Marianne V. Merritt

The volar approach to proximal interphalangeal joint arthroplasty.

Proximal interphalangeal joint arthroplasty has resulted in good outcomes in patients treated for osteoarthritis, posttraumatic arthritis, and rheumatoid arthritis. Most hand surgeons complete arthroplasties of the proximal interphalangeal joint through a dorsal approach. However, for the past 7 years, we have had positive results with a volar approach. We describe this technique, which avoids injury to the extensor tendon and allows for a more simplified approach to postoperative therapy compared with the therapy regimen required after the dorsal approach.

Outcomes of minimally invasive myotomy for the treatment of achalasia in the elderly.

Laparoscopic Heller myotomy can safely be performed in elderly patients and can provide significant symptom relief.

Laparoscopic management of acute small bowel obstruction: evaluating the need for resection.

Background: Acute small bowel obstruction (SBO) is a common condition encountered by the on-call emergency surgeon. The role of laparoscopy in the management of SBO continues to be defined. This modality can be limited by dilated bowel and inadequate assessment of compromised tissue. This review was undertaken to determine the reliability of laparoscopic evaluation and the subsequent need for bowel resection. Methods: A retrospective review of all patients surgically managed for acute SBO between July 2005 and September 2010 was conducted. The clinical presentation, computed tomographic findings, indications for surgery, type of intervention, need for reoperation, length of stay (LOS), and outcomes were all abstracted. Results: A total of 119 patients were surgically managed for acute SBO during this period, 63 with initial laparoscopy and 56 with an open procedure. Twenty-five (40%) of the laparoscopy patients were converted to open, leaving 38 completed laparoscopically. Of the completed group, three patients underwent bowel resection compared with 16 in the converted group (8% vs. 64%, p < 0.0001). No patients in the completed group required a subsequent procedure for bowel resection. Twenty-three (41%) patients in the open cohort required a resection. LOS was significantly reduced in the completed group (7.7 days) compared with the converted (11.0 days, p = 0.01) and open groups (11.4 days, p = 0.002). Conclusions: Overall, 32% of acute SBOs were managed solely with laparoscopy. No patients requiring a bowel resection were missed using this method of evaluation. Laparoscopic management should be considered as safe and effective initial therapy in most cases of acute SBO. Level of Evidence: III, therapeutic study.

Volar Capsulodesis of the Thumb Metacarpophalangeal Joint at the Time of Basal Joint Arthroplasty: A Surgical Technique Using Suture Anchors

PURPOSE To document the long-term results of our volar metacarpophalangeal (MCP) joint capsulodesis technique that is completed concomitantly with basal joint arthroplasty and involves a suture anchor placement, short-term pinning, and a rigid hand therapy protocol. METHODS We conducted a retrospective chart review to examine results over a 30-month period of our volar capsulodesis technique. Follow-up results were recorded 26 to 48 months after surgery. The treatment regimen included suture anchors, joint pinning for 6 weeks, and a strict hand therapy protocol. Indications for surgery were thumb MCP joint hyperextension deformity of at least 30° and radiographic evidence of stage 3 (or greater) basal joint arthritis. We examined preoperative and postoperative range of motion, pain, pinch strength, and complications. Average patient age was 63 years (range, 55-77 y). We treated 14 thumbs in 14 patients. RESULTS After capsulodesis, average range of motion for the MCP joint of the thumb was 4° extension and 46° flexion. The last follow-up indicated no cases of hyperextension contracture. Complications included one superficial pin track infection (treated with oral antibiotics) and one patients report of pain at the thumb MCP joint. CONCLUSIONS When completed as described, thumb MCP joint capsulodesis performed concurrently with trapeziometacarpal arthroplasty can be a straightforward procedure that produces positive results. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Epithelioid Hemangioendothelioma of the Distal Radius: A Case Report.

Epithelioid hemangioendothelioma is a rare vascular tumor with cytologic behavior between angiosarcoma and hemangioma. We present the case of a 58-year-old male with primary epithelioid hemangioendothelioma of the distal radius measuring 6.2 × 5 cm with extension into the pronator quadratus and brachioradialis muscles. We discuss our approach to performing a limb-sparing resection combined with reconstruction to preserve upper extremity function. A review of the clinical, radiographic, and pathologic features of epithelioid hemangioendothelioma is also presented.

Results of the Volar Approach in Proximal Interphalangeal Joint Arthroplasty

BACKGROUND Most hand surgeons use a dorsal approach for proximal interphalangeal (PIP) joint implant arthroplasty. However, a volar approach offers the advantage of no disturbance to the extensor mechanism, thus allowing early initiation of active range of motion. We examined our results in patients who underwent PIP joint arthroplasty via a volar approach. METHODS Using a retrospective chart review, we evaluated the outcomes of patients undergoing PIP joint arthroplasty through a volar approach between 2001 and 2005 by 3 fellowship-trained hand surgeons at our institution. The indication for surgery was PIP joint pain with radiographic evidence of joint destruction. Variables included implant type, diagnosis, affected digit(s), preoperative and postoperative range of motion, and complications. Hand therapy was initiated on postoperative day 3 or 4. RESULTS Over the 5 years, 25 PIP joints were replaced in 18 women and 2 men with the volar approach. Replacements consisted of 14 surface replacement prostheses, 9 pyrocarbon prostheses, and 2 silicone prostheses. The average age of patients at prosthesis implantation was 64 years (range, 39-75 years). Prostheses were placed in 1 index, 12 long, 7 ring, and 5 small digits. Average follow-up period was 33 months (range, 24-69 months). Preoperative diagnoses were osteoarthritis (14), rheumatoid arthritis (4), and posttraumatic arthritis (2). Preoperative total arc of motion averaged 42° (range, 0° extension to 80° flexion); postoperative total arc of motion averaged 56° (range, -10° extension to 90° flexion). Complications comprised 1 swan neck deformity, 1 deep infection, 1 dislocation (early), and 2 loose implants with flexion contractures. Seventeen patients had minimal or no pain at their last follow-up visit. CONCLUSIONS PIP joint arthroplasty can be successfully implemented through a volar approach with various implant types and has outcomes similiar to the published results of the dorsal approach.

Revision of failed, recurrent or complicated pectus excavatum after Nuss, Ravitch or cardiac surgery

Pectus excavatum (PE) can recur after both open and minimally invasive repair of pectus excavatum (MIRPE) techniques. The cause of recurrence may differ based on the initial repair procedure performed. Recurrence risks for the open repair are due to factors which include incomplete previous repair, repair at too young of age, excessive dissection, early removal or lack of support structures, and incomplete healing of the chest wall. For patients presenting after failed or recurrent primary MIRPE repair, issues with support bars including placement, number, migration, and premature removal can all be associated with failure. Connective tissue disorders can complicate and increase recurrence risk in both types of PE repairs. Identifying the factors that contributed to the previous procedures failure is critical for prevention of another recurrence. A combination of surgical techniques may be necessary to successfully repair some patients.