Jeffry T. Watson

Treatment of Syndesmotic Disruptions of the Ankle with Bioabsorbable Screw Fixation

Background: Bioabsorbable implants have restricted indications because of their unique biochemical properties and their inferior biomechanical properties compared with those of conventional metallic implants. The purpose of this prospective study was to assess the efficacy of screws made of polylevolactic acid (PLLA) in the treatment of syndesmotic disruptions associated with ankle fractures and fracture-dislocations. Methods: Thirty-three consecutive patients with a syndesmotic disruption were managed with standard metallic plate-and-screw fixation of the malleolar fracture and with 4.5-mm polylevolactic acid screws, with purchase in four cortices, for fixation of the syndesmosis. Intraoperative radiographs confirmed reduction of the syndesmosis, and all of the patients were managed with a non-weight-bearing plaster splint or brace for six weeks. Clinical and radiographic assessment and functional evaluation with use of the Olerud-Molander scoring system were performed at the time of follow-up. Results: Ten patients were lost to follow-up prior to the twenty-four-month evaluation, leaving twenty-three patients with an average duration of follow-up of thirty-four months (range, twenty-four to forty-three months). All of the malleolar fractures healed in an anatomical position at an average of three months, and no postoperative displacement of the syndesmosis or widening of the medial clear space was detectable on radiographs. No episodes of osteolysis or late inflammation secondary to the hydrolyzed polylactide occurred. Nineteen patients (83%) had an excellent result, and four patients (17%) had a good result. All twenty-three patients returned to their preinjury level of work and activities of daily living. No patient had malunion, nonunion, loss of reduction, or complications attributable to the biomechanical or biochemical properties of the implants. Conclusions: Polylevolactic acid screws are effective in stabilizing disruption of the syndesmosis during healing of unstable ankle fractures. In this small series, the bioabsorbable screw was well tolerated, and there was no need for a second operation to remove it.

Precontoured Fixed-Angle Volar Distal Radius Plates: A Comparison of Anatomic Fit

PURPOSE To compare distal radius volar fixed-angle plates for anatomic fit. METHODS Twenty embalmed radii were stripped of soft tissues. The volar lip (watershed line) on the volar distal radius served as a reference line. Seven volar fixed-angle plates were tested (Acumed Acu-loc Standard, Hand Innovations DVRAW and DVRAN, Synthes Juxta-articular [JA], Synthes Extra-articular [EA], Trimed Volar Bearing, Zimmer Volar Lateral Column). Four parameters of anatomic fit were studied: (1) site of best fit; (2) percent plate contact; (3) pin-subchondral bone distance; and (4) extraosseous penetrations. The Wilcoxon signed rank test and Pearsons correlation coefficient were used to compare interobserver plate placement. A Kruskal-Wallis analysis of variance was used to compare percent plate contact and pin-subchondral bone distance across all plates. The Bonferroni correction for multiple comparisons was used to compare pin-subchondral bone distances for all possible plate combinations. RESULTS There was no difference between observers for plate placement. Each plate had a specific site of best fit, and the 7 plates varied widely in best fit location. Percent contact (range, 3% to 6%) between plates was significantly different. Pin-subchondral bone distance across all plates was significantly different. Analysis of all possible plate combinations showed that the Synthes EA pin-subchondral bone distances were significantly different than those of all plates except Zimmer. Amongst the 140 plate insertions, the radiocarpal joint was penetrated in 17, the styloid in 7, (with 6 associated with the DVRAW plate), and the distal radioulnar joint in 9 (all associated with the DVRAW plate). CONCLUSIONS There was considerable variation in ideal plate location among the 7 plates tested. Total contact was minimal for all plates tested. The Synthes EA pin-subchondral bone distance was significantly greater than those of other plates tested. Joint penetration was relatively common, necessitating use of fluoroscopy and proper plate width.

Outcomes of Hook of Hamate Fracture Excision in High-Level Amateur Athletes

PURPOSE To determine the overall long-term postoperative clinical and functional results of high-level amateur athletes after hook of hamate excision, based on complications; return to sport; Disabilities of the Arm, Shoulder, and Hand (DASH) score; and a self-reported questionnaire. METHODS We evaluated 11 patients representing 12 cases of hook of hamate excision. All patients were high-level amateur athletes (rising collegiate or collegiate level). We performed a retrospective chart review to elicit information pertaining to the patients injury. We assessed long-term postoperative outcomes with a self-reported questionnaire, the DASH form, and the DASH Sport/Performing Arts Module form. RESULTS All patients successfully returned to full participation in their respective sports an average of 6 weeks after surgery. The average postoperative DASH score was less than 1, and all patients scored a 0 on the DASH Sports form. There was a significant improvement in preoperative pain after surgical intervention. There was no significant difference between preinjury and postoperative performance scores. Finally, every patient was very satisfied with the surgical outcome. There was only 1 postoperative complication in which a patient developed transient ulnar nerve paresthesias, which completely resolved by 6 weeks after surgery. CONCLUSIONS Surgical excision of hook of hamate fractures in high-level amateur athletes allows for successful return to sports participation at preinjury performance levels, achievement of normal function as measured by validated objective outcome measures, significant reduction in pain, and high overall patient satisfaction. We consider surgical excision to be a safe and effective technique to restore normal function and hasten return to play for high-level amateur athletes. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Driving with an Arm Immobilized in a Splint: A Randomized Higher-Order Crossover Trial

BACKGROUND The aim of this study was to determine whether immobilization of an arm has detrimental effects on driving performance. METHODS Thirty-six healthy officers-in-training were assigned a sequence of fiberglass splints (left and right-sided above-the-elbow thumb spica and below-the-elbow splints) with use of a randomized higher-order crossover design. Runs were scored on a cone-marked driving course used for officer certification with predetermined passing requirements. Driving time, the number of cones hit per course section, and the cone-adjusted total time (a five-second penalty per hit cone) were recorded. A linear mixed-effect model with random environmental and learning effects for cone-adjusted time analysis was used. Participants rated perceived driving difficulty and safety with each splint, and ratings were compared with the Wilcoxon signed-rank test. RESULTS Thirty participants completed the entire set of runs. Analysis of total cone-adjusted time revealed a significant performance decrease with the left arm in an above-the-elbow thumb spica splint (average, 22.2 seconds; p < 0.001) and with the left arm in a below-the-elbow splint (average, 16.2; p = 0.007). Analysis of forward-only course sections revealed poorer performance trends with all splints, with the worst performance with the left arm in an above-the-elbow thumb spica splint. Driving with the left arm in an above-the-elbow thumb spica splint had the highest perceived difficulty (median, 8.0) and lowest perceived safety (median, 3.0). CONCLUSIONS Driving performance as measured with a standardized track and scoring system was significantly degraded with splint immobilization of the left arm. Further studies are required to determine the effect of arm immobilization on normal driving conditions.

Radiographic Outcomes of Volar Locked Plating for Distal Radius Fractures

PURPOSE To assess the ability of volar locked plating to achieve and maintain normal radiographic parameters for articular stepoff, volar tilt, radial inclination, ulnar variance, and radial height in distal radius fractures. METHODS We performed a retrospective review of 185 distal radius fractures that underwent volar locked plating with a single plate design over a 5-year period. We reviewed radiographs and recorded measurements for volar tilt, radial inclination, ulnar variance, radial height, and articular stepoff. We used logistic regression to determine the association between return to radiographic standard norms and fracture type. RESULTS At the first and final postoperative follow-up visits, we observed articular congruence less than 2 mm in 92% of fractures at both times. Normal volar tilt (11°) was restored in 46% at the first follow-up and 48% at the final one. Radial inclination (22°) was achieved in 44% at the first follow-up and 43% at the final one, and ulnar variance (01 ± 2 mm) was achieved in 53% at the first follow-up and 53% at the final one. In addition, radial height (14 ± 1mm) was restored in 14% at the first follow-up and 12% at the final one. More complex, intra-articular fractures (AO class B and C and Frykman types 3, 4, 7, and 8) were less likely to be restored to normal radiographic parameters. However, because of the small sample size for some fracture types, it was difficult to discover significant associations between fracture type and radiographic outcome. CONCLUSIONS Volar locked plating for distal radius fractures achieved articular stepoff less than 2 mm in most fractures but only restored and maintained normal radiographic measurements for volar tilt, radial inclination, and ulnar variance in 50% of fractures. The ability of volar locked plating to restore and maintain ulnar variance and volar tilt decreased with more complex intra-articular fracture types. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Lunotriquetral Ligament Tears

1 c THE PATIENT A 35-year-old landscaper presents with pain on the ulnar side of the wrist 5 weeks after a fall at work onto an outstretched dominant right hand. Notable physical examination findings include isolated tenderness over the lunotriquetral (LT) interval, pain and excessive motion relative to the left side on lunotriquetral ballottement test, and a positive Kleinman shear test. Radiographs are normal.

Nerve entrapment syndromes in musicians.

Nerve entrapment syndromes are common in instrumental musicians. Carpal tunnel syndrome, ulnar neuropathy at the elbow, and thoracic outlet syndrome appear to be the most common. While electrodiagnostic studies may confirm the diagnosis of nerve entrapment, they may be falsely normal in musicians. Non‐operative treatment with instrument and technique modification may help. Involvement with the musicians teacher to implement appropriate treatment is recommended. Outcomes for both non‐operative and operative treatment for various nerve entrapment syndromes have yielded mostly good to excellent results, similar to the general population. Clin. Anat. 27:861–865, 2014.

Surgical Hand Antisepsis for the Hand Surgeon

o r SURGICAL HAND ANTISEPSIS removes transient microorganisms and reduces the number of resident microorganisms on the surgeon’s hands in an ffort to minimize the risk of a surgical site infection SSI). This practice began in the 1860s with Joseph ister’s experiments in using carbolic acid to disinfect he hands of the surgical team members. Since that ime, preoperative hand scrubbing has evolved; howver, SSIs remain the most common nosocomial infecion among surgical patients. Although sterile gloves limit the transfer of bacteria from hand to patient, they can become perforated (in up to 24% of surgical procedures) making it desirable to maintain hands as germfree as possible. Although it is not definitive, it is likely that the risk of SSI caused by wound inoculation from hand microflora is lessened with reductions in the number of colony-forming units (CFUs). In recent ears, there have been several new developments in this eld. We describe the most commonly used methods of urgical hand antisepsis and briefly review the pertinent iterature on the subject. An ideal antiseptic agent should be fast acting, peristent, and cumulative; have a broad spectrum of acivity; and be safe to use. There are 3 types of antieptic solutions available for surgical hand antisepsis: queous scrubs, alcohol rubs, and alcohol rubs containng additional active ingredients (Table 1). The 2 most ommonly used agents in aqueous scrubs are povidone odine (PI) and chlorhexidine gluconate (CHG). Alcool rubs come in preparations of 60% to 90% strength nd are typically ethanol, isopropanol, or n-propanol. lcohol rubs containing additional active ingredients, uch as biguanides (chlorhexidine) and phenolic comounds (triclosan), combine the rapid bacteriocidal efect of alcohol with the persistent chemical activity of queous scrubs (Table 1).

Anterior Elbow Capsulodesis

ABSTRACT The technique and role of an anterior elbow capsulodesis in restoring elbow instability following an unstable elbow fracture-dislocation are described. Six patients with an unstable posterior elbow fracture-dislocation were retrospectively reviewed. The average age of the patients was 45.5 years. Five of the 6 patients had a type I coronoid fracture, and 5 patients had a radial head fracture. All patients had an associated posterior dislocation of the elbow. Two patients had previous surgery. All patients underwent elbow reconstruction with restoration of the ulnohumeral joint and lateral collateral ligament complex repair. Five patients had a radial head replacement. An anterior elbow capsulodesis was performed in all patients for residual, postreconstruction, posterior elbow instability. A hinged fixator was used in 1 patient. At an average follow-up of 19 months (range, 6-33 months), all patients had a stable elbow. The average extension-flexion arc was 26 to 133 degrees. Pronation and supination averaged 54 and 69 degrees, respectively. Conclusion: A stable elbow joint can be achieved by restoring ulnohumeral joint congruency, repairing the lateral collateral ligament complex, and repairing or replacing an injured radial head. An anterior elbow capsulodesis is used when further stabilization of residual posterior elbow instability is needed.

Techniques for Intraoperative Peripheral Nerve Assessment and Implications for Treatment

One of the main challenges of peripheral nerve surgery continues to be knowing when to operate and what strategies to use intraoperatively. Nevertheless, new techniques are increasingly allowing peripheral nerve surgeons to assess and treat nerve lesions with more precision. This chapter seeks to summarize the surgeon’s options for analyzing peripheral nerves intraoperatively. Methods discussed include electrodiagnostics, specifically intraoperative nerve actions potentials, somatosensory and motor-evoked potentials, histochemical stains, and radioisotopic analysis.