Kevin J. Renfree

Anatomy and biomechanics of the acromioclavicular and sternoclavicular joints.

The acromioclavicular and sternoclavicular joints have important soft-tissue static constraints that, based on biomechanical studies, imply a great deal of stability. The infrequency of significant symptoms following dislocations of these joints certainly highlights the fact that the dynamic muscle support is also very important. In performing resections of these joints for degenerative disease, our goal should be to preserve these important ligamentous supports by minimizing the amount of bone excised, as this seems to optimize results [84]. Precise isometric reconstruction of these complex, three-dimensional ligamentous structures merits further investigation in the laboratory and clinical settings.

Ligamentous anatomy of the distal clavicle.

We describe the insertional variations of supporting ligaments of the acromioclavicular joint, especially with respect to gender. We analyzed 41 cadaveric clavicles (22 female and 19 male) with attached ligaments. The distance between the insertion of the trapezoid ligament and the distal end of the clavicle was not significantly different between sexes, although that of the conoid ligament and the mean anteroposterior width of the distal clavicle was significantly greater in men. Although there are significant sex-related differences in the insertional distances of the CC ligaments, resection of less than 11.0 mm should not violate the trapezoid ligament and less than 24.0 mm should not violate the conoid ligament in either sex in 98% of the general population. Resection of more than 7.6 mm of the distal clavicle in men and 5.2 mm in women, performed by an arthroscopic approach, may violate the superior acromioclavicular ligament.

Cost utility analysis of reverse total shoulder arthroplasty

BACKGROUND Reverse shoulder arthroplasty provides satisfactory outcomes, but its cost-effectiveness is unproven. We prospectively analyzed outcomes and costs for primary reverse shoulder arthroplasty. METHODS Thirty serial patients (16 women and 14 men; mean age, 74.1 years [range, 61.1-87.3 years]) with rotator cuff arthropathy had active motion recorded and completed function tests (visual pain analog scale; Simple Shoulder Test; American Shoulder and Elbow Surgeons Shoulder Outcome score; EuroQol; and Short Form-36 Health Survey) preoperatively and postoperatively at 1 and 2 years. Costs included professional fees, operating room and supply costs, and hospital care. Changes were compared by the Wilcoxon signed rank test, and quality-adjusted life-years were calculated preoperatively and postoperatively. RESULTS Twenty-seven patients completed the study. Clinical and functional outcomes demonstrated significant improvement (P < .05). Significantly improved (P < .05) Short Form-36 subgroups included physical functioning, role limitations due to physical health, bodily pain, vitality, and physical composite score. EuroQol dimensions of usual activities and pain/discomfort improved significantly (P < .05). Calculations with the SF-6D showed that median QALYs improved from 6.56 preoperatively to 7.43 at 1-year follow-up (P <.09) and from 6.56 preoperatively to 7.58 at 2-year follow-up (P <.003). The increase in QALYs calculated from the EQ-5D was somewhat greater, changing from 6.21 preoperatively to 7.69 at 1-year follow-up (P <.0001) and from 6.13 to 8.10 at 2-year follow-up (P <.04). Mean cost was

Quadrilateral Space Syndrome: The Mayo Clinic Experience With a New Classification System and Case Series

21,536. Cost utility at 2 years was

Two-stage Shoulder Reconstruction for Active Glenohumeral Sepsis

26,920/quality-adjusted life-year by the Short Form 6 Dimensions and

Percutaneous in situ versus open arthrodesis of the distal interphalangeal joint

16,747/quality-adjusted life-year by the EuroQol. CONCLUSION EuroQol and Short Form-36 results demonstrated modestly cost-effective (<

Coccidioidal Tenosynovitis of the Hand and Wrist: Report of 9 Cases and Review of the Literature

50,000/quality-adjusted life-year) improvement for cuff tear arthropathy patients after primary reverse shoulder arthroplasty. LEVEL OF EVIDENCE Level II, economic and decision analysis.

Improvement in patient-specific outcomes after carpal tunnel release in patients older than 80 years

Quadrilateral space syndrome (QSS) arises from compression or mechanical injury to the axillary nerve or the posterior circumflex humeral artery (PCHA) as they pass through the quadrilateral space (QS). Quadrilateral space syndrome is an uncommon cause of paresthesia and an underdiagnosed cause of digital ischemia in overhead athletes. Quadrilateral space syndrome can present with neurogenic symptoms (pain and weakness) secondary to axillary nerve compression. In addition, repeated abduction and external rotation of the arm is felt to lead to injury of the PCHA within the QSS. This often results in PCHA thrombosis and aneurysm formation, with distal emboli. Because of relative infrequency, QSS is rarely diagnosed on evaluation of athletes with such symptoms. We report on 9 patients who presented at Mayo Clinic with QSS. Differential diagnosis, a new classification system, and the management of QSS are discussed, with a comprehensive literature review. The following search terms were used on PubMed: axillary nerve, posterior circumflex humeral artery, quadrilateral space, and quadrangular space. Articles were selected if they described patients with symptoms from axillary nerve entrapment or PCHA thrombosis, or if related screening or imaging methods were assessed. References available within the obtained articles were also pursued. There was no date or language restriction for article inclusion; 5 studies in languages besides English were reported in German, French, Spanish, Turkish, and Chinese.

Comparison of Extension Orthosis Versus Percutaneous Pinning of the Distal Interphalangeal Joint for Closed Mallet Injuries.

In some circumstances, two-stage reconstruction is recommended for the treatment of glenohumeral sepsis. This study retrospectively reviewed the results in 25 patients after this treatment. Pain was the only consistent preoperative symptom, found in 95% of patients. The most common infecting organisms were coagulase-negative Staphylococcus in 8 cases, Proprionibacterium acnes in 7, and methicillin-sensitive Staphylococcus aureus in 3. Outcomes were reviewed in 21 patients with 2-year minimum follow-up, at an average 4.1 years. Infection was eradicated in 18 of 21 shoulders. Success was related to the specific infecting organism, as all failures were among shoulders infected with Proprionibacterium (P=.0198). Pain was typically relieved, with a mean visual analog pain score of 1.67 at follow-up. Motion was similarly improved, with flexion increased to 100.9 degrees (P<.001), abduction to 93.6 degrees (P<.001), and external rotation 32.6 degrees (P=.0012). Two-stage shoulder reconstruction for infection is typically effective for curing the infection and improving pain and motion; however, function tends to remain limited.

Intra-articular osteoid osteoma of the proximal ulna

We compared the results of percutaneous in situ arthrodesis with open arthrodesis of the distal interphalangeal joint with a headless compression screw. In the percutaneous in situ arthrodesis group (17 joints), the screw was inserted from the fingertip across the unprepared joint. In the open group (12 joints), flat cancellous surfaces were prepared before screw insertion. Solid fusion was found in 10/17 joints (59%) with percutaneous in situ arthrodesis and in 11/12 joints (92%) with open arthrodesis. Among the other seven joints with percutaneous in situ arthrodesis, six had fibrous union and were asymptomatic at a mean of 18 months, and one failed, requiring revision. One joint with open arthrodesis had fibrous union and was asymptomatic 12 months after surgery. We conclude that open arthrodesis is better than the percutaneous method, as a greater percentage achieve bone union. The open approach allows osteophyte removal and slightly better correction of angular deformity in the coronal plane.