingement following failure of a Darrach resection of the entire distal end of the ulna. The technique was devised to prevent simultaneous coronal and sagittal instability. The procedure used longitudinal intramedullary tenodesis of the extensor carpi ulnaris tendon, dorsal transfer of the pronator quadratus through the interosseous space, and temporary percutaneous pinning to maintain corrected distal radioulnar relationship. The were evaluated for 11 to 39 months (average, 20 months) following reconstruction. The preoperative wrist extension-flexion arc was preserved following surgery; there was a minimal loss of radial and ulnar deviation. The arc of forearm rotation increased 24 degrees to a range equal to 95% of the rotational arc of the opposite, unoperated wrist. Postoperative grip strength improved to an average value of 65 lb., two and one half times the preoperative value, representing 80% of the value for the opposite extremity. Four patients were able to return to their previous employment. All patients achieved pain-free forearm rotation and relief of their preoperative complaints of painful mechanical popping, clicking, and catching.

Clinical Outcomes of Scaphoid and Triquetral Excision With Capitolunate Arthrodesis Versus Scaphoid Excision and Four-Corner Arthrodesis

PURPOSE To compare the clinical outcomes of scaphoid and triquetral excision combined with capitolunate arthrodesis versus 4-corner (capitate, hamate, lunate, triquetrum) intercarpal arthrodesis. METHODS We retrospectively identified 50 patients with scapholunate advanced collapse wrist changes who had 4-corner arthrodesis. Thirty-four patients were able to return and complete all follow-up evaluations. Patient demographics were similar between the 2 groups. Follow-up evaluation included radiographs, wrist range of motion (flexion-extension, radial-ulnar deviation, and pronation-supination); grip strength; visual analog scale (VAS); and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Complications of nonunion, hardware migration, conversion to wrist arthrodesis or arthroplasty, and pisotriquetral arthritis were recorded. RESULTS Sixteen patients had capitolunate arthrodesis, and 18 patients had a 4-corner arthrodesis. There was no statistical difference in radial-ulnar deviation, pronation-supination, grip strength, VAS, or DASH scores between groups. There was a slight increase in flexion-extension in the 4-corner group. There were 2 nonunions in the 4-corner group and none in the capitolunate group. Five patients in the capitolunate group required screw removal secondary to migration. Three patients in the 4-corner group required a subsequent pisiform excision. CONCLUSIONS Capitolunate arthrodesis compares favorably to 4-corner arthrodesis at an average 3-year follow-up in this series with respect to range of motion, grip strength, DASH scores, and VAS. Advantages of capitolunate arthrodesis include a lessened need for bone graft harvesting while maintaining a similarly low nonunion rate, easier reduction of the lunate following triquetral excision, and avoiding subsequent symptomatic pisotriquetral arthritis. Screw migration, however, remains a concern with this technique. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

X-ray changes after expanded polytetrafluoroethylene (gore-tex) interpositional arthroplasty

Thirty-one patients with degenerative osteoarthritis at the trapeziometacarpal joint underwent 34 expanded polytetrafluoroethylene interpositional arthroplasties. The average follow-up period for the group of patients was 41 months (range, 15-82 months). Subjective results and objective measurements for the patients at the time of review were favorable. X-ray analysis, however, revealed a high incidence of osteolytic lesions associated with microparticulate degeneration consistent with reactive particulate synovitis. Owing to the unacceptably high rate of secondary osteolysis, the authors recommend that use of this material for trapeziometacarpal or pantrapezial arthroplasty be abandoned.

Endobutton Repair of Distal Biceps Tendon Ruptures

Anatomic reconstruction is now recognized as the optimal treatment for distal biceps ruptures to maximize functional upper extremity potential. Reconstruction minimizes the loss of flexion and supination strength and endurance that is associated with neglected or untreated ruptures. A single-incision, anterior approach for reconstruction of distal ruptures is facilitated by the use of a titanium button that is anchored to the end of the tendon and then engaged on the posterior proximal radius. This construct has been shown to have superior strength, facilitating early rehabilitation and return to activity.

Achilles allograft interposition for failed Darrach distal ulna resections.

Many treatment options exist for the symptomatic patient with a failed Darrach distal ulna resection. Tendon transfers, osteoplasties, soft tissue interpositions, and combinations have been used to mitigate the symptoms of impingement. Recently, implant arthroplasty of the distal ulna has become a favorable option for treating the patient with a symptomatic distal ulna resection. This article presents an alternative treatment option using Achilles tendon allograft as a soft tissue interposition.

Subperiosteal osteoid osteoma of the hamate: A case report☆

Osteoid osteoma is uncommon in the hand. The lesion can arise from either cortical or cancellous bone or subperiosteally. The latter localization is extremely rare in the hand, with only 4 reported cases in the English-language literature. Furthermore, characteristic radiographic findings of a central lucency surrounded by reactive sclerosis often emerge only late in the process, or not at all. Consequently, the diagnosis of osteoid osteoma of the hand can be delayed. We report a case of a subperiosteal osteoid osteoma of the hamate in which the diagnosis was delayed 2 years.

Distal Metaphyseal Ulnar-Shortening Osteotomy: Surgical Technique

Ulnar impaction is a common condition encountered by hand surgeons. Historically, treatment of this condition has been with wafer resection of the distal ulna, by either open or arthroscopic means, or diaphyseal ulnar shortening osteotomy; however, both of these have the potential for prolonged recovery or a need for additional procedures. Wafer procedures, whether done by open or arthroscopic techniques, can result in hemarthrosis, and diaphyseal osteotomies can require hardware removal. Recently, Slade and Gillon described a technique of ulnar shortening in the osteochondral region of the ulnar head, which offers advantages over previously used techniques. The purpose of this manuscript is to describe this technique, as well as pearls and pitfalls associated with the procedure. To more accurately describe the location of the osteotomy, we have changed the name of the procedure from Dr. Slades original description to distal metaphyseal ulnar-shortening osteotomy.

Use of continuous marcaine irrigation in the management of suppurative flexor tenosynovitis.

We describe a surgeon, nursing, and patient-friendly method of treating acute pyogenic tenosynovitis using a 2-incision, closed sheath irrigation method and postoperative usage of a continuous marcaine ON-Q pain pump. The advantages of this technique include the ease of catheter placement intraoperatively and the use of a smaller diameter tubing within the flexor sheath. In addition, this technique eliminates the need for nursing staff to perform irrigation, and most importantly, the technique results in improved postoperative pain control allowing an early aggressive postoperative therapy protocol. We retrospectively reviewed 9 patients with an average age of 42.8 years (range: 20 to 66 y) who presented with acute pyogenic flexor tenosynovitis. All patients underwent surgery on the day of presentation to us with the described technique with the catheter left in place for 2 days. Outcome measurements included length of hospital stay, final range of motion, recurrence of infection, and complications. Average hospital stay was 2.8 days (range: 2 to 6 d). There were no recurrent infections. Seven patients regained full total active motion of the involved digit. The 2 patients with incomplete recovery of digital motion regained 125 and 105 degrees of total active motion, respectively. In addition, there were 3 minor complications including cold intolerance (2 patients) and local skin necrosis that responded to local wound care (1 patient). This novel method of managing acute flexor tenosynovitis seems to be safe, effective, and very friendly for surgeons, nurses as well as patients. Intraoperative pearls for catheter placement using a 22-guage wire inside a ♯5 pediatric French feeding tube are also described.

Radiographic evaluation of the elbow.

Despite a number of advanced imaging modalities, plain film x-ray is essential for diagnostic evaluation of the elbow. Although computed tomography and magnetic resonance imaging continue to provide many uses in subtle processes or advanced evaluation, x-rays should typically provide initial, and often all, necessary imaging. Plain film imaging is used to evaluate trauma including fractures and dislocations, occult or suspected bony injury, instability patterns, tumor, arthritis and degenerative disease, and causes of associated pathology such as compression neuropathy.

Distal ulnar neuropathy : coexisting anatomic variants

A 4 1 -year-old right-handed man complained of weakness, cold sensitivity, and signs of ulnar intrinsic paresis in his right hand. He denied having pain, numbness, or paresthesia. He had no other upper extremity problems or other health problems. Physical examination showed a healthy, thin man with hypothenar and interosseous wasting but with minimal clawing and normal function of ulnar nerve-innervated extrinsic muscles. Tinel’s sign could not be elicited over the entire course of the ulnar nerve or over the median nerve at the wrist. Allen’s test confirmed ulnar artery patency. Grip strength was diminished by one third and pinch strength by two thirds as compared with the normal hand. X-ray films were normal. Electrodiagnostic studies confirmed major interference with motor branches of the ulnar nerve, but sensory conduction was normal. Guyon’s canal was explored. We found a small, pale, atrophic muscle arising from the forearm fascia and attaching to the pisiform bone (Fig. 1). This muscle compressed the ulnar nerve, and after the muscle was divided we determined that there was a neural loop of the ulnar nerve with take-off