Steven I. Grindel

Fatty infiltration and rotator cuff atrophy.

Abstract Moderate to severe fatty infiltration and rotator cuff atrophy are commonly associated with poor clinical outcomes and failed rotator cuff repair. Numerous animal and human studies have attempted to elucidate the etiology of fatty infiltration and rotator cuff atrophy. Mechanical detachment of the tendon in rotator cuff tears is primarily responsible. Suprascapular nerve injury may also play a role. CT, MRI, and ultrasonography are used to evaluate severity. The Goutallier staging system is most commonly used to evaluate fatty infiltration, and rotator cuff atrophy is measured using multiple techniques. The presence and severity of fatty infiltration have been associated with increasing age, tear size, degree of tendon retraction, number of tendons involved (ie, massive tears), suprascapular neuropathy, and traumatic tears. Fatty infiltration is irreversible and progressive if left untreated. Slight reversal of muscle atrophy has been noted after repair in some studies. Novel therapies are currently being evaluated that may eventually allow clinicians to alter the natural history and improve patient outcomes.

An Experience of the Snow–Littler Procedure

This paper reviews the results of the Snow–Littler procedure performed in twelve hands with classical central longitudinal deficiency and in one hand with symbrachydactyly, cleft type. There were no instances of major flap necrosis although two flaps showed tip ischaemia. The width of the first web was, in the main, satisfactory but four webspace revisions were performed. Supplementary skin grafting at the time of surgery was necessary in complete and/or complex thumb index syndactylies and in the patient with symbrachydactyly. In eight cases, a transverse metacarpal ligament was reconstructed. In the five other cases, no clinical instability or radiological divergence of the index and ring fingers occurred, in spite of no transverse metacarpal ligament reconstruction. Three de-rotational osteotomies of transposed index fingers were performed in patients who had a transverse metacarpal ligament reconstruction. These results indicated significantly improved appearance and improved function following the Snow–Littler procedure.

Hand involvement in 13q Deletion syndrome

Deletion in the long arm of chromosome 13 is relatively rare. Fewer than 100 cases are reported in the literature. Patients with 13q deletion have widely variable phenotypes. Hand anomalies, when present, include absent or hypoplastic thumbs, bony synostoses of the metacarpals, and brachyphalangy of the middle phalanx of the little finger. We report four cases with 13q deletion seen at our Hand Clinic.

Ultrasound Imaging Improves Identification of Prominent Hardware in the Surgical Treatment of Distal Radius Fractures: A Cadaveric and Prospective Clinical Study.

Background Volarly applied locking plates are one of several current treatment options for displaced fractures of the distal radius. Presently, surgeons use intraoperative depth gauges and fluoroscopy to select and confirm proper screw length. The contour of the dorsal cortex beneath the extensor compartments along with fracture comminution may limit the accuracy of screw length selection. Question/Purpose To evaluate the accuracy of ultrasound (US) and fluoroscopy in the detection of dorsally prominent screws placed during volar plating of experimentally created distal radius fractures and extend this prospectively into the clinical setting. Patients and Methods Distal radius fractures were experimentally induced in fresh cadaveric arms. The fractures were then internally fixated with volar locking plates utilizing fluoroscopic imaging. US imaging of the dorsal surface of the radius was then performed followed by dorsal dissection and direct caliper measurements to quantitate screw tips as recessed, flush, or protruding from the dorsal cortex. A small, prospective clinical study was also conducted to validate the clinical usefulness of using US to provide additional information regarding screw tip prominence. Results Our study demonstrated that US was able to detect dorsally prominent screw tips not visible on fluoroscopy. Cadaveric dissection showed a higher statistical correlation between US imaging and actual prominence than between fluoroscopy and actual prominence. Conclusions US examination after volar plate fixation of comminuted distal radius fractures may detect dorsal screw tip prominence when screw lengths are selected to engage the dorsal cortex. Level of Evidence IV.

Outcomes of shoulder replacement in humeral head avascular necrosis

BACKGROUND This retrospective review evaluated 25 patients with 29 shoulders treated with arthroplasty for humeral head avascular necrosis (HHAVN) between 2004 and 2015. We hypothesized that regardless of implant, radiographic stage, or etiology, patients would appreciate significant improvement in pain, range of motion, and shoulder functionality after surgical intervention. METHODS Data were obtained by record review on all patients meeting inclusion criteria. Outcomes were evaluated using Simple Shoulder Test, Modified Constant Score, University of California Los Angeles Shoulder Rating Scale, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form. The data were assessed by all patients and subcategories (treatment, avascular necrosis stage, and underlying cause). RESULTS At a mean follow-up of 3.9 years (range, 1-8.5 years), all patients who underwent operative intervention for HHAVN showed statistically significant improvement in functionality measurements (P < .01). Patients who underwent total shoulder arthroplasty (TSA) noted higher median outcome scores and greater improvement in all scoring methods compared with their hemiarthroplasty counterparts. The high-stage disease shoulders showed similar trends over low-stage counterparts. The shoulders in the trauma causal group had the highest scores in 3 of 4 outcome measures and favorable change in all scoring methods. These differences were not statistically significant (P > .05). No revision arthroplasties were required. Minor complications (suture abscess and intraoperative calcar fracture requiring cabling) occurred in 2 TSA patients. CONCLUSIONS Our outcomes demonstrate that in the short- to midterm follow-up, TSA or hemiarthroplasty is a safe and equally effective treatment for patients diagnosed with HHAVN regardless of etiology and radiographic staging.

Assessment of Kinematics and Electromyography Following Arthroscopic Single-Tendon Rotator Cuff Repair

The increasing demand for rotator cuff (RC) repair patients to return to work as soon as they are physically able has led to exploration of when this is feasible. Current guidelines from our orthopedic surgery clinic recommend a return to work at 9 weeks postoperation. To more fully define capacity to return to work, the current study was conducted using a unique series of quantitative tools. To date, no study has combined 3‐dimensional (3D) motion analysis with electromyography (EMG) assessment during activities of daily living (ADLs), including desk tasks, and commonly prescribed rehabilitation exercise.

The Indications and Importance of Obtaining Electrical Studies

The use of electromyography (EMG) and nerve conduction studies (NCS) in the evaluation of carpal tunnel syndrome (CTS) has evolved over the last few decades. Its use has been debated when patients undergoing carpal tunnel release in light of normal EMG findings had significant relief of their symptoms (Grundberg, J Hand Surg 8:348–349, 1983). Currently, however, the use of EMG and nerve conduction studies in the evaluation of compression neuropathies is accepted as a common practice. A recent survey of ASSH members showed 90% of surgeons used electrodiagnostic studies preoperatively at least occasionally, and that number was as high as 96% among younger surgeons (Munns and Awan, J Hand Surg Am 40:767–771, 2015). This more recent near-universal use of electrodiagnostic studies most likely is multifactorial, and can be at least partly related to defensive medicine in light of current published guidelines for the treatment of CTS, which recommend NCS/EMG (Keith et al., J Am Acad Orthop Surg 17:389–396, 2009; Keith et al., J Am Acad Orthop Surg 17:397–405, 2009). Given the prevalence and importance of electrodiagnostic testing in the management of carpal tunnel syndrome, the treating surgeon should have a basic understanding in its use and interpretation.