John D. Beck

Reverse Total Shoulder Arthroplasty in Obese Patients

PURPOSE To determine function and complications after reverse total shoulder arthroplasty (RTSA) in obese patients compared with a control group of nonobese patients. METHODS Between 2005 and 2011, we performed 76 RTSAs in 17 obese, 36 overweight, and 23 normal weight patients, based on World Health Organization body mass index classification. We reviewed the charts for age, sex, body mass index, date of surgery, type of implant, type of incision, length of stay, comorbidities, surgical time, blood loss, American Society of Anesthesiologists score, shoulder motion, scapular notching, and postoperative complications. Complications and outcomes were analyzed and compared between groups. RESULTS Reverse total shoulder arthroplasty in obese patients was associated with significant improvement in range of motion. Complication rate was significantly greater in the obese group (35%), compared with 4% in the normal weight group. We found no significant differences between scapular notching, surgical time, length of hospitalization, humeral component loosening, postoperative abduction, forward flexion, internal and external rotation, pain relief, or instability between groups. CONCLUSIONS Our results show that obese patients have significant improvement in motion after RTSA but are at an increased risk for complication. Obesity is not a contraindication to RTSA, but obese patients need to understand fully the increased risk of complication with RTSA. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Differential latency testing: A more sensitive test for radial tunnel syndrome

A modification of the standard electrodiagnostic test was developed in an effort to provide a more sensitive electrodiagnostic evaluation in radial tunnel syndrome. Radial motor nerve latency recordings were obtained in 3 different forearm positions: neutral, passive supination, and passive pronation. The maximal difference in these recordings, the differential latency, in 25 patients with radial tunnel syndrome of greater than 6 months duration (test group) was compared with those in 25 asymptomatic volunteers (control group). Differential latency recordings were obtained in all patients in the test group before and after surgery. Radial nerves that were compressed demonstrated a significantly greater differential latency (0.44+/-0.12 ms) versus controls (0.12+/-0.008 ms). Following radial nerve decompression, differential motor latencies in the test group decreased below control values, demonstrating a resolution of the provoked electrical response with a postoperative differential latency of 0.07+/-0.05 ms. Our results demonstrate the differential motor latency of the radial nerve to be a sensitive electrodiagnostic tool in patients with radial tunnel syndrome. A differential latency of > or =0.30 ms was considered indicative of radial tunnel syndrome.

Results of endoscopic carpal tunnel release relative to surgeon experience with the Agee technique.

PURPOSE To establish the rate of iatrogenic injury after endoscopic carpal tunnel release (ECTR) for a surgeon in the first 2 years of practice; to report the rate of conversion from ECTR to open carpal tunnel release (OCTR), the reason for conversion, and any increase in morbidity found in patients converted to OCTR; and to determine whether the conversion rate decreased with increasing surgeon experience. METHODS We conducted a retrospective review of patients undergoing ECTR by a single surgeon in the first 2 years of practice. Data collected or calculated included symptom relief, rate of conversion to OCTR, reason for conversion, and neurovascular complications. For patients converted to OCTR, we assessed satisfaction and function using the Disabilities of the Arm, Shoulder, and Hand questionnaire. We compared these results for 1 to 6 months, 7 to 12 months, and 12 to 24 months to determine whether a learning curve was present. RESULTS A total of 278 patients (358 procedures) underwent ECTR. Of these, 12 patients required conversion to OCTR during the index procedure over a 2-year period. In the first 6 months of practice, 8 of 71 ECTRs were converted to OCTR compared to 1 of 72 in the second 6 months. This was a statistically significant decrease (p = .017). In year 2, 3 of 215 patients were converted to OCTR. Average Disabilities of the Arm, Shoulder, and Hand score for patients converted from ECTR to OCTR was 9. No patients required repeat surgery for recurrence of carpal tunnel symptoms. We observed no major neurovascular complications. CONCLUSIONS A learning curve for ECTR was present. Rates of conversion significantly diminished with increased surgeon and anesthesia experience. Patients requiring conversion showed no variation in Disabilities of the Arm, Shoulder, and Hand scores from established values after OCTR. Patients may be at a higher risk of conversion to OCTR during the learning curve time period; nevertheless, we found no increased morbidity. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic III.

Volar Plate Fixation Failure for Volar Shearing Distal Radius Fractures With Small Lunate Facet Fragments

PURPOSE To determine the percentage of AO B3 distal radius fractures that lose reduction after operative fixation and to see whether fracture morphology, patient factors, or fixation methods predict failure. We hypothesized that initial fracture displacement, amount of lunate facet available for fixation, plate position, and screw fixation would be significant risk factors for loss of reduction. METHODS A prospective, observational review was conducted of 51 patients (52 fractures) with AO B3 (volar shearing) distal radius fractures treated operatively between January 2007 and June 2012. We reviewed a prospective distal radius registry to determine demographic data, medical comorbidities, and physical examination findings. Radiographs were evaluated for AO classification, loss of reduction, length of volar cortex available for fixation, and adequacy of stabilization of the lunate facet fragment with a volar plate. Preoperative data were compared between patients who maintained radiographic alignment and those with loss of reduction. A multivariate logistic regression analysis was completed to determine significant predictors of loss of reduction. RESULTS Volar shearing fractures with separate scaphoid and lunate facet fragments (AO B3.3), preoperative lunate subsidence distance, and length of volar cortex available for fixation were significant predictors for loss of reduction; the latter was significant in multivariate analysis. Plate position and number of screws used to stabilize the lunate facet were not statistically different between groups. CONCLUSIONS Patients with AO B3.3 fractures with less than 15 mm of lunate facet available for fixation, or greater than 5 mm of initial lunate subsidence, are at risk for failure even if a volar plate is properly placed. In these cases, we recommend additional fixation to maintain reduction of the small volar lunate facet fracture fragments in the form of plate extensions, pins, wires, suture, wire forms, or mini screws. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Anomalous tendon to the middle finger for sagittal band reconstruction: report of 2 cases.

Multiple techniques with good outcomes have been described for sagittal band reconstruction. We describe 2 cases of sagittal band reconstruction using an anomalous slip of the extensor tendon to the middle finger. This anomalous slip can be a resource for surgical reconstruction that can add stability to primary sagittal band repair.

Outcomes of Elbow Arthroscopic Osteocapsular Arthroplasty.

PURPOSE To evaluate the results of elbow arthroscopic osteocapsular arthroplasty (AOA) and determine which factors influence the outcome in a large group of patients with primary osteoarthritis. METHODS A consecutive series of 46 patients with elbow osteoarthritis underwent AOA by a single surgeon (N.G.H.) between December 2005 and January 2013. Thirty-one patients returned for a comprehensive physical examination an average of 3.4 years later. The outcomes measures included visual analog scale (VAS), Mayo Elbow Performance Scores (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH), and American Shoulder and Elbow Society (ASES) scores. Preoperative and postoperative continuous variables were compared and a multivariable regression analysis was performed. RESULTS Thirty-one patients with a mean age of 48 years (range, 19-77 years) returned for final follow-up, including 27 men and 4 women. Statistically significant improvement was observed in extension deficit (24° before surgery to 12° after surgery), flexion (126° before surgery to 135° after surgery), visual analog scale (6.4 before surgery to 1.6 after surgery), and Mayo Elbow Performance Scores (57 [poor] before surgery to 88 [good] after surgery). Subjective scores included a mean postoperative Disabilities of the Arm, Shoulder, and Hand score of 13 and an American Shoulder and Elbow Society pain score of 40. No complications were noted at final follow-up. CONCLUSIONS Elbow AOA is a safe, efficacious treatment for patients with mild to moderate osteoarthritis. Our retrospective review found significant improvement in elbow motion, pain and clinical outcomes.

Clinical Outcomes of Endoscopic Carpal Tunnel Release in Patients 65 and Over

PURPOSE To examine outcomes of endoscopic carpal tunnel release (ECTR) in patients 65 and older. We hypothesized that this population could expect relief of pain, night pain/numbness, and numbness. METHODS A retrospective review was conducted of all patients 65 years of age and over who had ECTR for nerve conduction study-confirmed carpal tunnel syndrome (CTS) from October 2007 to July 2010. The charts were reviewed for demographic data, symptoms and physical findings, patient satisfaction, and 3 patient-reported outcome scores. Preoperative and postoperative results for pain, night pain/numbness, and numbness were compared. Logistic regression analysis was used to assess whether age influenced symptom resolution. Boston carpal tunnel, Short Form-36 and Disabilities of the Arm, Shoulder, and Hand scores were compared between patients with mild, moderate, or severe CTS. RESULTS A total of 78 patients had ECTR. Their ages ranged from 65 to 93 years (mean, 73 y). Before surgery 69% of patients had constant numbness. Night pain/numbness was present in 65 patients before surgery, and 61 had complete resolution. All 70 patients who presented with pain reported complete relief by the 6-month follow-up. Following ECTR, the average Boston carpal tunnel symptom severity, functional status, and Disabilities of the Arm, Shoulder, and Hand scores were 1.5,1.5, and 13, respectively. At final evaluation, 79% of patients were very satisfied or satisfied with their outcome. A significant number of patients were found to have improvement in pain, night pain/numbness, and numbness following ECTR. CONCLUSIONS This study has demonstrated relief of symptoms in a statistically significant number of patients following ECTR. We found that preoperative CTS severity, based on nerve conduction study result, did not significantly correlate with patient outcome following ECTR. Advanced symptoms at presentation do not preclude symptom resolution and should not be a contraindication to ECTR. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Anomalous Extensor Tendons to the Long Finger: A Cadaveric Study of Incidence

PURPOSE To evaluate the incidence and anatomic insertion sites of extensor medii proprius and extensor indicis medii communis tendons to the long finger in cadaveric dissection and to describe the insertion of the extensor medii proprius. METHODS Thirty randomly selected adult cadavers, 44 upper extremities, were examined for the presence or absence of an anomalous extensor tendon to the long finger. If present, tendon origin and insertion sites were documented, and the width of the tendon was evaluated. RESULTS The extensor medii proprius was observed in 4 of 44 extremities, an incidence of 9%. The extensor indicis medii communis was observed in 7 of 44 extremities, an incidence of 16%. Tendon widths for both the extensor medii proprius and extensor indicis medii communis specimens ranged from 1.5 to 3.0 mm. CONCLUSIONS The incidence of an anomalous slip of tendon to the long finger might be higher than previously reported, with a combined incidence of 25% in this cadaveric study. This anomalous slip can be a resource for surgical reconstruction. CLINICAL RELEVANCE The presence of anomalous tendinous slips to the long finger can be easily overlooked. Understanding the anatomical relationships, incidence, and donor tendon availability of these anomalous tendons might aid with surgical planning.

Provocative motor nerve conduction testing in presumptive carpal tunnel syndrome unconfirmed by traditional electrodiagnostic testing

In this controlled prospective study, 22 consecutive surgical candidates with clinically diagnosed CTS and negative findings on median nerve-sensory and motor-conduction velocity tests in both hands were reexamined with a protocol incorporating 5 specific positions of the wrist. Four of the 5 positions represented maximum physiologic ranges of motion for the patient. These positions were neutral (unstressed), extension, flexion, radial deviation, and ulnar deviation. Motor latency was recorded in each of the 5 positions using otherwise standard technique. The least latency value in the test sequence was subtracted from the greatest to yield a value called differential latency. Thirty-two control studies were obtained on both hands of 16 normal volunteers and were used to establish a control differential latency, which was seen to have a mean of .13 ms. A 2 standard deviation z value of .11 ms was calculated, giving an upper limit of normal (control) differential latency of .24 ms. Preoperative studies yielded an average differential latency of .44 ms, with 20 of 22 patients having differential latency values of greater than .24 ms. Evaluations of these same patients 3 months after surgery showed differential latency values within the same range as those of the control group. Simple modification of standard nerve testing techniques to include positional variation increased the yield of positive test results in 20 of 22 patients with CTS whose electrodiagnostic tests otherwise produced negative findings.

Avulsive Axillary Artery Injury in Reverse Total Shoulder Arthroplasty

In addition to neurologic injuries such as peripheral nerve palsy, axillary vessel injury should be recognized as a possible complication of reverse total shoulder arthroplasty. Limb lengthening associated with Grammont-type reverse total shoulder arthroplasty places tension across the brachial plexus and axillary vessels and may contribute to observed injuries. The Grammont-type reverse total shoulder arthroplasty prosthesis reverses the shoulder ball and socket, shifts the shoulder center of rotation distal and medial, and lengthens the arm. This alteration of native anatomy converts shearing to compressive glenohumeral joint forces while augmenting and tensioning the deltoid lever arm. Joint stability is enhanced; shoulder elevation is enabled in the rotator cuff–deficient shoulder. Arm lengthening associated with reverse total shoulder arthroplasty places a longitudinal strain on the brachial plexus and axillary vessels. Peripheral nerve palsies and other neurologic complications of reverse total shoulder arthroplasty have been documented. The authors describe a patient with rotator cuff tear arthropathy and a history of radioulnar synostosis who underwent reverse total shoulder arthroplasty complicated by intraoperative injury to the axillary artery and postoperative radial, ulnar, and musculocutaneous nerve palsies. Following a seemingly unremarkable placement of reverse shoulder components, brisk arterial bleeding was encountered while approximating the incised subscapularis tendon in preparation for wound closure. Further exploration revealed an avulsive-type injury of the axillary artery. After an unsuccessful attempt at primary repair, a synthetic arterial bypass graft was placed. Reperfusion of the right upper extremity was achieved and has been maintained to date. Postoperative clinical examination and electromyographic studies confirmed ongoing radial, ulnar, and musculocutaneous neuropathies.