Kenneth F. Taylor

Arthroscopic Release for Lateral Epicondylitis: A Cadaveric Model

At least 10 different surgical approaches to refractory lateral epicondylitis have been described, including an arthroscopic release of the extensor carpi radialis brevis tendon. The advantages of an arthroscopic approach include an opportunity to examine the joint for associated pathology, no disruption of the extensor mechanism, and a rapid return to premorbid activities with possibly fewer complications. A cadaveric study was performed to determine the safety of this procedure. Ten fresh-frozen cadaveric upper extremities underwent arthroscopic visualization of the extensor tendon and release of the extensor carpi radialis brevis tendon. The specimens were randomized with regard to the use of either a 2.7-mm or a 4.0-mm 30 degree arthroscope through modified medial and lateral portals. Following this, the arthroscope remained in the joint, and the portal, cannula track, and surgical release site were dissected to determine the distance between the cannula and the radial, median, ulnar, lateral antebrachial, and posterior antebrachial nerves, and the brachial artery and the ulnar collateral ligament. No direct lacerations of neurovascular structures were identified; however, the varying course of the lateral and posterior antebrachial nerves place these superficial sensory nerves at risk during portal placement. As in previous reports, the radial nerve was consistently in close proximity to the proximal lateral portal (3 to 10 mm: mean, 5.4 mm). The ulnar collateral ligament was not destabilized. Arthroscopic release of the extensor carpi radialis brevis tendon appears to be a safe, reliable, and reproducible procedure for refractory lateral epicondylitis. Cadaveric dissection confirms these findings.

Intraspinal anomalies associated with isolated congenital hemivertebra: the role of routine magnetic resonance imaging.

BACKGROUND Previous studies have demonstrated high rates of intraspinal anomalies in patients with congenital scoliosis; however, various authors have not considered the presence of an isolated hemivertebra to be sufficient reason for further evaluation with magnetic resonance imaging. Consequently, the rate of magnetic resonance imaging-detected intraspinal anomalies and subsequent neurosurgical intervention in patients with a single hemivertebra is unknown. Therefore, we studied all patients with a hemivertebra, after eliminating patients with a myelomeningocele, to compare those who had a single hemivertebra with those who had a complex hemivertebral pattern. METHODS A retrospective review of the history, physical examination findings, and magnetic resonance imaging findings for patients who had presented with at least one hemivertebra, excluding those who had a myelomeningocele, was conducted to identify the prevalence of intraspinal anomalies as seen on magnetic resonance imaging and the rate of subsequent neurosurgical intervention. Additionally, the diagnostic value of the history and the physical examination in predicting the presence of intraspinal anomalies was determined. RESULTS One hundred and sixteen patients with congenital scoliosis and a curve that included at least one hemivertebra were identified. Seventy-six of these patients had had magnetic resonance imaging and were included in the present study. The mean age of these patients at the time of presentation was 4.9 years, and the mean duration of follow-up was 7.7 years. Twenty-nine patients had an isolated hemivertebra, and forty-seven patients had a complex hemivertebral pattern. Eight (28%) of the twenty-nine patients with an isolated hemivertebra and ten (21%) of the forty-seven patients with a complex hemivertebral pattern had an intraspinal anomaly that was detected with magnetic resonance imaging. Overall, an abnormal finding on the history or physical examination demonstrated an accuracy of 71%, a sensitivity of 56%, a specificity of 76%, a positive predictive value of 42%, and a negative predictive value of 85% for the diagnosis of an intraspinal anomaly. Three patients with an isolated hemivertebra and five patients with a complex hemivertebral pattern underwent neurosurgical intervention. All eight patients who underwent neurosurgical intervention had had detection of an intraspinal anomaly with magnetic resonance imaging, whereas only four of these patients (two of whom had an isolated hemivertebra and two of whom had a complex hemivertebral pattern) had had an abnormal finding on either the history or the physical examination. CONCLUSIONS Patients who have an isolated hemivertebra and those who have a complex hemivertebral pattern have similar rates of intraspinal anomalies that are detected with magnetic resonance imaging and similar rates of subsequent neurosurgical intervention. The history and physical examination findings are not predictive of intraspinal anomalies. Therefore, a magnetic resonance imaging evaluation of the entire spine should be considered for all patients with congenital scoliosis, including those with an isolated hemivertebra.

Multicentric Giant Cell Tumor of Bone: A Case Report and Review of the Literature

Multicentric giant cell tumor of bone is the rare variant of a lesion that is relatively common in a skeletally mature population. An otherwise healthy 13-year-old boy presenting with this entity was followed up for 6 years. During this period, the patient was diagnosed with and treated for six individual lesions. One recurrence required resection, Ilizarov bone lengthening, and subsequent ankle arthrodesis. He remains fully active and free of distant metastasis.

Low-intensity pulsed ultrasound does not enhance distraction callus in a rabbit model.

Low-intensity pulsed ultrasound has been reported to have a positive effect when applied during the consolidation phase of distraction osteogenesis and bone transportation, but the optimal application time has not been determined. We used a rabbit model to determine whether low-intensity pulsed ultrasound applied during the distraction and early consolidation phases of tibial lengthening would have a positive effect on regenerated bone formation. Radiographic analysis showed no differences in regenerated callus area or in percent of callus mineralization between treated and control tibias immediately after distraction or at 1, 2, or 3 weeks after distraction. Similarly, we observed no differences in structural stiffness or maximal torque to failure at 1.5 or 3 weeks after distraction. We detected no differences in bone mineral appositional rates or percent tissue composition measured histologically between groups. Our data do not support the application of low-intensity pulsed ultrasound to regenerated bone during distraction osteogenesis.

Pedicled Thoracoabdominal Flap Coverage About the Elbow in Traumatic War Injuries

Current military conflicts in Iraq and Afghanistan have produced a significant number of complex injury patterns. Multiple extremity trauma and wide zones of injury mandate a flexible approach to these problems. We report our experience with periarticular elbow injuries with large soft tissue defects. Acute vascular reconstruction and multiple wound debridements throughout the evacuation chain set the stage for successful rigid fixation. The judicious use of pedicled thoracoabdominal flaps remains a viable solution when microvascular techniques are less appropriate.

Radial Collateral Ligament Injuries of the Thumb Metacarpophalangeal Joint: Epidemiology in a Military Population

PURPOSE The reasons for variation in the reported incidence rates between thumb metacarpophalangeal joint radial collateral ligament (RCL) and ulnar collateral ligament (UCL) injuries are unclear. Delay in diagnosis of injury to the RCL leads to greater time of patient disability. The purpose of this study was to define the demographics and presentation of patients with RCL injuries in a military health care system. METHODS We performed a retrospective review of electronic medical records over a 5-year period to determine the incidence and epidemiology related to patients with instability of the thumb metacarpophalangeal joint resulting from injury of the radial or ulnar collateral ligaments. RESULTS A total of 56 patients presented with thumb metacarpophalangeal joint instability. Of these, 18 (32%) had an RCL injury. Patients with an RCL injury were, on average, younger than those with UCL injuries. Those with RCL injuries were more likely to require surgery than were those with UCL injuries (67% vs 40%). With regard to time to presentation, most patients with UCL injuries presented 2 to 10 weeks after injury, whereas nearly all patients with RCL injuries presented greater than 10 weeks after injury. Radial collateral ligament injuries were more likely than UCL injuries to have resulted from an axial load (56% vs 16%), whereas UCL injuries were more likely to have been caused by an abduction-adduction moment (50% vs 22%). CONCLUSIONS In this series, patients sustaining injuries to the RCL were younger and presented later than their counterparts with UCL instability. Close attention to subtle or frank instability presenting as pain in younger patients with axial loading injury mechanisms may allow early diagnosis and appropriate treatment of this injury.

Multiplanar wrist joint proprioception: The effect of anesthetic blockade of the posterior interosseous nerve or skin envelope surrounding the joint

STUDY DESIGN Randomized clinical trial. PURPOSE Contribution of the posterior interosseous nerve (PIN) and surrounding skin envelope to wrist proprioception is a topic of debate and the primary focus of this research. METHODS We performed a double-blinded, placebo control study in which subjects underwent baseline multiplanar testing of wrist proprioception. They were randomized to receive either anesthetic blockade of the PIN within the fourth dorsal compartment, or circumferential topical anesthetic blockade of skin surrounding the wrist. Corresponding opposite wrists underwent placebo intervention with saline injection or inert ultrasound gel. Subjects repeated proprioceptive testing. RESULTS Eighty subjects, 45 male and 35 female, mean age 33 years (range, 19-64 years), completed testing. The percentage of measurements falling outside a ±18° range did not differ between pre-treatment and post-treatment PIN blockade or for circumferential skin anesthesia. CONCLUSIONS Wrist proprioception appears to be a multifactorial phenomenon. Surgeons may sacrifice the PIN without concern for effect on joint proprioception. LEVEL OF EVIDENCE Level I.

Linear increase in axial stiffness of regenerate callus during limb lengthening.

Distraction osteogenesis is a powerful tool for addressing segmental defects and limb-length discrepancies. Guidelines for the rate and rhythm of distraction have been described. The possibilities of early consolidation or nonunion threaten clinical success. A quantifiable method for monitoring the distraction gap would be useful. Previous methods to measure regenerate callus stiffness have not gained widespread clinical acceptance, largely because of cumbersome instrumentation. A rabbit tibial lengthening model was used to show the clinical utility of a digital torque wrench in monitoring axial stiffness of the regenerate bone callus during distraction osteogenesis. We confirmed the linear increase in peak torsional stiffness with time, which has been reported by others. This relationship may prove to be a useful clinical adjunct in guiding the rate and rhythm of distraction during limb lengthening.

Restoring Volar Tilt in AO Type C2 Fractures of the Distal Radius With Unilateral External Fixation

PURPOSE To determine whether unilateral external fixation using a staged multiplanar reduction technique restores anatomic volar tilt in a distal radius fracture model. METHODS We used radiographic images to obtain baseline measurements in 20 fresh-frozen cadaveric wrists. Through a standard dorsal approach to the radius, we performed osteotomies to simulate displaced AO/ASIF type C2 fractures. After placement of a unilateral external fixator, a stepwise technique of applying longitudinal traction followed by a volar translational maneuver was performed. Radiographic imaging was obtained after each step of the multiplanar reduction technique. RESULTS Standard longitudinal traction did not restore volar tilt angles to their baseline measurements. The addition of a volar translation maneuver had a significant effect on restoring baseline volar tilt. There was a statistically significant difference in volar tilt measurements between straight longitudinal traction and volar translation. Radial inclination, radial height, and ulnar variance did not differ significantly between longitudinal traction and the addition of volar translation. CONCLUSIONS A criticism of traditional external fixation is the inability of longitudinal ligamentotaxis to attain sagittal plane (volar tilt) reduction of the articular surface. This study demonstrates that a multiplanar reduction technique using unilateral external fixation devices on cadaveric distal radius fractures can achieve an acceptable reduction. CLINICAL RELEVANCE External fixation of distal radius fractures may be favorable in situations where soft tissue loss, wound contamination, and comorbid medical factors preclude the use of internal fixation techniques. A multiplanar reduction technique using a unilateral external fixation device may facilitate fracture reduction in acceptable alignment.

Self-Reported Outcomes for Patients Undergoing Revision Carpal Tunnel Surgery With or Without Hypothenar Fat Pad Transposition

Background: Carpal tunnel surgery is the most common surgical procedure performed on the hand. Although complications are rare, recurrent or persistent carpal tunnel syndrome can be a significant problem after primary decompression. Various procedures have been described for the treatment of these patients including repeat decompression and hypothenar fat pad transposition. The purpose of this study is to compare the outcomes of patients undergoing revision carpal tunnel decompression with and without hypothenar fat pad transposition. Methods: We performed a retrospective review of all patients undergoing revision carpal tunnel surgery at our institution between 2002 and 2014. Identified patients were contacted by telephone. A Boston Carpal Tunnel Questionnaire (BCTQ) was administered to all participants. Results: Seventy-six patients underwent revision carpal tunnel surgery over the study period. Twenty-nine of 45 potential participants provided a survey response (64.9%) representing a total of 33 carpal tunnel revision surgeries. Seventeen hands underwent repeat decompression alone, and 16 hands underwent repeat decompression with hypothenar fat pad transposition. A trend toward improved overall BCTQ score was noted for patients undergoing decompression alone; however, no significant difference was determined for total survey score by procedure type. Similarly, total symptom severity and functional scores were not statistically significant between groups; however, a trend toward significance for improved symptom severity score was observed in patients undergoing decompression alone. Conclusions: Our results reveal no difference in self-reported symptom severity and functional scores between patients undergoing revision carpal tunnel surgery with repeat decompression alone or decompression with fat pad transposition.