Lindley B. Wall

Diagnostic performance and reliability of ultrasonography for fatty degeneration of the rotator cuff muscles

BACKGROUND Diagnostic evaluation of rotator cuff muscle quality is important to determine indications for potential operative repair. Ultrasonography has developed into an accepted and useful tool for evaluating rotator cuff tendon tears; however, its use for evaluating rotator muscle quality has not been well established. The purpose of this study was to investigate the diagnostic performance and observer reliability of ultrasonography in grading fatty degeneration of the posterior and superior rotator cuff muscles. METHODS The supraspinatus, infraspinatus, and teres minor muscles were prospectively evaluated with magnetic resonance imaging (MRI) and ultrasonography in eighty patients with shoulder pain. The degree of fatty degeneration on MRI was graded by four independent raters on the basis of the modified Goutallier grading system. Ultrasonographic evaluation of fatty degeneration was performed by one of three radiologists with use of a three-point scale. The two scoring systems were compared to determine the diagnostic performance of ultrasonography. The interobserver and intraobserver reliability of MRI grading by the four raters were determined. The interobserver reliability of ultrasonography among the three radiologists was determined in a separate group of thirty study subjects. The weighted Cohen kappa, percentage agreement, sensitivity, and specificity were calculated. RESULTS The accuracy of ultrasonography for the detection of fatty degeneration, as assessed on the basis of the percentage agreement with MRI, was 92.5% for the supraspinatus and infraspinatus muscles and 87.5% for the teres minor. The sensitivity was 84.6% for the supraspinatus, 95.6% for the infraspinatus, and 87.5% for the teres minor. The specificity was 96.3% for the supraspinatus, 91.2% for the infraspinatus, and 87.5% for the teres minor. The agreement between MRI and ultrasonography was substantial for the supraspinatus and infraspinatus (kappa = 0.78 and 0.71, respectively) and moderate for the teres minor (kappa = 0.47). The interobserver reliability for MRI was substantial for the supraspinatus and infraspinatus (kappa = 0.76 and 0.77, respectively) and moderate for the teres minor (kappa = 0.59). For ultrasonography, the interobserver reliability was substantial for all three muscles (kappa = 0.71 for the supraspinatus, 0.65 for the infraspinatus, and 0.72 for the teres minor). CONCLUSIONS The diagnostic performance of ultrasonography in identifying and grading fatty degeneration of the rotator cuff muscles was comparable with that of MRI. Ultrasonography can be used as the primary diagnostic imaging modality for fatty changes in rotator cuff muscles.

Proximal Row Carpectomy: Minimum 20-Year Follow-Up

PURPOSE Proximal row carpectomy (PRC) is a motion-sparing procedure for degenerative disorders of the proximal carpal row. Reported results at a minimum 10-year follow-up consistently show maintenance of strength, motion, and satisfaction with an average conversion rate to radiocarpal arthrodesis of 12%. We hypothesized that PRC would continue to provide a high level of satisfaction and function at a minimum of 20 years. METHODS Seventeen wrists in 16 patients, including 7 laborers, underwent PRC for symptomatic degenerative disorders of the proximal carpal row at an average age of 36 years. Patients returned for radiographic and clinical evaluation, and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire and Patient-Related Wrist Evaluation were used for subjective assessment. Follow-up was a minimum of 20 years (average, 24 y). RESULTS Eleven wrists (65%) underwent no further surgery at a minimum 20-year follow-up. The average time to failure of PRC, defined as the time from PRC to radiocarpal arthrodesis, was 11 years (range, 8 mo to 20 y). Ten of 11 patients who did not undergo radiocarpal arthrodesis continued to be satisfied, with minimal decrease in motion and grip strength compared with the uninvolved side. Average score for QuickDASH was 16 and for Patient-Related Wrist Evaluation was 26. The flexion-extension arc was 68°, and grip strength was 72% of the contralateral side. All patients returned to their original employment. There was no correlation between degenerative radiographic changes and satisfaction level. The predicted probability of failure revealed a higher risk in patients who underwent PRC at a younger age, which leveled off at age 40 years. CONCLUSIONS PRC provides satisfaction at a minimum of 20 years with a survival rate of 65%. Whereas we recommend a minimum age for PRC between 35 and 40 years, young patients should not be excluded as PRC candidates; these patients should undergo appropriate preoperative counseling of their increased failure risk secondary to their young age. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Clinical Outcomes of Double-Row Versus Single-Row Rotator Cuff Repairs

PURPOSE The purpose of this review was to determine whether there is a difference in the clinical outcome between single-row and double-row rotator cuff repairs. METHODS We performed a systematic review of the results of clinical studies investigating and comparing double-row and single-row repair techniques. The articles meeting the inclusion and exclusion criteria were assessed for quality of the study; the results were then reviewed to provide a concise conclusion regarding the clinical outcomes of double-row versus single-row rotator cuff repair. RESULTS There were 3 Level I studies and 2 Level II studies comparing the clinical outcomes of double-row and single-row rotator cuff repair. At 1-year follow-up, there was no statistically significant clinical difference between patients who had undergone double-row repair and those who had undergone single-row rotator cuff repair. CONCLUSIONS Arthroscopic rotator cuff repairs with double-row repair show no significant difference compared with single-row repair in clinical outcome at 1-year follow-up. Additional prospective, randomized controlled trials are needed with longer-term follow-up to determine whether there is any clinical difference between the 2 techniques. LEVEL OF EVIDENCE Level II, systematic review of Level I and II studies.

Double-row vs single-row rotator cuff repair: A review of the biomechanical evidence

HYPOTHESIS A review of the current literature will show a difference between the biomechanical properties of double-row and single-row rotator cuff repairs. BACKGROUND Rotator cuff tears commonly necessitate surgical repair; however, the optimal technique for repair continues to be investigated. Recently, double-row repairs have been considered an alternative to single-row repair, allowing a greater coverage area for healing and a possibly stronger repair. MATERIALS AND METHODS We reviewed the literature of all biomechanical studies comparing double-row vs single-row repair techniques. Inclusion criteria included studies using cadaveric, animal, or human models that directly compared double-row vs single-row repair techniques, written in the English language, and published in peer reviewed journals. Identified articles were reviewed to provide a comprehensive conclusion of the biomechanical strength and integrity of the repair techniques. RESULTS Fifteen studies were identified and reviewed. Nine studies showed a statistically significant advantage to a double-row repair with regards to biomechanical strength, failure, and gap formation. Three studies produced results that did not show any statistical advantage. Five studies that directly compared footprint reconstruction all demonstrated that the double-row repair was superior to a single-row repair in restoring anatomy. CONCLUSIONS The current literature reveals that the biomechanical properties of a double-row rotator cuff repair are superior to a single-row repair. LEVEL OF EVIDENCE Basic Science Study, SRH = Single vs. Double Row RCR.

Long-Term Results of Swanson Silicone Arthroplasty for Proximal Interphalangeal Joint Osteoarthritis

PURPOSE To review the long-term outcome of the Swanson silicone arthroplasty in the osteoarthritic proximal interphalangeal (PIP) joint at a single institution. METHODS We identified 51 patients who had undergone PIP joint Swanson silicone arthroplasty for osteoarthritis and included in the study only those 22 patients (38 joints) who responded and could follow up. These patients returned for follow-up evaluation at an average of 10 years (range, 2-24 y). Subjective outcomes were assessed using the Quick-Disabilities of the Arm, Shoulder, and Hand questionnaire, visual analog pain scale, and Likert questionnaire scores. Clinical and radiographic objective data were collected by measuring range of motion and coronal plane deformation and assessing final radiographs. RESULTS Silicone arthroplasty at the PIP joint consistently provided pain relief in patients who returned for follow-up. The average Quick-Disabilities of the Arm, Shoulder, and Hand score was 17 and the average pain visual analog scale score was 0.4. The Likert questionnaire revealed that on average, patients agreed or strongly agreed that they would have surgery again, would recommend surgery to another patient, and were satisfied at an average of 10 years after surgery. Patients had neutral responses when they rated appearance, functional improvement, and range of motion. Objectively, range of motion (flexion arc of 50°) did not significantly change from the preoperative flexion arc (55°). Radiographically, 31 implants had deformation, including 21 with implant fracture. There were 3 revisions for symptomatic implant fractures and 1 implant was removed for infection. There was no correlation between radiographs and satisfaction. CONCLUSIONS Despite unchanged range of motion and considerable radiographic implant deformation or fracture, patients obtained consistent pain relief and satisfaction. With an implant survivorship of 90% at average of 10 years postoperatively, silicone implant arthroplasty remains our treatment of choice for the symptomatic osteoarthritic PIP joint. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Clinical and Radiographic Outcomes of Metacarpophalangeal Joint Pyrolytic Carbon Arthroplasty for Osteoarthritis

PURPOSE To determine the effectiveness of pyrolytic carbon arthroplasty for the management of primary osteoarthritis of the metacarpophalangeal joint. METHODS A retrospective review of 11 pyrolytic carbon arthroplasties for osteoarthritis of the metacarpophalangeal joint, performed by a single surgeon, was conducted. All patients returned for clinical assessment at a minimum of 2 years after surgery. Evaluation included range of motion, pain and functional scores, and patient satisfaction. Validated outcome measures included the Michigan Hand Questionnaire and Quick Disabilities of the Arm, Shoulder, and Hand. Radiographs were assessed for implant failure, loosening, migration, and subsidence. RESULTS The average follow-up was 4 years (minimum 2 y). The arc of motion significantly improved from 62° before surgery to 76° after surgery. Grip strength decreased slightly compared to the contralateral side (average, 3 kg). The average pain score was 1 on a 10-point visual analog scale. All but 1 patient were fully satisfied at final follow-up. All patients who were working before surgery returned to work after surgery. The Michigan Hand Questionnaire average score was 80, and the Quick Disabilities of the Arm, Shoulder, and Hand average score was 22. Two patients experienced persistent, asymptomatic squeaking and clicking, and 1 patient reported extensor tendon subluxation. One joint had conversion to arthrodesis for continued, unexplained pain. All surviving implants had a surrounding lucency on radiographs. The average subsidence was 3 mm; there was no implant migration, fracture, or dislocation. CONCLUSIONS Pyrolytic carbon arthroplasties of the metacarpophalangeal joint resulted in satisfactory outcomes at average 4-year follow-up, with improved joint motion, good pain relief and satisfaction, and few complications. Radiographic outcomes revealed a consistent, asymptomatic surrounding lucency with no evidence of implant failure or migration.

Digit Replantation: Experience of Two U.S. Academic Level-I Trauma Centers

BACKGROUND Despite advances in microsurgery, digit replantation now is performed less frequently in the U.S. compared with fifteen years ago. There has been uncertainty regarding whether previously reported U.S. replantation success rates and results reported from other countries reflect the current experience in the U.S. We hypothesized that the success of digit replantation at two academic level-I referral hospitals in the U.S. would be similar to previously published results. METHODS In this retrospective case series, we examined all cases of digit replantation that were performed from 1997 through 2010 at two institutions. The cumulative rate of viable digit replantations was determined. Binary logistic regression modeling determined the relative impact of patient, injury, and operative factors on replantation survival. RESULTS During the study period, 135 digit replantations were performed in 106 patients. Fourteen cases did not meet our inclusion criteria, yielding a cohort of 121 replantations. The thumb (n = 40) was the most commonly replanted digit, followed by the long finger (n = 31). The mechanism of injury was classified as sharp in eighty-three digits, crush in nineteen digits, and avulsion in eighteen digits. The majority of replantations were performed following Tamai level-III (n = 49) or level-IV (n = 56) amputations. Sixty-nine (57%) of the digit replantation procedures were successful. Logistic regression analysis identified replantation of the radial three digits and no history of tobacco use as significant independent predictors of replantation success. CONCLUSIONS The rate of success of digit replantation (57%) at two academic level-I trauma hospitals was lower than previously published rates. Radial-digit involvement and no prior tobacco use were associated with replantation success. This modest success rate reflects a need for additional evaluation of our current benchmarks and clinical settings for replantation surgery. These data help to better inform patients, families, and physicians who are considering digit replantation.

Development of novel 3D-printed robotic prosthetic for transradial amputees

Background and aim: Upper extremity myoelectric prostheses are expensive. The Robohand demonstrated that three-dimensional printing reduces the cost of a prosthetic extremity. The goal of this project was to develop a novel, inexpensive three-dimensional printed prosthesis to address limitations of the Robohand. Technique: The prosthesis was designed for patients with transradial limb amputation. It is shoulder-controlled and externally powered with an anthropomorphic terminal device. The user can open and close all five fingers, and move the thumb independently. The estimated cost is US

Acute compartment syndrome after intramedullary nailing of isolated radius and ulna fractures in children.

300. Discussion: After testing on a patient with a traumatic transradial amputation, several advantages were noted. The independent thumb movement facilitated object grasp, the device weighed less than most externally powered prostheses, and the size was easily scalable. Limitations of the new prosthetic include low grip strength and decreased durability compared to passive prosthetics. Clinical relevance Most children with a transradial congenital or traumatic amputation do not use a prosthetic. A three-dimensional printed shoulder-controlled robotic prosthesis provides a cost effective, easily sized and highly functional option which has been previously unavailable.

Osteotomy for Clinodactyly

Background: There exist varying reports in the literature regarding the incidence of compartment syndrome (CS) after intramedullary (IM) fixation of pediatric forearm fractures. A retrospective review of the experience with this treatment modality at our institution was performed to elucidate the rate of postoperative CS and identify risk factors for developing this complication. Methods: In this retrospective case series, we reviewed the charts of all patients treated operatively for isolated radius and ulnar shaft fractures from 2000 to 2009 at our institution and identified 113 patients who underwent IM fixation of both-bone forearm fractures. There were 74 closed fractures and 39 open fractures including 31 grade I fractures, 7 grade II fractures, and 1 grade IIIA fracture. If the IM nail could not be passed easily across the fracture site, a small open approach was used to aid reduction. Results: CS occurred in 3 of 113 patients (2.7%). CS occurred in 3 of 39 (7.7%) of the open fractures compared with none of 74 closed fractures (P=0.039), including 45 closed fractures that were treated within 24 hours of injury. An open reduction was performed in all of the open fractures and 38 (51.4%) of the closed fractures. Increased operative time was associated with developing CS postoperatively (168 vs. 77 min, P<0.001). CS occurred within the first 24 postoperative hours in all 3 cases. Conclusion: CS was an uncommon complication after IM fixation of pediatric diaphyseal forearm fractures in this retrospective case series. Open fractures and longer operative times were associated with developing CS after surgery. None of 45 patients who underwent IM nailing of closed fractures within 24 hours of injury developed CS; however, 51.4% of these patients required a small open approach to aid reduction and nail passage. We believe that utilizing a small open approach for reduction of one or both bones, thereby avoiding the soft-tissue trauma of multiple attempts to reduce the fracture and pass the nail, leads to decreased soft-tissue trauma and a lower rate of CS. We recommend a low threshold for converting to open reduction in cases where closed reduction is difficult.