Mark E. Baratz

Meniscal tears: The effect of meniscectomy and of repair on intraarticular contact areas and stress in the human knee A preliminary report

The role of the meniscus in load transmission across the knee has long been a subject of debate. In this study, we examined the biomechanical consequences of the operative treatments for bucket-handle and pe ripheral meniscal tears. Contact areas and instanta neous intraarticular pressure distributions were meas ured in two groups of human cadaver knees. In Group I, consisting of four knees, we created a bucket-handle tear involving the inner one-third of the meniscus, followed by partial, and then total meniscec tomy. Knees were tested in an Instron testing machine after each procedure, using a 400 pound load at 0° or 30° flexion. Contact areas and local stresses were measured using Prescale, a pressure-sensitive film. After partial meniscectomy, contact areas decreased approximately 10%, and peak local contact stresses (PLCS) increased approximately 65%. After total men iscectomy, contact areas decreased approximately 75%, and PLCS increased approximately 235%. In Group II, consisting of three additional knees, we created a 2 cm peripheral tear of the posterior meniscal horn, followed by open repair, arthroscopic repair, seg mental, and then total meniscectomy. Repair of the tear was accomplished with either vertically placed sutures by an open technique or horizontally placed sutures by an arthroscopic technique. Knees were tested in the neutral position in the Instron machine and contact areas and local stresses measured using Prescale. PLCSs and contact areas were found to be the same using either repair technique. There was, however, a 110% increase in PLCS after segmental meniscectomy of that portion of the meniscus involved in the peripheral tear. These data suggest that the meniscus does have a weightbearing role. Contact stresses increased in pro portion to the amount of meniscus removed and the degree to which the structure of the meniscus was disrupted. Furthermore, there was no difference in the weightbearing characteristics of the meniscus when repaired by open versus arthroscopic technique when the knee is loaded at 0° flexion.

Elbow Arthritis: Current Concepts

Elbow arthritis is a debilitating condition manifesting as a painful, stiff elbow. The purpose of this article is to provide an update and analyze current management, treatment options, and outcomes of treatment for elbow arthritis. This article focuses on recent developments in the treatment for elbow arthritis. Nonsurgical management may provide symptomatic relief in the majority of patients in the early stages of the disease process. Surgical treatment is guided by disease etiology and severity, patient age, and functional demands. Arthroscopic or open synovectomy, debridement arthroplasty, and interposition arthroplasty are generally recommended for the young and active patient population, whereas for low-demand and elderly patients with end-stage painful arthritis, total elbow arthroplasty is considered a more suitable surgical option. Advances in arthroscopic techniques and implant design have led to substantial improvements in the treatment of elbow arthritis.

Life-threatening clavicular osteomyelitis in two debilitated patients.

Two cases are presented of immunologically compromised patients who developed acute pyogenic clavicular osteomyelitis from direct spread of a contiguous focus. Each patients condition declined despite antibiotic therapy drainage procedures until survival was in doubt. Both showed striking reversal of their conditions and recovery when an aggressive surgical debridement (total claviculectomy) was performed. Acute pyogenic osteomyelitis of the clavicle is uncommon and rarely reported. The special implications in our patients of this disease of the adapted therapy are discussed.

Arthroscopically assisted elbow interposition arthroplasty without hinged external fixation: surgical technique and patient outcomes.

BACKGROUND Total elbow arthroplasty is successful in older, lower demand patients but not in the younger, more active individual with severe elbow arthritis. Interposition arthroplasty is an alternative for younger patients who hope to minimize the degree to which arm use is restricted. Interposition arthroplasty traditionally involves release of all ligaments and capsule. As a result, the postoperative care included the use of a hinged external fixator of the elbow to apply distraction and to permit motion during the early phases of healing. We describe a novel surgical technique without a hinged external fixator that allows secure fixation of the interposition graft through arthroscopic assistance and maintains the integrity of the medial collateral ligament with only a takedown and repair of the lateral collateral ligament complex. METHODS A retrospective chart review was performed to analyze 4 patients with an average age of 57 years who underwent surgery between 2007 and 2011. The patients were also contacted to assess elbow-specific American Shoulder and Elbow Surgeons and Disabilities of the Arm, Shoulder, and Hand scores. RESULTS The average follow-up was 3.6 years (range, 2.5-6 years), and 1 patient was converted to a total elbow arthroplasty after 2.5 years because of persistent pain. The remaining 3 patients have done well with regard to pain control, stability, and functional use of the operative extremity. There were no postoperative complications. DISCUSSION On the basis of our small series of patients, an arthroscopically assisted elbow interposition arthroplasty without hinged external fixation can provide satisfactory medium-term outcomes as a salvage procedure for a difficult condition with limited options.

Tethering the Extensor Apparatus Limits PIP Flexion Following K-wire Placement for Pinning Extra-articular Fractures at the Base of the Proximal Phalanx.

Background: Closed reduction with percutaneous Kirschner wires (K-wires) is the most minimally invasive surgical option for stabilizing phalanx fractures. This study examines the effect of K-wire placement on proximal interphalangeal (PIP) joint motion. Methods: PIP joint flexion was measured in the digits of 4 fresh-frozen cadaver hands after placing a suture loop through the flexor tendons and placing tension on the flexors via a mechanical scale. The load necessary to flex the PIP joint to 90° or to maximum flexion was recorded. The load was removed and K-wires were inserted in 3 locations about the metacarpophalangeal joint (MPJ): through the extensor tendon and across the MPJ, adjacent to the extensor tendon insertion site and across the MPJ, and through the sagittal band and into the base of the proximal phalanx (P1). The load on the tendons was reapplied, and angles of PIP joint flexion were recorded for each of the 3 conditions. Results: The mean angle of PIP joint flexion prior to K-wire insertion was 87°, and the mean load applied was 241 g. The angles of flexion were 53° when the K-wire was placed through the extensor tendon, 70° when the K-wire was placed adjacent to the tendon, and 75° when the K-wire was placed into the base of P1 by going through the sagittal band, midway between the volar plate and the extensor tendon. Conclusions: K-wires placed remote from the extensor tendon create less of an immediate tether to PIP joint flexion than those placed through or adjacent to the extensor tendon.

Long-Term Outcome of Step-Cut Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

BACKGROUND Extra-articular ulnar shortening osteotomy is a common procedure for the surgical treatment of ulnar impaction syndrome. Several techniques for this osteotomy have been developed to avoid the morbidity associated with a standard transverse osteotomy. However, these techniques require special instrumentation and are expensive. The purpose of this study was to evaluate the outcome of step-cut ulnar shortening osteotomy without special jigs for ulnar impaction syndrome. METHODS A retrospective study of 164 consecutive patients who underwent step-cut ulnar shortening osteotomy between 2000 and 2010 was performed. The long arm of the step-cut osteotomy was oriented in the coronal plane parallel to the long axis of the ulna. The short arms of the osteotomy were perpendicular to the long axis in the axial plane. Fixation was performed with a palmar 3.5-mm standard neutralization plate and a lag screw. The goal of the osteotomy was to reduce ulnar variance, which was assessed in all patients with pronated grip-view radiographs preoperatively and postoperatively. Preoperative ulnar variance ranged from +1 to +6 mm. RESULTS All patients were followed for at least 24 months. Union of the osteotomy site was achieved at a mean of 8.2 weeks. The union rate was 98.8%. There were 2 cases of nonunion, which required additional surgery. The mean postoperative ulnar variance was +0.2 mm (range, -1 to +1.5 mm) after a mean overall ulnar shortening of 2.5 mm. All patients returned to their previous work, in a mean of 4 months. The plate was removed from 12 patients because of plate-related symptoms. No other complications were encountered. CONCLUSIONS The step-cut ulnar shortening osteotomy provides ample bone-to-bone contact and simplifies control of rotation. Stable internal fixation with standard techniques allowed an early return to functional activities. Palmar placement of the plate diminishes the need for plate removal. This is a simple and less expensive technique for ulnar shortening that does not require the use of special instrumentation in patients with ulnar impaction syndrome. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Neurologic complications in common wrist and hand surgical procedures

Nerve dysfunction after upper extremity orthopedic surgery is a recognized complication, and may result from a variety of different causes. Hand and wrist surgery require incisions and retraction that necessarily border on small peripheral nerves, which may be difficult to identify and protect with absolute certainty. This article reviews the rates and ranges of reported nerve dysfunction with respect to common surgical interventions for the distal upper extremity, including wrist arthroplasty, wrist arthrodesis, wrist arthroscopy, distal radius open reduction and internal fixation, carpal tunnel release, and thumb carpometacarpal surgery. A relatively large range of neurologic complications is reported, however many of the studies cited involve relatively small numbers of patients, and only rarely are neurologic complications included as primary outcome measures. Knowledge of these neurologic outcomes should help the surgeon to better counsel patients with regard to perioperative risk, as well as provide insight into workup and management of any adverse neurologic outcomes that may arise.

Revision Carpal Tunnel Surgery Options

Carpal tunnel syndrome (CTS) affects 1% of the general population and 5% of the working population. Consequently, carpal tunnel release (CTR) is one of the most common procedures performed on the hand. Median nerve entrapment symptoms at the carpal tunnel after CTR can be defined as either failed (persistent or new symptoms) or recurrent CTS. Recurrent CTS is characterized by a symptom-free interval after surgery. The cause of recurrent carpal tunnel is thought to be due to progressive constriction of the nerve via scar formation.

The diagnostic clinical value of thumb metacarpal grind, pressure-shear, flexion, and extension tests for carpometacarpal osteoarthritis

Study design: Clinical measurement. Introduction: Common provocative maneuvers to differentiate thumb carpometacarpal (CMC) osteoarthritis from other sources of pain are the grind, metacarpal (MC) flexion, and MC extension tests. A maneuver known as the pressure‐shear test is described here. Purpose of the study: To compare the diagnostic value of the grind, metacarpal flexion, metacarpal extension, and pressure‐shear tests for CMC osteoarthritis of the thumb. Methods: The diagnostic accuracy of each test was compared in 127 thumbs from 104 patients. Sensitivity, specificity, and predictive values of each test were calculated. In a secondary analysis, polychoric correlation coefficients were used to assess the correlation of each test with severity defined by Eaton‐Littler stage. Results: The overall diagnostic accuracy of the thumb MC grind, pressure‐shear, flexion, and extension tests were 70%, 98%, 47%, and 55%, respectively. The sensitivities were 64%, 99%, 36%, and 46%, respectively, and specificities were 100%, 95%, 100%, and 100%, respectively. For the diagnosis of Thumb CMC arthritis, the MC pressure‐shear test was superior overall in terms of overall diagnostic accuracy and sensitivity, while having comparable specificity to the other maneuvers. Conclusion: The pressure‐shear test was found to be superior to the commonly used grind maneuver and the provocative maneuvers of MC flexion and extension tests to confirm diagnosis of CMC osteoarthritis.

Long-Term Outcome of Step-Cut Ulnar-Shortening Osteotomy for Ulnar Impaction Syndrome

Objective/Hypothesis: Extra-articular ulnar-shortening osteotomy is a common procedure for the surgical treatment of ulnar impaction syndrome. Several techniques for this osteotomy have been developed to avoid the morbidity associated with a standard transverse osteotomy. However, these techniques require special instrumentation and are expensive. The purpose of this study was to evaluate the outcome of step-cut ulnar-shortening osteotomy without special jigs for ulnar impaction syndrome. Materials and Methods: A retrospective review was performed of 164 consecutive patients who underwent step-cut ulnar-shortening osteotomy between 2000 and 2010. Eighty-eight patients were female and 76 were male with a mean age of 36.8 years. Idiopathic ulnar impaction syndrome was diagnosed in 116 patients, while a posttraumatic etiology was seen in 48 patients. The step-cut osteotomy had its long arm oriented in the coronal plane parallel to the long axis of the ulna. The short arms of the osteotomy were perpendicular to the long axis in the axial plane. Fixation was performed with a palmar 3.5 mm standard neutralization plate and a lag screw. The goal of the osteotomy was to reduce ulnar variance by shortening the ulna 2 to 3 mm and not to create neutral variance. Ulnar variance was assessed radiographically preoperatively and postoperatively with the pronated grip view in all patients. The preoperative ulnar variance ranged from +1 mm to +6 mm. Results: Mean follow-up was 62.4 months (24-86 months). Union of the osteotomy was achieved with a mean of 8.2 weeks. The union rate was 98.78%. There were 2 cases of nonunion, which required additional surgery. The mean postoperative ulnar variance was +0.2 mm (range, −1 mm to +1.5 mm) after a mean overall shortening of 2.5 mm. Modified Mayo Wrist Scores improved significantly from a mean of 47.3 (25-65) preoperatively to 88.8 (60-100) postoperatively. All patients returned to their work in a mean of 4 months. Hardware removal was performed in 12 patients (7.3%) due to plate-related symptoms. No other complications were encountered. Conclusions: The step-cut ulnar-shortening osteotomy provides ample bone-to-bone contact and simplifies control of rotation. Stable internal fixation with standard techniques allowed early return to functional activities. Palmar placement of the plate diminishes the need for plate removal caused by irritation. The step-cut ulnar-shortening osteotomy is a simple and cost-effective technique for ulnar-shortening without the use of special instrumentation in patients with ulnar impaction syndrome.