Zahab S. Ahsan

The importance of pronator quadratus repair in the treatment of distal radius fractures with volar plating

BackgroundOpen reduction internal fixation (ORIF) of distal radius fractures via a volar approach involves surgical release of the overlying pronator quadratus (PQ) muscle. Complete repair of the PQ, defined as full and stable replacement of the periphery of the PQ back to its original anatomic location, is not always possible upon conclusion of the operation. Postoperative consequences of incomplete PQ repair with regards to range of motion (ROM), grip strength, and complications are not well documented. It was hypothesized that the completeness of PQ repair would yield no significant difference in the postoperative ROM, grip strength, and incidence of complications.MethodsA retrospective review was performed of 110 repairs of distal radius fractures with ORIF via placement of a volar locking plate. The following clinical data were extracted: complete or incomplete PQ repair, patient age, gender, follow-up ROM/grip strength, and incidence of postoperative complications.Results and conclusionsNo significant difference in ROM, grip strength, and postoperative complications was detected between the complete and incomplete PQ repair groups. Complications consisted of two incidences of malunion requiring revision surgery and one occurrence of complex regional pain syndrome. There were no tendon ruptures. No statistical difference in ROM/grip strength or incidence of postoperative complications was detected between the complete and incomplete PQ repair groups. Regardless of the level of injury sustained by the PQ, surgeons should make an effort to cover the distal aspect of the volar plate during closure following distal radius fracture ORIF. Coverage of the distal aspect of the plate with the PQ (at a minimum) provides adequate results in ROM and grip strength, as well as protection against flexor tendon injury.Level of evidenceTherapeutic Level III: Retrospective Comparative Study.

Incidence of Failure of Continuous Peripheral Nerve Catheters for Postoperative Analgesia in Upper Extremity Surgery

PURPOSE To explore the incidence of failure of continuous peripheral nerve blockade (CPNB) after upper extremity operations. METHODS Patient data regarding postoperative CPNB were retrospectively obtained from our institutions regional anesthesia database. Documented information on the first postoperative day included pain assessment ratings (numerical verbal pain scale, patient-reported breakthrough pain upon perceived return of sensation, appearance of the catheter site, complications, time of return of sensation, day of return of sensation, residual blockade, patient satisfaction with the block, and whether patient would receive the block again). RESULTS A total of 207 patients received CPNB for postoperative analgesia. The failure rate on the first postoperative day for infraclavicular (133 patients) and supraclavicular (58 patients) CPNB was 19% and 26%, respectively. Interscalene CPNB (16 patients) yielded 3 incidences of failure. No significant difference was found between supraclavicular and infraclavicular block techniques. In addition, no significant differences were found between the incidences of CPNB failures with potentially more painful surgeries involving bone compared with potentially less painful soft tissue procedures. CONCLUSIONS The CPNB technique used for hand surgery postoperative analgesia was associated with nontrivial failure rates. The potential of CPNB failure and resulting breakthrough pain upon recovery from the primary nerve block is important to help establish patient expectations. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Outcomes of Ulnar Shortening Osteotomy Fixed With a Dynamic Compression System

PURPOSE To evaluate the outcomes of patients with ulnar impaction syndrome treated with a jig-facilitated, oblique, diaphyseal ulnar shortening osteotomy and fixed with a TriMed (Santa Clarita, CA) ulnar osteotomy compression plate. METHODS A retrospective chart review of patients with ulnar impaction syndrome identified 38 patients who had had ulnar shortening osteotomy and fixation with the TriMed dynamic compression system. The following clinical data were obtained: patient age, sex, follow-up range of motion, grip strength, and complications. After a minimum of 2 years after surgery, patients reported complications and completed a Disabilities of the Arm, Shoulder, and Hand questionnaire. RESULTS Eight patients were lost to follow-up. Compared to the opposite limb at an average of 8 months after surgery, the remaining 30 patients attained 92% to 97% of wrist and forearm motion and 71% of grip strength. The average Disabilities of the Arm, Shoulder, and Hand score was 12 after a minimum of 2 years after surgery. Four patients required plate removal due to irritation. Two patients reported persistent ulnar-sided pain, and 2 other patients developed atrophic nonunions and required autologous bone grafting. There were no infections. CONCLUSIONS Ulnar shortening osteotomy using the TriMed system yielded good clinical outcomes that are comparable to those previously documented using other systems. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Characterizing the Propionibacterium Load in Revision Shoulder Arthroplasty: A Study of 137 Culture-Positive Cases

Background: Propionibacterium is commonly recovered from explants or surrounding tissues in revision shoulder arthroplasty. Rather than attempting to differentiate a true infection from a false-positive result on the basis of the number of positive cultures, we characterized the amount of these bacteria in each specimen and shoulder. Methods: The study included 137 revision shoulder arthroplasties from which a minimum of 4 specimens had been submitted for culture and at least 1 was positive for Propionibacterium. Standard microbiology procedures were used to assign a semiquantitative value (0.1, 1, 2, 3, or 4), called the Specimen Propi Value, to the amount of growth in each specimen. The sum of the Specimen Propi Values for each shoulder was defined as the Shoulder Propi Score, which was then divided by the total number of specimens to calculate the Average Shoulder Propi Score. Results: The number and percentage of positive specimen-specific cultures (of material obtained from the stem explant, head explant, glenoid explant, humeral membrane, collar membrane, other soft tissue, fluid, or other) per shoulder ranged from 1 to 6 and 14% to 100%. A high percentage of specimens (mean, 43%; median, 50%) from the culture-positive shoulders showed no growth. Only 32.6% of the fluid cultures were positive in comparison with 66.5% of the soft-tissue cultures and 55.6% of the cultures of explant specimens. The average Specimen Propi Value (and standard deviation) for fluid specimens (0.35 ± 0.89) was significantly lower than those for the soft-tissue (0.92 ± 1.50) and explant (0.66 ± 0.90) specimens (p < 0.001). The Shoulder Propi Score was significantly higher in men (3.56 ± 3.74) than in women (1.22 ± 3.11) (p < 0.001). Similarly, men had a significantly higher Average Shoulder Propi Score (0.53 ± 0.51) than women (0.19 ± 0.43) (p < 0.001). Conclusions: This investigation suggests that Propionibacterium is unevenly distributed within culture-positive revised shoulders. As a result, the specimen number and source (explant, soft tissue, or fluid) have major influences on the culture results for a revised shoulder arthroplasty. We found no evidence that suggested useful threshold values for defining a true infection. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Snyder Classification of Superior Labrum Anterior and Posterior (SLAP) Lesions.

In 1938, Bankart and Cantab [2] initially described injury to the anteroinferior glenoid labrum. It was not until 1985 that Andrews and colleagues [1] first identified superior glenoid labral disorders by describing the classic mechanism of injury and biomechanics of labral tears through arthroscopic evaluation of 73 elite overhead-throwing athletes. In 1990, Snyder et al. [22] published a retrospective review of 700 shoulder arthroscopies, with diagnosis of 27 superior labral injuries in a cohort of throwing athletes. Their 1990 landmark article [22] established the acronym ‘‘SLAP’’ (superior labral tear, anterior to posterior) lesion and presented the first comprehensive classification of four major injury patterns as a cause of pain and instability, particularly in the overhead throwing athlete. Although the emphasis of this article is to describe the original Snyder classification, continued clinical and diagnostic advancements have given rise to the recognition of variations in complex labral disorders [4]. Numerous subclassification and expanded classification systems have been developed based on the original description of SLAP lesions [14, 15, 17, 25]. Despite this, reporting of SLAP lesions in the literature using even the original Snyder classification [22] is widely variable and inconsistent, as is the clinical diagnosis, indication for surgical intervention, and surgical treatment [13].

Complications of Wrist and Hand Arthroscopy

Arthroscopy of the wrist continues to evolve and advance as a valuable clinical technique in hand surgery. This article aims to address safety of wrist arthroscopy and provide an overview of the known iatrogenic complications. Ultimately, the likelihood of associated injuries during wrist arthroscopy is dependent on the surgeons ability and understanding of the equipment. Case volume and duration of experience directly correlate with mitigating iatrogenic injury and optimizing patient outcomes.

Ligamentous injuries of the hand

The carpometacarpal (CMC), metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints of the hand are supported by highly intricate and functionally vital ligamentous structures. Injuries to these ligaments are very common. After injury to these ligaments, adequate management must be provided to maintain functional integrity of the digital joints. Most of these ligament injuries may be treated without surgery, but some will require operative repair. The ligamentous structures of interest include the CMC ligaments as well as collateral ligaments, volar plates, and flexor tendon pulleys of the MCP, PIP, and DIP joints. This article presents a review of recent literature pertaining to injuries of the aforementioned structures, with a focus on developments within the past 18 months.