Richard J. Miller

Scapholunate advanced collapse wrist : proximal row carpectomy or limited wrist arthrodesis with scaphoid excision ?

Proximal row carpectomy (PRC) and limited intercarpal arthrodesis with scaphoid excision (LWF) are useful alternatives to wrist arthrodesis for treatment of degenerative wrist disorders secondary to scapholunate advanced collapse. Because consensus regarding the ideal motion-preserving option is lacking, we sought to better define the indications for and relative merits of PRC versus LWF. Twenty-four wrists treated for symptomatic scapholunate advanced collapse arthritis between 1980 and 1990 with either PRC or LWF were retrospectively reviewed at an average of 5.5 years postoperatively. At follow-up evaluation, satisfactory pain relief, grip strength, and functional performance were observed except in three patients with PRC, one of whom had developed symptomatic radiocarpal arthritis requiring conversion to arthrodesis. Differences in subjective and objective results between the two treatment groups were not statistically significant except for residual range of motion. Incomplete correction of lunate extension when LWF was performed resulted in diminished wrist extension, compared to PRC. Improvements in grip strength and range of motion were noted for at least 1 year after both procedures, and neither declined with time. A stage-dependent surgical approach to the symptomatic scapholunate advanced collapse wrist is advocated in light of comparable outcomes following both PRC and LWF. For wrists without capitolunate arthritis, PRC avoids the technical demands, lengthy postoperative immobilization, and risk of nonunion associated with LWF, but for stage III disease (capitolunate arthritis) pain relief may be unsatisfactory, and LWF is recommended.

The prevalence of carpal tunnel syndrome in patients with basal joint arthritis of the thumb

Basal joint arthritis of the thumb and carpal tunnel syndrome are common conditions with an acknowledged coexistence. This article attempts to quantify the prevalence of carpal tunnel syndrome in patients with basal joint arthritis and to examine some of the etiologic factors that affect the coexistence of the two disorders. Of 246 patients who had surgery about the basal joint, 95 patients (39%) were identified by chart review as having carpal tunnel syndrome. Eleven of 122 remaining patients contacted had symptomatic carpal tunnel syndrome confirmed by nerve-conduction studies, bringing the total to 106 (43%). The prevalence was higher in workers compensation patients and those with diabetes mellitus. The prevalence was lower in men than in women, and patients with inflammatory joint disease were at less risk than those with osteoarthritis. Given this high association, great care should be taken to diagnose or exclude coexistent carpal tunnel syndrome in patients scheduled for basal joint surgery so that, if present, it can be treated at the same time, diminishing the risk of postoperative morbidity and delayed symptoms.

Treatment of traumatic radioulnar synostosis by excision and postoperative low-dose irradiation☆

Post-traumatic radioulnar synostosis can have a profound effect on upper extremity function. Prior reports of excision, with and without interposition material, have demonstrated frequent recurrence and disappointing results. Based on a favorable experience with radiation prophylaxis of heterotopic ossification following total hip arthroplasty, this modality has been used in the management of post-traumatic forearm synostosis. Four cases using excision of bony synostosis followed by single-fraction, low-dose (800 cGy), limited-field irradiation are presented. With a follow-up period of 1-4 years after excision and irradiation, all four patients had total arcs of forearm rotation between 115 degrees and 120 degrees. Each patient noted sustained functional improvement, and there was no x-ray film evidence of recurrent synostosis formation. Single fraction irradiation did not require ongoing patient compliance nor did it complicate rehabilitative efforts. Furthermore, soft tissue and bony healing were not impaired.

Comparison of Postoperative Pain in Patients Receiving Interscalene Block or General Anesthesia for Shoulder Surgery

A retrospective review of 114 patients who underwent elective shoulder surgery from January 1, 1995 to December 31, 1996 was performed. Eighty-eight patients received general anesthesia and 26 patients received regional anesthesia (interscalene block). There were no differences in surgical and anesthesia time and time to hospital discharge between groups. Patients who received regional anesthesia had a shorter recovery room stay (63 +/- 25 minutes versus 85 +/- 33 minutes [P.002]) and required less intraoperative fentanyl (174 +/- 96 microg versus 379 +/- 193 microg [P<.0001) and morphine in the recovery room (2 +/- 3 mg versus 6 +/- 7 mg [P=.006]). A higher percentage of patients who received regional anesthesia had a lower pain rating at 4 hours. Regional anesthesia for shoulder surgery decreases pain and facilitates recovery in the immediate postoperative period.

The static and dynamic behavior of the human knee in vivo.

Abstract Tests are described in which the in vivo dynamic behavior of human knees are assessed by means of dynamic, static and creep tests. The dynamic behavior was investigated by means of impedance techniques in which the subjects leg was compared to the contralateral fellow over a frequency range of 0–10 Hz. Agreement was reached between the two knees of control subjects. The knee was found to behave dynamically as a Kelvin body. A complex rheological model describing the behavior of the knee both statically and dynamically is given.

Analysis of Version in the Acetabular Cup

To determine the amount of anteversion or retroversion of the acetabular component of the implanted total hip prosthesis, two anteroposterior radiographs of the hip are obtained, with the contralateral hip flexed to compensate for the possible existing flexion contracture. The X-ray beam is centered on the implanted total hip in one radiograph, and moved away from it toward the contralateral hip in the second radiograph. If the cup is anteverted, the opening will seem wider in the second radiograph. To calculate the angle, the location of the center of the X-ray beam on the X-ray plate must be know. The center of the X-ray beam can be marked on the radiograph by putting a metalic cross on the patient, over the centering cross of the X-ray light source. If the distance of the signature of the X-rays center beam is less than 8 mm for the center of the cup on the X-ray film, the cup version can be calculated from the arcsin of the shortest to the largest diameter of the cup. If the central rays signature is farther away, correction is necessary for this calculation. Also, the variable parameters, e.g., cup size, and magnification rate, should be considered in the calculations. The anteroposterior radiographs of the implanted total hip, obtained with the central beam being marked on the X-ray plate, not only are useful for evaluation of the implant but also can be used to calculate the version angle with an accuracy of +/-2 degrees. The necessary calculation is tabulated for cups with an outside diameter of 44-56 mm.

The impedance of the human knee

Abstract Tests are described in which the in vivo dynamic behavior of both intact and injured human knees in varus-valgus and axial rotation are assessed by means of mechanical impedance techniques. The impedance characteristics of the subjects leg were compared to the contralateral fellow over a frequency range of 0.5–10 Hz. Agreement was reached between the two knees of control subjects whereas significant differences were noted between the injured and uninjured knees of injured subjects. The knee was found to behave dynamically as a Kelvin body.

Radiographic results of fully uncemented trabecular metal reverse shoulder system at 1 and 2 years' follow-up.

BACKGROUND The purpose of this study was to assess the short-term radiographic outcome of a fully uncemented reverse total shoulder arthroplasty (RTSA) system. MATERIALS AND METHODS We reviewed the radiographs of 98 consecutive patients undergoing uncemented RTSA. All patients had a standardized series of radiographs taken at 2 weeks, 1 year, and 2 years postoperatively. Humeral stems were evaluated for radiolucent lines by zone and component subsidence. Evaluation for scapular notching and radiolucency surrounding the baseplate implant within the glenoid vault was also performed. RESULTS At 1 year, 93.9% of humeral stems had no lucent lines and 6.1% had less than 2 mm of lucency. Of the scapulae, 76.6% showed no evidence of notching, 21.4% had type 1 scapular notching, and 2.0% had type 2 notching at 1 year. At 2 years, 89.5% of humeral stem components had no lucent lines and 10.5% had less than 2 mm of lucency. Fifty-seven percent of scapulae had no notching, 34.2% had type 1 notching, 5.3% had type 2 notching, and 2.6% had type 3 notching. No stems had lucency in more than 1 zone or lucency ≥ 2 mm; 9.2% had subsidence of 2 mm or less. No glenoid components had any lucency around the baseplate or screws. CONCLUSIONS Cementless trabecular metal porous-coated implants for RTSA are associated with secure glenoid fixation and minimal radiographic evidence of humeral stem loosening or subsidence at short-term follow-up. The rates of scapular notching found in our study are comparable to previous studies and did not affect implant stability.

Basic Anatomy of the Shoulder by Magnetic Resonance Imaging

Summary: An understanding of the normal magnetic resonance (MR) infrastructural details of musculotendinous elements of the rotator cuff forms the basis for analysis of its pathology. The muscular bellies of the teres minor, infraspinatus, supraspinatus, and subscapularis are easily identified in MR images. In their lateral course both the supraspinatus and infraspinatus muscles transition to tendons gradually. Their lateral tendinous portions partially overlap and form a layered appearance on MR images. The subscapularis, with its fan-like tendinous insertional slips at the lesser tuberosity, can be identified easily in all imaging planes. The ligamentous structures of the shoulder, including the coracoacromial and coracohumeral ligaments, are visualized as low signal bands in all imaging planes. The capsuloligamentous structures including the superior, middle, and inferior glenohumeral ligament and glenoid labrum present considerable anatomic variations. This is especially true with respect to the anterior labrum, which varies from absent to a well-formed triangular appearance. Understanding the basic MRI anatomy of all soft tissue structures of the shoulder is essential for appropriate interpretation of lesions related to the shoulder.

Preoperative PROMIS Scores Predict Postoperative PROMIS Score Improvement for Patients Undergoing Hand Surgery

Background: Patient-Reported Outcomes Measurement Information System (PROMIS) can be used alongside preoperative patient characteristics to set postsurgery expectations. This study aimed to analyze whether preoperative scores can predict significant postoperative PROMIS score improvement. Methods: Patients undergoing hand and wrist surgery with initial and greater than 6-month follow-up PROMIS scores were assigned to derivation or validation cohorts, separating trauma and nontrauma conditions. Receiver operating characteristic curves were calculated for the derivation cohort to determine whether preoperative PROMIS scores could predict postoperative PROMIS score improvement utilizing minimal clinically important difference principles. Results: In the nontrauma sample, patients with baseline Physical Function (PF) scores below 31.0 and Pain Interference (PI) and Depression scores above 68.2 and 62.2, respectively, improved their postoperative PROMIS scores with 95%, 96%, and 94% specificity. Patients with baseline PF scores above 52.1 and PI and Depression scores below 49.5 and 39.5, respectively, did not substantially improve their postoperative PROMIS scores with 94%, 93%, and 96% sensitivity. In the trauma sample, patients with baseline PF scores below 34.8 and PI and Depression scores above 69.2 and 62.2, respectively, each improved their postoperative PROMIS scores with 95% specificity. Patients with baseline PF scores above 52.1 and PI and Depression scores below 46.6 and 44.0, respectively, did not substantially improve their postoperative scores with 95%, 94%, and 95% sensitivity. Conclusions: Preoperative PROMIS PF, PI, and Depression scores can predict postoperative PROMIS score improvement for a select group of patients, which may help in setting expectations. Future work can help determine the level of true clinical improvement these findings represent.