Peter C. Rhee

Management of Thumb Metacarpophalangeal Ulnar Collateral Ligament Injuries

Untreated ulnar collateral ligament (UCL) injury of the thumb metacarpophalangeal joint (MCPJ) can lead to long-term pain and functional limitations.Detection of a UCL injury involves sequential examination of true and accessory ligaments and comparison with the uninjured side.Acute partial UCL injuries can be successfully treated nonoperatively.Acute complete or displaced UCL injuries can be successfully treated with operative repair.In cases of chronic UCL injury, treatment options include static and dynamic reconstructions.If painful arthrosis is present with chronic UCL instability, salvage may be performed with MCPJ fusion.

Iatrogenic Brachial Plexus Injuries Associated With Open Subpectoral Biceps Tenodesis A Report of 4 Cases

Open subpectoral biceps tenodesis (OSPBT) is performed with increasing frequency as a treatment for instability of the long head of the biceps tendon (LHBT) or tendinosis. The technique was first described in 2005 as an efficient and reproducible technique, afforded by the clearly identifiable surgical anatomy. Advocates stressed that OSPBT does not violate muscle-tendon units, can re-create the length-tension relationship of the LHBT, provides stable initial fixation, and removes the tendon from the intertubercular groove, which may be a source of persistent tenosynovitis and pain. In this same report, the clinical results of 41 patients who underwent OSPBT were presented, and no complications were described at a mean follow-up of 29 months. Although OSPBT has been recommended as a safe and technically straightforward procedure, rare iatrogenic brachial plexus injuries (BPIs) can occur. Nho et al noted 1 patient with musculocutaneous nerve palsy 10 days after OSPBT who underwent surgical exploration at 6 weeks postoperatively without evidence of nerve discontinuity and subsequent resolution of symptoms by 6 months postoperatively. Similarly, Ma et al reported on a patient with musculocutaneous nerve palsy after OSPBT that was caused by malpositioning of the LHBT deep into the musculocutaneous nerve with consequent entrapment of the nerve. The patient had full resolution of symptoms after revision OSPBT (with the LHBT in an anatomic position) and neurolysis at 3 months postoperatively. To our knowledge, no other nerve injuries have been reported after OSPBT. The purpose of this case series is to illustrate a variety of iatrogenic BPIs sustained at the time of OSPBT that were evaluated and treated at a national, referral, multidisciplinary brachial plexus center. In addition, a review of the potential causes of BPIs that can occur during OSPBT is presented with perioperative measures that may prevent the occurrence of these iatrogenic injuries. The patients described in this case series underwent their index OSPBT at various outside medical facilities. Their clinical history and operative details were obtained from transferred medical records and in communication with the primary surgeon when available.

Revision total shoulder arthroplasty for painful glenoid arthrosis after humeral head replacement: the nontraumatic shoulder

HYPOTHESIS This study was conducted to test the hypothesis that patients would have improved pain and range of motion after conversion total shoulder arthroscopy but that overall outcome would be substantially affected by the need for removal of the humeral component and associated alterations of bony anatomy or soft tissue deficiencies. MATERIALS AND METHODS Thirty-four patients (34 shoulders) with HHR after a proximal humeral fracture underwent revision total shoulder arthroplasty for painful glenoid arthrosis, with mean follow-up of 9.4 years (range, 2.3-20.4 years). After initial review, repeat analysis was performed based on the complexity of osseous (humeral stem revision) and soft tissue management, including rotator cuff tear, greater tuberosity resorption, malunion or nonunion, or instability. RESULTS Overall, patients had reduction in pain (P = .0001), and improved active abduction (P = .05) and external rotation (P = .0005). Less improvement in active abduction was documented in patients who required soft tissue management (P = .03). Results of the modified Neer rating documented 3 excellent, 9 satisfactory, and 22 unsatisfactory results (motion deficiencies in 14). Kaplan-Meier survival analysis free of repeat revision was 100% at 1 year, 96.8% at 5 years (95% confidence interval, 90%-100%), and 92.2% at 10 years (95% confidence interval, 82% to 100%). DISCUSSION Conversion total shoulder arthroplasty is effective for addressing painful glenoid arthrosis after primary HHR for a proximal humeral fracture, with or without the need to change the humeral component. However, active motion may not improve in patients with rotator cuff tearing, a greater tuberosity nonunion, malunion, or resorption.

Association Between Lunate Morphology and Carpal Collapse in Cases of Scapholunate Dissociation

PURPOSE Type II lunate morphology has recently been shown to decrease the incidence of dorsal intercalated segment instability (DISI) deformity in patients with scaphoid nonunions. A similar association has been suggested for scapholunate dissociation, but a formal comparison has yet to be performed. The purpose of this study was to determine if an association exists between lunate morphology and DISI in cases of scapholunate dissociation. METHODS A retrospective review was performed on 58 patients with the diagnosis of scapholunate dissociation as determined by use of radiographs, magnetic resonance imaging, arthrotomy, and arthroscopy. Posteroanterior radiographs were used to assess the presence of a medial facet on the lunate and to determine the distance between the capitate and the triquetrum. A DISI deformity was defined as a radiolunate angle >15 degrees, and scapholunate instability was defined as a scapholunate angle >60 degrees using the tangential method. Statistical analysis was performed with a chi-squared test and kappa test. RESULTS Twenty-five patients had a type I lunate, and 33 patients had a type II lunate. A total of 15 patients had DISI deformity on preoperative radiographs; of these, 10 patients with a type I lunate and 5 patients with a type II lunate had DISI deformity. This difference was found to be significant. CONCLUSIONS In cases of scapholunate dissociation, type II lunates were associated with a significantly lower incidence of DISI despite having radiographic or arthroscopic evidence of a complete scapholunate interosseous ligament tear. Osseous morphology may play a role in the development of a radiographic DISI deformity. Further research is required to assess the clinical importance of this finding and the biomechanical cause of this phenomenon. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.

Vascularized bone grafts for scaphoid nonunions.

Scaphoid fractures that fail to unite are at risk of developing avascular necrosis and progressive structural collapse, thereby complicating attempts at revision surgical treatment. Vascularized bone grafts have demonstrated utility in promoting consolidation in the treatment of scaphoid nonunions complicated by avascular necrosis. Numerous pedicled and free vascularized grafts have been described with variable, but generally favorable, outcomes. Understanding the indications for different grafts is critical to the successful application of these techniques and grafts in the treatment of challenging scaphoid nonunions.

Avoiding and Treating Perioperative Complications of Distal Radius Fractures

Numerous methods of treatment are available for the management of distal radius fractures, with modern trends favoring volar fixed-angle distal radius plates. Whatever the method of fixation, recognition, management, and prevention of the known associated complications are essential to achieve a good outcome. This article reviews the common preventable complications that are associated with operative treatment of distal radius fractures, including tendon injuries, inadequate reduction, subsidence or collapse, intra-articular placement of pegs or screws, nerve injuries, complex regional pain syndrome, carpal tunnel syndrome, and compartment syndrome.

The rate of successful four-corner arthrodesis with a locking, dorsal circular polyether-ether-ketone (PEEK-Optima) plate.

The purpose of this study is to evaluate the rate of union after four-corner arthrodesis with a locking, dorsal circular plate comprised of polyether-ether-ketone. A retrospective review was conducted of all patients who underwent four-corner arthrodesis with a locking, dorsal circular plate at our institution from January 2005 to May 2009. The primary outcome measure was radiographic and clinical union. During the study period, 26 consecutive wrists underwent four-corner arthrodesis with a locking, dorsal circular plate. Twenty-three wrists were included. The mean clinical follow-up was 16 months (range 3–37). Union was achieved in 22 of 23 wrists at a mean time of 3 months (range 1–12). There was one partial union that underwent successful revision arthrodesis. In summary, four-corner fusion with a polyether-ether-ketone locking, dorsal circular plate results in high union rates. The use of a radiolucent plate allows for more accurate assessment of union with the biomechanical advantages of a fixed angle construct.

The role of eccentric and offset humeral head variations in total shoulder arthroplasty

BACKGROUND Humeral head variations were developed based on anatomic and biomechanical advantages; however, the effect of this expanded prosthetic inventory has yet to be investigated clinically. This study seeks to determine whether prosthetic variety has led to better outcomes, has led to similar outcomes facilitating joint reconstruction, or created any unanticipated complications. METHODS One hundred sixty primary total shoulder arthroplasties were performed for osteoarthritis. Patients received 52 standard, 60 eccentric, and 48 offset humeral heads. Head geometry was selected intraoperatively during trialing based on a complementing relationship to the glenoid throughout a near-normal range of motion. Patients had 2 years of follow-up or follow-up until reoperation (mean, 4.7 years; range, 0.8-8.3 years). RESULTS Mean pain scores decreased from 4.5 to 1.9 on a 5-point scale (P < .001), mean elevation increased from 94° to 150°, mean external rotation increased from 22° to 57° (P < .001), larger lucent lines (≥ 1.5 mm) or change in glenoid position occurred around 19 components, and survivorship was 98% (95% confidence interval, 97%-100%) at 1 year and 98% (95% confidence interval, 95%-100%) at 5 years. No difference among head configurations was found for any of these outcomes. CONCLUSIONS Evolution of designs has provided options to more accurately re-create anatomy including changes caused by osteoarthritis. At the length of follow-up in this study, clinical outcomes, radiographic performance, and survivorship are equivalent when applying these humeral head variations, and no special complications have developed.

The Shenton line in the diagnosis of acetabular dysplasia in the skeletally mature patient.

BACKGROUND Undetected developmental dysplasia of the hip can progress to hip instability, which can lead to the development of early osteoarthritis. The purpose of the present study was to determine the reliability and accuracy of the Shenton line in the diagnosis of acetabular dysplasia in the skeletally mature patient. METHODS Supine anteroposterior pelvic radiographs were obtained for a total of 128 hips in patients with a diagnosis of developmental dysplasia of the hip prior to pelvic osteotomy (sixty-four hips, including thirty-two left and thirty-two right hips) and normal patients (sixty-four hips, including thirty-two left and thirty-two right hips). Six orthopaedic surgeons determined if the Shenton line was broken or intact to determine interobserver reliability. Four observers reviewed the randomized radiographs again after four weeks to determine intraobserver reliability. RESULTS The mean intraclass kappa value was 0.90 (range, 0.79 to 0.97), indicating excellent agreement between each reviewers primary and secondary reviews. The kappa estimate for interobserver reliability among all six reviewers was 0.80 (95% confidence interval, 0.75 to 0.84), indicating an excellent agreement. The determination of a normal or abnormal Shenton line had a mean sensitivity of 83.3% (range, 60.9% to 93.8%) and specificity of 98.4% (range, 92.2% to 100%). CONCLUSIONS The Shenton line is a reliable and accurate radiographic marker to detect superior femoral head subluxation indicative of acetabular dysplasia.

Minimally invasive flexible insertion and rigid intramedullary nail fixation for distal radius fractures.

Intramedullary (IM) devices are currently available for the surgical treatment of various distal radius fractures. The proposed advantages of IM fixation include minimally invasive operative techniques, less opportunity for hardware irritation, decreased postoperative pain, and stable fixation allowing for early range of motion. However, many complications have been reported with the use of IM devices in the distal radius such as injury to the superficial branch of the radial nerve, screw penetration into the distal radial ulnar joint, and loss of reduction. Nonetheless, early clinical reports of IM fixation for purely extra-articular distal radius fractures (AO type 23-A) and those with simple intra-articular extension (AO type 23-C1 and C2) have been promising. The purpose of this article is to describe the indication, technique, and rehabilitation after IM nail fixation for select distal radius fractures with a novel IM device, which provides locked fixed angle distal screws to support the articular subchondral bone and a unique flexible IM component that conforms to the patient’s anatomy, is made rigid, and locks proximally with IM fixation within the radial diaphysis. This unique device is theorized to be more patient specific (due to the flexible portion of the nail) and further minimize soft tissue irritation compared with those IM devices currently available.