Michael R. Hausman

Latissimus dorsi tendon transfer for massive rotator cuff tears: a cadaveric study.

Certain massive defects of the rotator cuff tendinous insertion cannot be repaired primarily to the greater tuberosity. If restoration of strength is an important treatment goal to the patient, then a tendon transfer may be considered. Ten cadaver shoulders were dissected to define the anatomy of the latissimus dorsi tendon (LDT) and its distance relationship to the axillary and radial nerves with the arm in various positions. The axillary nerve lies superior to the LDT insertion, and the radial nerve passes medial and inferior to the LDT insertion. With the arm internally rotated and the shoulder flexed, the distances from the axillary and radial nerves to the LDT insertion were 2.3 cm and 2.8 cm, respectively. With the arm internally rotated and the shoulder abducted, the distances from the axillary and radial nerves to the LDT insertion were 1.8 cm and 2.0 cm, respectively. Understanding specific anatomic relationships is one of the factors contributing to the safety of the LDT transfer procedure with respect to nerve injury.

Effectiveness of interventions for secondary Raynaud's phenomenon: a systematic review.

OBJECTIVES To present an evidence-based overview of the effectiveness of (non)surgical symptomatic interventions to treat secondary Raynauds phenomenon (RP). DATA SOURCES The Cochrane Library, PubMed, Embase, PEDro, and CINAHL were searched for relevant systematic reviews and randomized controlled trials (RCTs). STUDY SELECTION Two reviewers independently applied the inclusion criteria to select potential studies. DATA EXTRACTION Two reviewers independently extracted data and assessed the methodologic quality. DATA SYNTHESIS If pooling of data was not possible, a best-evidence synthesis was used to summarize the results. Of the 5 reviews and 19 RCTs included, 1 RCT studied acupuncture and another RCT reported on percutaneous radiofrequency thoracic sympathectomy. All others concentrated on the effectiveness of drugs (oral or intravenous [IV]). It appeared that calcium channel blockers significantly reduce the frequency and severity of Raynaud attacks, and are therefore effective in the treatment of secondary RP. Iloprost (oral and IV) was also found to be effective. Limited evidence was found for atorvastatin. For other traditional and more recently discovered interventions, no clear favorable effects were found. CONCLUSIONS This review shows that there is clear evidence in favor of calcium channel blockers and iloprost (oral and IV) to treat secondary RP. For all other interventions, only limited, conflicting, or no evidence was found. More high-quality, well-designed RCTs are needed in this field, especially for new interventions based on recent knowledge about the pathophysiology of secondary RP.

Recalcitrant distal humeral and proximal forearm nonunion: salvage using an extended pedicled radial forearm osseous flap.

Although most humeral fractures unite without surgical intervention there is a published nonunion rate of up to 30%. Good results are generally obtained in approximately 90% of patients with repeat open reduction and internal fixation with autogenous bone graft or substitutes. However, intractable nonunion remains a problem with serious morbidity and disability. Such patients may have undergone multiple surgical procedures resulting in bony deficiencies or infection. Risk factors for nonunion include mechanical instability, insufficient vascularity, and presence of infection. Mechanical instability may be a feature of the fracture characteristics or inappropriate surgical intervention. Insufficient vascularity may be caused by systemic factors such as cigarette smoking or local insufficiency, for example, because of iatrogenic excessive soft tissue stripping at the time of surgery. Adequate vascularity is necessary for reliable bone healing. Trueta and Rhinelander noted the high incidence of nonunion when capillaries failed to bridge the fracture site in a dog tibia model. Richards et al. demonstrated regional differences in healing rates with the submuscular areas of the bone healing first. He attributed this to increased blood flow in these areas. Hausman et al. produced consistent nonunion in an established, low-energy, nondisplaced, internally fixed rat femur fracture model solely be interfering with vascular endothelial cell recruitment and migration. This is striking for a fracture model that shows robust and reliable healing under most conditions. Clinical experience confirms the importance of good vascularity. Aside from the liver, bone has the greatest density of microvascular networks in the body. Nonunion or delayed union complicate fractures with marginal circulation, including scaphoid, femoral head, and open grade III fractures with soft tissue stripping. Other studies also implicate defective angiogenesis in impaired fracture healing. Clinical observation shows atrophic nonunion to be fibrous and relatively hypovascular. They are resistant to conventional therapies, such as PEMF, nonvascularized bone grafting and BMP. Wide resection of the atrophic, avascular or infected area, and vascularized bone grafting, which bridges from healthy bone to healthy bone has become the treatment of choice for resistant nonunion and has a high rate of success. Unfortunately, vascularized bone grafting usually entails a microvascular-free tissue transfer, and thus has several disadvantages. Such procedures are likely to be lengthy and technically challenging. Donor sites are also limited, with the fibula being the donor site of choice for many applications. Also, microvascular transfer to a highly compromised area may put the pedicle or anatomosis at risk because of unfavorable geometry or scarred and noncompliant tissues. Pedicled or island flaps that do not involve a microvascular anastomosis are technically easier and less time consuming. However, good, suitable, reliable local bone flaps are infrequently available for most fractures. We describe a versatile, previously unreported osseous or osteocutaneous pedicled island bone flap useful for fractures in the forearm and distal third of the humerus and report our experience in five cases.

Outcomes, complications, utilization trends, and risk factors for primary and revision total elbow replacement.

BACKGROUND Using a validated database, 30-day complications of primary and revision total elbow arthroplasty (TEA) were analyzed to identify risk factors of adverse events. METHODS Primary and revision TEAs from 2007 to 2013 were identified in the National Surgical Quality Improvement Program database. Bivariate and multivariate analyses of risk factors for 30-day adverse events were assessed using preoperative and intraoperative variables. RESULTS The study reviewed 189 primary and 53 revision TEA patients. Fracture (34%), osteoarthritis (24%), and rheumatoid arthritis (23%) were the most common indications for TEA. Adverse event rate was similar in primary and revision TEA (12% vs. 15%; P = .49), and infectious complications occurred in 3.2% of primary TEAs and 7.5% of revision TEAs (P = .23). Bivariate analysis of risk factors for 30-day adverse events identified dependent functional status in primary TEA (P = .03) and age in revision TEA (P = .02). Multivariate analysis of primary TEA revealed that adverse events were significantly less likely with rheumatoid arthritis compared with osteoarthritis etiology (odds ratio, 0.15; P = .02), and smoking was associated with an increased chance of infection (odds ratio, 6.96; P = .03). Revision TEA was not associated with an increased 30-day adverse event or infection rate compared with primary TEA in multivariate analysis. Among primary and revision TEA patients, dependent functional status (P = .02) and hypertension (P = .04) were independent predictors for adverse events. CONCLUSION Modifiable risk factors should be addressed before TEA to limit postoperative complications as well as cost. The risk of short-term complications after revision TEA is comparable to that of primary TEA.

Examination of the Elbow: Current Concepts

The elbows complex anatomy and synergism of bony and ligamentous stabilizers make physical examination challenging. Adequate elbow assessment is essential for accurate diagnosis and initiating proper treatment. Isolated elbow injuries are rare; fractures should be interpreted as proxies for associated, often unappreciated, soft tissue injuries. A careful elbow examination informs the need for and interpretation of radiological studies, including fluoroscopy, magnetic resonance imaging, and computed tomography scanning.

Turek's Orthopaedics: Principles and Their Application. 6th ed.

Stuart L. Weinstein and Joseph A. Buckwalter, editors. Philadelphia: Lippincott Williams and Wilkins; 2005. 761 pages.

Outcome of arthroscopic reduction association of the scapholunate joint

139.00. “He was a collector of information not notoriety,” was how Leonard Goldner described Samuel L. Turek, the original author of this text. The first edition, written entirely by Dr. Turek and published in 1959, was prefaced, “This book was born of a desire to compile scientifically accurate information relating to orthopaedic surgery and to formulate a method by which these facts are readily accessible.” The book achieved those goals and Dr. Turek edited three subsequent editions, with the last being published in 1984. The first edition had 906 pages in a single volume, while the fourth edition contained 1797 pages in two volumes. Stuart Weinstein and Joseph Buckwalter became coeditors in 1994, in time for the fifth edition. They returned to Dr. Tureks original size and purpose for that edition and have continued the tradition in the sixth edition. There are thirty-five contributing …

Percutaneous Freehand™ System Intramuscular Electrode Placement

This study evaluates the arthroscopic reduction association scapholunate technique and outcomes. A total of 18 patients with chronic scapholunate instability with mean follow-up of 36 months were reviewed. Postoperatively, the mean visual analogue score was 2.5 and the mean DASH score was 8. The grip strength was 27 kg on the operative side compared with 32 kg on the uninjured side. The mean wrist flexion was 46° and extension was 56°. Seven patients had complications. Six patients had scapholunate joint widening, one had windshield-wipering of the screws with loss of reduction, and two demonstrated progression of scapholunate advanced collapse deformity. Four patients underwent revision surgeries: two revision arthroscopic reduction association scapholunates and two proximal row carpectomies. A preoperative scapholunate gap of greater than 5 mm and the presence of scapholunate advanced collapse Grade I were both predictive of a complication or revision surgery. Patients with a scapholunate gap of greater than 5 mm or scapholunate advanced collapse had statistically higher complications rates. Level of Evidence IV.

Distal biceps tendon history, updates, and controversies: from the closed American Shoulder and Elbow Surgeons meeting—2015

The FreeHand™ (NeuroControl Corporation, USA) system is an implantable electronic neuroprosthesis designed to stimulate muscles of tetraplegic upper limbs to achieve lateral pinch and simple grasp. When first introduced, the system required insertion through multiple large incisions, but recently introduced intramuscular electrodes have allowed the development of a percutaneous electrode placement technique. The technique minimizes incisions, decreases overall operative time and patient morbidity and improves the outcome by minimizing tendon adhesions.

Chronic Mycobacterium infection of first dorsal web space after accidental Bacilli Calmette-Guérin injection in a health worker: case report.

Understanding of the distal biceps anatomy, mechanics, and biology during the last 75 years has greatly improved the physicians ability to advise and to treat patients with ruptured distal tendons. The goal of this paper is to review the past and current advances on complete distal biceps ruptures as well as controversies and future directions that were discussed and debated during the closed American Shoulder and Elbow Surgeons meeting in 2015.